A stay in the hospital's Intensive Care Unit (ICU) can be daunting. Wires, tubes, beeping monitors, unfamiliar noises lurking in the background and the constant fear of whether you will make it through the illness.
For critically ill patients who survive, the near-death experience can leave a lasting impact on their health. The road to recovery, then, stretches way beyond getting off the ventilator and coming back home.
Post Intensive Care Syndrome (PICS) is characterized by physical, cognitive and psychological symptoms that appear after a patient leaves the ICU.
For longer ICU stays, some kind of impact is almost inevitable. The issue is pertinent during the COVID-19 pandemic, which often manifests itself into severe respiratory complications, multiple organ failure or Acute Respiratory Distress Syndrome (ARDS), making specialised treatment in the ICU the only option. Almost five percent of the severe cases are critical, where the patient requires ventilators or ICU admission.
FIT speaks to critical care specialists to understand what really goes on for these patients - and exactly how the damage could be minimised.
The Physical Impact of an ICU Stay
‘Post-intensive care syndrome’ is a fairly recent term which came about in 2010 to acknowledge the long-term outcomes on patients after they discharge from intensive care.
In conversation with FIT, Dr Sumit Ray, a senior consultant, Critical Care Medicine, Delhi, says, “The longer you stay in the ICU, the more you are at risk of these long-term consequences, and the longer it will it take for you to get back to normal. The effects of ICU stay have been observed particularly in patients who had sepsis, who were on the ventilator with ARDS, people who stayed on life support for a long period of time or had gone into shock, or those who were on medication to keep their blood pressure up.”
How does this manifest physically?
The answer lies in the body’s response to a critical illness, which eventually leads to neuromuscular weakness. Dr Shruti Tandon, Consultant, Critical Care, Jaslok Hospital and Research Centre explains how that happens. “There is an inflammatory response in the body and cytokines are needed to fight the illness. These are essentially made up of proteins. Since our bodies do not have a protein stock, the protein used for muscle building is diverted for the cytokine response. This is why many patients are left with muscle wasting, muscle loss and weakness which can carry on for months or years.”
This study, for instance, found that every additional day of bed rest in the ICU lowers a patient’s muscle strength between 3 to 11 percent over the following months or even years.
The Mental Toll of Intensive Care
“For many patients, the psychological impact resembles Post-Traumatic Stress Disorder (PTSD),” Dr Sumit Ray says.
In fact, a John Hopkins study found that nearly one-quarter of ICU survivors suffer from PTSD,
Dr Tandon explains that these are all a result of the near-death experiences which some of these patients have just come out of. “They often don’t talk about it openly, but it comes about when we have a consultation later.”
The impact on the brain is as explicit and shows up in the form of cognitive dysfunction. Simple mathematical work, cognitive ability to perform tasks, effect on memory, concentration, problem-solving - everything gets compromised depending on the length of stay and the amount of sedation used, Dr Ray adds.
This is observed even in younger people, although the severity may vary. A study, published in the New England Journal of Medicine, found cognitive impairment in almost 20-30% of patients even after 12 months of discharge, with scores similar to patients with moderate traumatic brain injury or those with mild Alzheimer’s.
Another largely unaddressed issue remains that of ‘ICU delirium’ which impacts anywhere between 20-80 percent of patients, especially mechanically ventilated people. This delirium can include hallucinations, delusions and paranoia during and after the stay.
Moreover, the mental health impact goes beyond the patients to also impact those who are involved in their care and wellbeing. Post-Intensive Care Syndrome-Family (PICS-F) refers to the development of adverse psychological outcomes such as fatigue, anxiety, acute stress disorder, post-traumatic stress, depression and complicated grief among family members.
How Doctors and Family Members Can Help
A common approach that has been found to help prevent PICS rates is the ‘ABCDEF’ bundle: Awakening and Breathing Coordination to free patients from sedation and mechanical ventilation, Choosing drugs to reduce risk of delirium, Delirium management, Early mobility and Exercise, and Family engagement.
Dr Sumit Ray simplifies and explains the multiple ways to bring down the severity of the health impacts for people receiving this critical care.
- Good physiotherapy during hospital stay and after, and early mobilisiation in the ICU can help with the physical symptoms. Small attempts to make patients sit out of the bed on the chair, or to make them stand should be attempted, based on their conditions. “We need to reach a fine balance because we can’t go too hard on someone who is on life support.”
- The patient’s nutritional targets should be met without running the risk of overfeeding. Dr Tandon stresses the need to ensure that there is a good amount of protein going into the patient to rebuild the muscles. 1.5-2 kgs of protein per day should be the target for critically ill patients.
- Sedation needs to be balanced with a degree of arousability wherever possible, Dr Ray adds. According to this NJEM study, the best outcomes are achieved when the sedation is monitored and the administration of sedatives is kept to the minimum necessary for the comfort and safety of the patient.
- Your choice of drugs can also be of help. “Some drugs are known to have greater mental health implications than others, so we should avoid prescribing them until necessary”, says Dr Ray.
- Keeping a diary with the patient and helping them journal their experiences can also help for them to go back to later.
- The other thing is to design and place ICUs in a way that some amount of sunlight is directed into the room. Natural light helps the skin secrete melatonin, which can help with their psychological health. “If we can get the bed to face outside when the patient starts waking up so that they can see the world, it would be great to help them get over any negativity or hopelessness.”
- Familiar noises in the room, a dose of normalcy, having a television can all help.
- How doctors and the nursing staff speak to the patients is also extremely important. They should constantly be giving the patient positive inputs like “You are getting better.” Instilling a positive attitude is very important, even if the chances of survival are not very good, because if the patients do get out of it, they will carry the scars of the negativity forever. Dr Ray explains, “Being kind to the patient, taking care of their psychological needs is extremely important, but it’s something that is rarely taught to the medics. It is slowly becoming a part of our training.”
- Allow regular family visits for patients to feel close to home and surrounded by people they know and care about.
That essentially is the problem with COVID-19, Dr Ray explains. “It can be psychologically devastating, because the patients are not allowed to see their loved ones. They are in an unfamiliar environment with beeping monitors, unknown faces who often don’t talk to them, and affected by an illness which they don’t know much about - this can all impact them deeply.”
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