Post-intensive care syndrome: A crash course for general practice.

The inflammation, cerebral atrophy and reduced white matter integrity associated with delirium are hypothesised to underpin this process.3 Physical features ICU-acquired weakness is a serious complication affecting up to 50% of patients admitted to the ICU for at least one week.4 It is characterised by diffuse symmetrical limb and/or diaphragmatic weakness and is associated with increased mortality and long-term functional impairment.5 Major risk factors are prolonged mechanical ventilation, sepsis, organ failure and immobility.5 Undernutrition is another contributing factor, with ICU patients typically receiving only 60-80% of their enteral energy requirements.6 Rapid loss of weight and muscle bulk is associated with decreased mobility, patient fatigue and increased hospital length of stay.7 Malnourishment also impairs immune function, increasing risk of nosocomial infection and mortality.7 Furthermore, critical illness can lead to vitamin D deficiency and bone hyperresorption, with ICU survivors exhibiting decreased bone mineral density and significantly elevated Fracture Risk Assessment Tool (FRAX) scores at one-year follow-up.8 Long-term pulmonary dysfunction is another key issue. Lung function, measured with spirometry, typically improves by six months but can remain compromised for as long as five years.1 The trauma of critical illness can result in debilitating chronic pain, with one-year prevalence estimated at up to 77%.9 Studies examining health-related quality of life have consistently shown pain-related functional interference with activities of daily living at three and 12 months.9 Patients with physical sequelae of critical illness experience long-term impairment, and the consequent loss of agency can exacerbate psychological distress. The result is abnormal cognitive processing and a feeling of ongoing threat and vulnerability.12 Predisposing factors for psychological sequelae are younger age, female gender, pre-existing psychiatric conditions and socioeconomic variables such as unemployment and lower education level.1 Quality of life The amalgam of physical, cognitive and psychological symptoms in PICS can profoundly limit ICU survivors' functional independence and societal integration. COVID-19 factors increasing risk for PICS and PICS-F Cognition1819 * Potential virus-induced damage to the central nervous system * Secondary effects of systemic organ damage common in severe illness * Environmental factors exacerbating delirium * Depersonalised interactions with staff in frightening personal protective equipment * Limited human touch * Isolation from support networks, absence of reorientation and reassurance from loved ones, lack of shared experience * Iatrogenic factors * Prolonged mechanical ventilation, deep sedation, immobilisation Physical * ICU management of severe COVID-19 often involves protracted mechanical ventilation, deep sedation, neuromuscular blockade, proning and prolonged bed rest, increasing risk for:1 - ICU-acquired weakness - diaphragmatic dysfunction - post-extubation dysphagia - malnutrition * Chronic pain is more likely as acute pain is common in COVID-19:9 - painful sequelae of the disease such as myalgia, arthralgia, headache, abdominal and chest pain - iatrogenic pain from invasive procedures and neuropraxia from proning * Overstretched inpatient rehabilitation teams potentially delaying crucial early treatment Psychological * Patient-caregiver disconnect from infrequent communication or perceived lack of empathy from overburdened staff * Fear of infecting others, fear of social stigma, uncertainty regarding impact of global pandemic20 * Survivor's guilt20 * Disruptions to hospital religious or pastoral care services PICS-F19 * Prolonged separation from patient due to visiting restrictions * Inability to attend ICU and understand patient's care environment * Isolation from support systems due to social distancing * Discussing difficult or distressing subject matter with health professionals via telephone or teleconferencing * Inability to 'say goodbye' if bereaved, complicating grief ICU, intensive care unit;PICS, post-intensive care syndrome;PICS-F, post-intensive care syndrome-family correspondence ajgp@racgp.org.au References 1.