Post-intensive care syndrome is a complex of pathological conditions that have developed or worsened in connection with intensive care and restrict daily activity. It is manifested by memory disorders, depression, dissomnia, polymyoneuropathy, dysphagia, decreased physical endurance. It is diagnosed on the basis of medical history, stress tests, EEG data, ENMG, neuropsychological examination. Treatment involves active physical rehabilitation (physical therapy, electrical stimulation, inhalation, percussion massage), psychotherapy, taking antidepressants.
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Post-intensive care syndrome (PICS) includes long-term negative physical, neurological, psychological conditions developing against the background of IT. A year later, signs of Post-intensive care syndrome are present in 20-40% of patients discharged from the ICU. Half of the patients remain disabled for 12 months and need the help of others, and a third acquires a permanent disability. The high social significance of Post-intensive care syndrome dictates the need to find ways to prevent and rehabilitate it.
Intensive care provided to patients in critical condition, as a rule, includes massive infusion-transfusion therapy, anesthesia, respiratory and nutritional support, and many others. These measures have their side effects, which, combined, have adverse long-term effects on the physical and psychological state of patients. The greatest role in the development of Post-intensive care syndrome is played by:
- Bed rest. Forced immobility leads to deterioration of metabolic and trophic processes. As a result of the lack of movement, muscular atrophy develops, bedsores form, contractures occur, and the risks of thrombosis increase. Serious challenges are ischemic myelopathy, congestive pneumonia.
- VENTILATORS. Prolonged hardware replacement of respiratory function can cause lung damage: volumotrauma, barotrauma, biotrauma, atelectotrauma. Against the background of ventilation, electrolyte imbalance disorders (alkalosis, acidosis), respiratory tract infections (ventilator-associated pneumonia) often develop.
- Infusion therapy. The introduction of infusion solutions can lead to hyperhydration, overload of blood circulation, pyrogenic reactions. The need for catheterization of large veins increases the risk of thrombophlebitis, catheter-associated infections, sepsis. Transfusion of hemocomponents can be complicated by hemotransfusion shock, citrate intoxication, massive blood replacement syndrome.
- Parenteral nutrition. The complete exclusion of the gastrointestinal tract from the process of digesting food is accompanied by functional disorders – cholestasis, intestinal atony. Insufficiently balanced selection of drugs for nutritional support can cause hypo- or hyperglycemia, hyperammonemia, demineralization of bones.
- The use of medicines. The use of analgesics, anesthetics, muscle relaxants reduces protective respiratory reflexes, increases the time spent by patients on a ventilator. The appointment of vasopressors within IT increases the risk of thrombosis. The use of glucorticoids induces the development of steroid myopathy, etc.
Factors that increase the likelihood of developing PIT syndrome are:
- time spent in the ICU;
- presence of foreign bodies in the body (drains, catheters, probes);
- stress from being in the ICU, constant noise, lighting of the ward;
- burdened premorbid condition (presence of chronic somatic and mental diseases, addictions);
- old age.
Each of these factors contributes to the pathogenesis of Post-intensive care syndrome. Prolonged immobilization causes microcirculation disorders, degeneration of peripheral nerves, increased catabolic reactions, oxidative stress. Under these conditions, there is a rapid depletion of muscle mass: in two weeks, the muscle strength of a lying patient decreases by 15-23%, in a month – by 53%.
Artificial ventilation of the lungs not only causes mechanical damage to the alveolar tissue, but also triggers the release of pro-inflammatory factors that damage the endothelium of the pulmonary capillaries, contribute to increased platelet aggregation, and the development of DIC syndrome. In addition, against the background of hardware respiration, perfusion of the brain, kidneys, liver decreases, leading in the long term to the development of ischemic encephalopathy, ischemic nephropathy.
Massive infusions of solutions change the indicators of water-electrolyte metabolism, CBS, blood osmolarity, oncotic pressure. At the same time, transcapillary permeability increases, fluid extravasation is observed, tissue hypoxia develops, multiple organ dysfunction. Various components of Post-intensive care syndrome not only worsen the outcomes of critical condition by themselves, but also contribute to the exacerbation and progressive course of concomitant diseases, worsening the mental and somatic health of resuscitation patients.
All the consequences of intensive therapy can be divided into several groups depending on the type of impaired functions, risk factors and prognosis. The structure of Post-intensive care syndrome includes the following groups of dysfunctions:
- Neuromuscular. They are represented by polymyoneuropathy of critical states (PMCS) and dysphagia. The basis of PMCS is prolonged immobilization, analgesia, metabolic disorders, nutrient deficiency. Swallowing disorders are associated with prolonged intubation, standing tracheostomy, and the use of probe feeding.
- Vegetative. They include circadian rhythm disturbances and a decrease in the gravitational gradient (GG). Dissomnia is caused by analgesic sedation, melatonin imbalance, round-the-clock medical procedures. A decrease in GG develops against the background of prolonged bed rest, a position with a lowered head end, accompanied by orthostatic insufficiency.
- Mental. Factors such as cerebral hypoperfusion, sedation, premorbid vascular pathologies cause neurological deficits, emotional and cognitive disorders.
- Somatic. In elderly patients with concomitant diseases, against the background of bed rest, ventilator, IT, overall activity, physical endurance, respiratory volume, and well are significantly reduced.
A typical manifestation of Post-intensive care syndrome on the part of the peripheral nervous system is polyneuropathy of critical states (PCS). Develops in about 2% of ICU patients. Signs of PCS include sensitivity disorders, sluggish paralysis, and areflexia. After the patient is removed from the ventilator, there may be a violation of spontaneous breathing. Post-extubation oropharyngeal dysphagia often develops, against which food aspiration is possible.
Muscle weakness in the extremities persists for a long time, it takes years to restore motor function. Swallowing is most often restored spontaneously within a month.
Post-intensive care syndrome is accompanied by a disorder of the usual sleep and wakefulness, deterioration of sleep. At the same time, the structure of night sleep is disrupted, episodes of daytime sleep become more frequent, drowsiness and fatigue are constantly present. Heavy and nightmarish dreams can disturb.
Orthostatic insufficiency is manifested by arterial hypotension, dizziness, visual phenomena (flies, darkening in the eyes), which can provoke falls and injuries. It is also possible increased sweating, tachycardia, oliguria. Regression of vegetative symptoms takes from 6 months to 1 year.
Unpleasant memories of everything connected with the intensive care unit give rise to a depressive mood. Patients with PIT syndrome experience anxiety, irritability, emotional instability. There is a decrease in cognitive functions: attention, memory suffers, control and planning becomes difficult, rigidity of thinking is observed. Speech disorders are often noted. Mental disorders may weaken over time, but, as a rule, they do not completely regress.
With Post-intensive care syndrome, the physical status of the patient undergoes significant changes. Worries about pain syndrome, muscle weakness, difficulty breathing, deterioration of endurance. Some patients experience sexual dysfunction. Daily activity may decrease so much that patients require outside care and assistance in solving everyday issues. Improvement is noted throughout the year, but the somatic status does not always reach the premorbid level.
Post-intensive care syndrome itself is considered as an iatrogenic complication of intensive care. The main problem in the post-resuscitation period is a decrease in the quality of daily life due to motor dysfunction, impaired exercise tolerance, inability to self-care, cognitive deficits. In some cases, persistent disability develops.
The basis for the diagnosis of PIT syndrome is the fact of IT, resuscitation and subsequent deterioration of physical or mental health. To confirm individual violations, a complex of laboratory and instrumental studies is carried out.
- Neurological examination. ENMG is indicated for the verification of polyneuromiopathy. In case of circadian rhythm disorders, EEG, polysomnography is performed. If necessary, muscular atrophy and axonal degeneration are confirmed by biopsy.
- Cardio-respiratory diagnostics. In order to objectively assess the functional reserves of the cardiovascular and pulmonary systems, spirometry, ECG at rest and with load is performed. A 6-minute walking test, Tilt-test, and treadmill test are used as load tests.
- Psychodiagnostics. It is carried out to assess cognitive functions, identify the emotional state, psychological characteristics of the individual. For this purpose, conversations with patients, questionnaires, and special diagnostic scales are used.
The content of therapy and rehabilitation depends on the symptoms affecting the quality of life. As soon as the patient’s condition allows, it is necessary to begin active rehabilitation, which should be attended by resuscitators, neurologists, cardiologists, pulmonologists, physiotherapists, physical therapy instructors, clinical psychologists.
The basis of Post-intensive care syndrome correction is kinesiotherapy, which includes elements of passive gymnastics, cycling, verticalization, and later – walking, physical exercises. Physiotherapy methods include limb massage, percussion massage, electromyostimulation, IRT, inhalation.
To increase the lung capacity, respiratory gymnastics is performed. With dysphagia, special exercises, kinesiotaping, vibration massage, and VocaStim electrical stimulation are used. In order to stop psychological manifestations, it is recommended to prescribe antidepressants, behavioral therapy, cognitive training.
Prognosis and prevention
Physical, cognitive, and motor disorders negatively affect the recovery of patients who have survived critical conditions. With active rehabilitation, various manifestations of Post-intensive care syndrome regress within 1-5 years. In some cases, residual effects persist for life. Early verticalization and activation of resuscitation patients are proposed as measures to prevent PIT syndrome. Sedative and analgesic drugs should be canceled in a timely manner, patients should be transferred to enteral nutrition and independent breathing.