Post-ICU Ambulatory Care

Aka: Post-ICU Ambulatory Care, Post-ICU Complication, Chronic Complications of ICU Care, ICU Follow-up Care, Critical Care Follow-up, Intensive Care Unit Survivor Visit, Intensive Care Unit Survivor

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II. Epidemiology

  1. ICU Admission annual Incidence (U.S.): 5 Million/year
  2. Survival of ICU stay to discharge: 70%

III. Evaluation

  1. Evaluate for complications (see below) in ICU Survivors after discharge and periodic intervals
  2. Medication Reconciliation (pre and post ICU admission)
    1. Consider restarting chronic medications that were stopped and not yet restarted at ICU discharge
    2. Evaluate medications started during hospitalization and continued at time of discharge
      1. Are medications to be continued longterm (e.g. advanced or modified therapy for chronic conditions)?
      2. Are medications intended for short-term use wih fixed duration (e.g. antiplatelet agents, Antibiotics)?
      3. Do new medications require additional monitoring (e.g. Electrolytes, weights on Diuretics)?
      4. Are new medications appropriate for the patient (e.g. medications on STOPP or Beers List)
  3. Advance Care Planning
    1. Discuss Advance Directive, POLST, Medical Directive, Living Will and Do-Not-Resuscitate (DNR)
    2. Does the patient have a Durable Power of Attorney

IV. Complications: General

  1. See Corona Virus 19 for Covid19 related complications
  2. Anemia Following ICU Admission
  3. Metabolic Bone Disease Following ICU Admission
  4. Neuromuscular Effects
    1. Myopathy Following ICU Admission
    2. Critical Illness Polyneuropathy
    3. Approach
      1. Both conditions (Neuropathy, Myopathy) present with Muscle Weakness and difficult Ventilator Weaning
      2. Electromyography (EMG) and Nerve Conduction Velocity Study, as well as Muscle biopsy differentiate these two
      3. Both conditions are reduced by early mobilization in the ICU
      4. Myopathy Following ICU Admission improves with physical therapy and Exercises
      5. Polyneuropathy responds poorly to physical therapy, but typically improves as medical disorders improve
  5. Malnutrition Following ICU Admission
    1. Evaluate pre and post ICU admission weight and Caloric Intake
    2. Reduced appetite is common (Dysgeusia, Dysphagia)
  6. Deconditioning and Decreased Mobility
    1. New post-ICU related functional limitations persist at one year in 20% of ICU survivors
    2. Assess functional capacity after discharge and at 2-3 months after ICU discharge (PT referral as needed)
    3. Encourage regular Exercise and self-guided physical rehabilitation or formal physical therapy
    4. Consider Myopathy Following ICU Admission, Critical Illness Polyneuropathy, as well as Fatigue Causes (see below)
  7. Fatigue Causes
    1. Anemia Following ICU Admission
    2. Malnutrition Following ICU Admission
    3. Insomnia
    4. Major Depression
    5. Muscle Atrophy, Deconditioning or Neuromuscular effects (see above)
    6. Medication adverse effects
  8. Alopecia
    1. Consider Telogen Effluvium (most common after major illness)
    2. Consider lab evaluation (e.g. TSH, CBC, Ferritin, ANA)
  9. Amenorrhea
    1. Consider Hypothalamic Amenorrhea (most common after Critical Illness)
    2. Consider lab evaluation (bHCG, as well as GnRH, LH, FSH, Estrogen)
  10. Stridor
    1. Consider post-intubation tracheal stenosis
  11. Dyspnea
    1. See Dyspnea Causes
    2. Consider exacerbation of condition that required ICU admission or other preexisting comorbidity
    3. Pulmonary Embolism
    4. Congestive Heart Failure
    5. Anemia
    6. Fatigue
    7. Deconditioning
    8. Neuromuscular disorder (see above)

V. Complications: Psychosocial

  1. Cognitive Impairment
    1. Persistent Cognitive Impairment is present in up to 20% of ICU Survivors
    2. Risk Factors include Hypotension, Hypoxia, hyperthermia, Delirium and some medications (Vancomycin, Quinolones)
    3. Sakusic (2018) Crit Care Med 46(12): 1977-84 [PubMed]
  2. Anxiety Disorder
    1. See Generalized Anxiety Disorder Scale (GAD-7)
    2. Mood Disorder is present in 12 to 43% of ICU survivors at discharge
  3. Post-Traumatic Stress Disorder (PTSD)
    1. See Post-Traumatic Stress Disorder Screening Tool
    2. PTSD is present in 7-20% of ICU Survivors at one year
    3. PTSD is also present in 18-31% of close family members (esp. female gender, mental illness, ICU patient previously healthy)
    4. Reduced risk of PTSD with ICU diary review while recovering
      1. Jones (2010) Crit Care 14(5): R168 [PubMed]
  4. Major Depression
    1. See Patient Health Questionaire 9 (PHQ-9)
    2. Present in up to 30% of ICU Survivors at one year (esp. with Fatigue, depressed appetite)
    3. PTSD is associated with Severe Major Depression
    4. Associated with increased mortality at 2 years after ICU discharge
  5. Sexual Dysfunction
    1. Present in up to nearly half of ICU survivors
    2. Consider PTSD, Anxiety and Major Depression
  6. Sleep Disorder (esp. Insomnia)
    1. Present in 10-61% of ICU survivors at 6 months after discharge
    2. Risk Factors include comorbid mental illness and ICU-related Opioid use
    3. Associated with decreased physical functioning and increased pain
    4. Insomnia Nonpharmacologic Management is preferred
      1. Cognitive Behavioral Therapy for Insomnia (CBT-I)
      2. Sleep Hygiene
      3. Relaxation Technique

VI. Resources

  1. ICU Statistics (Society of Critical Care Medicine)
    1. https://www.sccm.org/Communications/Critical-Care-Statistics

VII. References

  1. Griffiths (1999) BMJ 319: 427-9 [PubMed]
  2. Volk (2009) Am Fam Physician 79(6): 459-64 [PubMed]
  3. Wilbur (2021) Am Fam Physician 103(10): 590-6 [PubMed]

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