The FLARE Four
- Patients with COVID-19 who survive an ICU stay are at high risk of developing post-intensive care syndrome (PICS): new or worsened impairment in cognition, mental health and/or physical function that persists beyond hospital discharge
- Risk factors for PICS include acute respiratory distress syndrome, mechanical ventilation and prolonged periods of sedation, delirium and immobility
- During an ICU course, assessment and management of pain/agitation/delirium, minimization of sedation, spontaneous awakening and breathing trials, early mobilization and family engagement may improve patient and family outcomes
- After hospital discharge, post-ICU clinics and peer support groups can play an important role in supporting patients
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Most survivors of respiratory failure develop post-intensive care syndrome (PICS). PICS can persist for months to years and may severely impair quality of life. In a fast literature update posted on May 20, 2020, Anica Law, MD, a clinician at Beth Israel Deaconess Medical Center and former fellow in the Division of Pulmonary and Critical Care Medicine at Massachusetts General Hospital, describes PICS and the measures that potentially improve outcomes of COVID-19 patients who survive an ICU stay.
Background on PICS
PICS is generally defined as new or worsened impairment following a critical illness that persists beyond hospital discharge in at least one of three domains:
- Cognitive impairment
- Mood disorders: Most commonly anxiety, depression and post-traumatic stress disorder
- Physical impairment: ICU-acquired weakness; complications such as falls and inability to perform activities of daily living; may be compounded by malnutrition, weight loss or contractures
Risk factors for PICS include mechanical ventilation, shock, longer hospitalization, higher benzodiazepine dosages and prolonged periods of sedation, delirium and immobility. Severe sepsis and acute respiratory distress syndrome (ARDS), in particular, are associated with higher levels of impairment.
Given the number of COVID-19 patients experiencing critical illness, ARDS and long periods of sedation/immobility, clinicians should be prepared to support a large population of patients and families experiencing long-term impairments after the ICU.
Background on PICS-F
PICS-Family (PICS-F) refers to impairments in mental health among family or caregivers of ICU patients. Like PICS, it can last for months to years. Families may also need help with changes to interpersonal relationships and new caregiving roles.
Minimizing the Impact of PICS
Optimization of the long-term outcomes of critically ill COVID-19 patients begins in the ICU:
- Minimize sedation
- Use both spontaneous breathing and spontaneous awakening trials
- Assess and manage pain, agitation and delirium
- Protocolize ventilator liberation
- Involve family through telephone and videoconferencing
- Offer early physical and occupational therapy (nurse-directed if necessary)
Post-ICU clinics and peer support groups can also play an important role in supporting patients after COVID-19.
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