Question:

A 56-year-old, previously healthy man is admitted to the intensive care unit for acute respiratory distress syndrome due to viral pneumonia. The patient requires prolonged mechanical ventilation with deep sedation, prone positioning, and paralytic agents. He develops hypoactive delirium, which slowly improves with sedation washout. After 7 days, the patient is successfully extubated and discharged to a skilled rehabilitation center. A week later, he is participating in daily physical therapy. The patient requires 2-person assistance to stand due to diffuse weakness. He has been irritable and confused in the evenings and is prescribed zolpidem to assist with sleep. Montreal Cognitive Assessment score is 25/30, with deficits in attention and memory. Neurologic examination reveals flattened affect and mild psychomotor retardation. He is on extended sick leave from his job as an air traffic controller. Which of the following statements best represents this patient's long-term prognosis?

He is likely to have memory and concentration deficits for years

He is likely to have complete resolution of mood and sleep symptoms in 2 weeks

He is likely to require a wheelchair indefinitely

He is likely to require lifelong supplemental oxygen therapy

He is likely to require opportunistic infection prophylaxis for 6 months

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Explanation:

Post–intensive care syndrome
Pathophysiology & risk factors	Risk factors: ICU delirium, ARDS, prolonged mechanical ventilation Pathophysiology: CNS hypoxia, neuroinflammation & metabolic disruption
Clinical features	Psychiatric: >50% have major depression, PTSD Neurocognitive: ↓ attention/memory, executive function & processing speed Physical: >50% have ↓ mobility & independence
Management implications	Prevention: PT/OT as soon as the patient can participate safely Treatment: multidisciplinary post-ICU clinic, pharmacotherapy for psychiatric symptoms Prognosis*: most require additional home care & never return to work
Setting realistic recovery expectations is important during GOC discussions. ARDS* = acute respiratory distress syndrome; GOC = goals of care; ICU = intensive care unit; PT/OT = physical therapy/occupational therapy; PTSD = posttraumatic stress disorder.

Although advances in the intensive care unit (ICU) have improved survival for patients affected by critical illness, longitudinal follow-up shows that these patients are at risk for post–intensive care syndrome (PICS), which is characterized by chronic morbidities that can span the following 3 domains:

Psychiatric: Many patients develop major depression (eg, dysphoria, flat affect, psychomotor retardation, irritability, sleep disturbances) and/or posttraumatic stress disorder, with diagnoses that can occur within 5 years of the ICU stay; sleep disturbances are common, particularly in the first few weeks (Choice B).
Neurocognitive: Most patients have attention/memory deficits persisting for several years, with the average global cognition score falling by 1.5 standard deviations, similar to moderate traumatic brain injury.
Physical: A majority lose functional independence, requiring daily assistance for months to years. About 50% of patients require community-based rehabilitation services such as outpatient physical therapy. Mild global weakness may persist, but most patients are able to walk independently again (Choice C).

Most ICU survivors are impaired in ≥1 domains for several years, usually with major negative impacts on quality of life. PICS is a significant health concern: Many patients require chronic health services and are unable to return to work. These medical and financial burdens frequently extend to patients' families and caregivers.

The pathobiology of PICS remains unclear. Well-established risk factors include ICU delirium, sepsis, acute respiratory distress syndrome (ARDS), and prolonged mechanical ventilation. Therefore, injury to the CNS due to cellular hypoxia, metabolic disruption, and massive inflammation likely play important roles.

(Choice D) In most ARDS survivors, pulmonary function recovers fully over several months; 25% of patients have chronic mild impairments (restrictive defect and reduced diffusion), but long-term oxygen therapy requirements are uncommon.

(Choice E) After hyperinflammatory sepsis, immune cell exhaustion leads to a state of immunoparalysis for several weeks. This heightens susceptibility to nosocomial pathogens (eg, Enterococcus urinary tract infection, hospital-acquired pneumonia) associated with institutional care settings such as skilled rehabilitation centers. Asymptomatic reactivation of latent viruses (eg, incidental cytomegalovirus viremia) may also occur. However, immune function recovers, and patients do not require antimicrobial prophylaxis for classic opportunistic infections (eg, Pneumocystis) associated with chronic immunodeficiency.

Educational objective:
Survivors of critical illness are often burdened by chronic (ie, years) psychologic, neurocognitive, and physical deficits, resulting in a reduced quality of life referred to as post–intensive care syndrome (PICS). Acute respiratory distress syndrome, prolonged mechanical ventilation, and delirium are the major risk factors for PICS.