Introduction
People admitted to the intensive care unit (ICU) survive life-threatening illnesses. They often suffer long-term complications such as anxiety, depression, post-traumatic stress disorder, pain, impaired physical functions, multi-organ failure, etc. Some patients survive the ICU illness without any impairments, but some experience physical and mental complications that can be managed by proper follow-up after hospital discharge.
What Is Post-ICU Morbidity?
Morbidity refers to diseases, symptoms, or medical problems arising after treatment. Post-ICU morbidity refers to the new impairments in the physical, mental, and cognitive health arising after the critical illness, which continue after the discharge. According to the NICE (National Institute for Health and Clinical Excellence), patients who stay in critical care for more than four days are at risk of morbidity. They should have a rehabilitation program at post-discharge follow-up.
What Are the Risk Factors for Post-ICU Morbidity?
The risk factors associated with post-intensive care unit morbidity are categorized into pre-existing and ICU-related factors.
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Pre-existing Factors - Neurological diseases, old age, diabetes mellitus, hypertension, cardiovascular diseases, weak immune system, and psychiatric history.
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ICU-Related Factors - High dose of sedatives (drugs that induce sleep), sepsis (body’s extreme response to an infection), prolonged mechanical ventilation, immobility for a longer period, and administration of glucocorticoids (drugs that reduce inflammation and suppress the immune system) and neuromuscular blocking agents (potent muscle relaxants used after surgery to prevent muscle movements).
What Are the Types of Post - ICU Morbidity?
A short clinical assessment before discharge from critical care or during ward-based care helps to determine a patient’s risk of developing prolonged morbidities. The two types of post-ICU morbidities are:
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Physical Morbidity - Problems such as musculoskeletal problems, muscle loss, weakness of muscle, respiratory problems, pain, sensory impairments, difficulty in swallowing (dysphagia), and communication problems.
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Non-Physical Morbidity - psychiatric problems, emotional and psychological problems, and cognitive impairments.
What Are the Indications for the Patients at Risk of Post - ICU Morbidity?
The examples that indicate the patients at risk of post-ICU morbidity are:
Indications for Physical Morbidity
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Need help getting out of bed independently.
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Need help to move independently for short distances.
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Anticipation of long ICU stay.
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Physical injuries.
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Neurological injuries.
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Lack of cognitive functioning.
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Unable to exercise alone.
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Respiratory problems (unable to self-ventilate on 35% oxygen or less).
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Premorbid mobility problems.
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Poor or excessive appetite.
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Presence of malnutrition.
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Inability to eat and drink.
Indications for Non-Physical Morbidity
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Recurrent nightmares (when patients report trying to stay awake to avoid nightmares).
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Patients are not willing to talk about their illness or change the topic.
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Recurrent anxiety or panic attacks.
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Disturbing memories of traumatic events before the critical care admission (for example, road traffic accidents).
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Acute stress reactions.
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Fear, anger, or irritability in the critical care unit.
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Hallucinations (seeing or hearing something that is not real).
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Suspiciousness.
What Are the Symptoms of Post - ICU Morbidity?
The functional assessment of the patients shows symptoms of the patient having the risk of post-ICU morbidity. The symptoms are:
Physical Symptoms
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Physical problems include weakness, inability to sit or stand, inability to walk, fatigue, pain, breathlessness, inability to self-care, and incontinence.
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Sensory problems like vision and hearing changes and altered sensations.
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Communication problems such as speech difficulties, writing problems, and difficulties in using language to communicate.
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Patients in need of equipment such as mobility aids.
Non-Physical Symptoms
- Post-traumatic stress-related symptoms such as recurrent palpitations (rapid or irregular heartbeat), sweating, irritability, avoidance behavior, signs of derealisation (being detached from one’s surroundings) or depersonalization (feeling of being an outside observer of one’s life), tearfulness, withdrawal, nightmares, delusions, and flashbacks.
- Behavioral and cognitive symptoms include loss of memory, lack of attention, lack of organizational skills, confusion, apathy (feeling of not being interested in anything), disinhibition (poorly controlled emotions or actions), and compromised insight.
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Psychological and psychosocial symptoms such as low self-esteem, low self-image, body image issues, and relationship difficulties (with families and caregivers).
How to Manage Post-ICU Morbidity?
Prevention and management of post-ICU morbidity take place at the intensive care unit stay and after discharge, respectively. Most morbidities symptoms will improve by themselves and can be managed by rehabilitation. A multidisciplinary team analyzes the physical, mental, and cognitive sequelae to prevent and manage post-ICU morbidity and improve the survivors' quality of life. Post-ICU morbidity is prevented and managed by
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Rehabilitation - It is essential in preventing and managing critical illness-related morbidity. Physical rehabilitation improves early mobilization in the intensive care unit with advanced techniques like electrical muscle stimulation and cycle ergometry to prevent physical morbidities. Rehabilitation in the ICU involves simple actions such as sitting on a chair, sitting on the bed, and walking with help. After discharge from the ICU, rehabilitation can be hospital-based or home-based.
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Sedation and Pain Management - In the ICU, large doses of sedatives are given to the patients to calm them and reduce pain. Overuse of sedatives causes delirium. About two-thirds of patients in the intensive care unit suffer from delirium. They may be awake at night and sleep during the daytime. Lack of proper sleep causes psychological and mental-related morbidities. To prevent this, sedation scales and daily awakening trials control the overuse of sedatives. The sedation dose is reduced based on how well patients wake up daily and answer. The best way to treat psychological problems is through environmental change. Families and friends should help the patient to stay awake during day time by engaging them.
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Nutrition Care - Nutrition plays an important role in preventing post-critical morbidities and promoting the recovery of patients. Patients in the ICU do not get enough nutrients due to poor appetite. Nutritionists and dieticians help with the nutrition plan of the patients.
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Physiotherapy, respiratory therapy, occupational therapy, and infection control during the ICU stay and after the discharge is important for managing post-ICU morbidities.
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Post-Intensive Care Follow-up - A minimum of 20 to 30 minute follow-up appointments for two to three months after hospital discharge are important. Follow-ups of the physical sequelae and medication reviews are performed to manage the morbidities. Psychological sequelae are facilitated by a review of the clinical notes with the patients or their family members and a screening questionnaire by a clinical psychologist.
Conclusion
The importance of the outcomes following a critical illness is increasing. It requires appropriate processes to minimize post-intensive care unit morbidities. Technological innovation and expanded usage of telecommunication help to face the current challenges in managing patients with post-ICU morbidities.
