Background
Methods
Level of evidence | According to OCEBM 2011 | Symbol |
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Evidence level 1 | Systematic review of randomized controlled studies | 1 |
Evidence level 2 | Randomized controlled study or observational study with dramatic effect | 2 |
Evidence level 3 | non-randomized controlled cohort study | 3 |
Evidence level 4 | case series, case-control studies, or historically controlled studies | 4 |
Evidence level 5 | Pathophysiological-mechanistic arguments | 5 |
Quality of evidence | In accordance to GRADE | |
---|---|---|
High quality | Further research is unlikely to affect our confidence in the estimation of the (therapeutic) effect | |
Medium quality | Further research is likely to affect our confidence in the estimation of the (therapeutic) effect and may alter the estimate | |
Low quality | Further research will most likely influence our confidence in the estimation of the (therapeutic) effect and will probably change the estimate | |
Very low quality | Any estimation of the (therapy) effect is very uncertain |
Recommendation grade | Wording | Symbol |
---|---|---|
Strong recommendation | Ought to/ought not to | A/A– |
Recommendation | Should/should not | B/B− |
Therapy option | Can be considered | 0 |
Results
Statement | |
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It is important to screen critically ill patients with a length of stay ≥ 48 h for risk factors to develop PICS and symptoms of PICS during the stay in intensive care, after discharge, during and at the end of rehabilitation, as well as in out-patient care. The choice of the optimal assessment depends on various factors such as the phase of the disease, the setting, the symptomatology, risk factors of the patient and the availability of further diagnostics | |
Recommendations and therapy options for PICS Rehabilitation | |
Rehabilitation of physical health | |
1. Early mobilization ought to be started within the first few days in the ICU, adapted to the patient's resilience and general condition. (A) | |
2. Supplemental use of ergometers (bed cycling) in addition to early mobilization can be considered. (0) | |
3. Wheelchair cycle ergometer training can be used in addition to the standard physical therapy to improve muscle strength and cardiovascular fitness. (0) | |
4. Strength training can be used as an adjunct to standard physical therapy to increase walking speed. (0) | |
5. Electrical stimulation of the ventral thigh musculature can be used to strengthen the muscles. (0) | |
6. Training of the inspiratory muscles using an inhalation trainer should be used to increase the strength of the inspiratory muscles and the quality of life in the short term as an adjunct to standard physical therapy. (B) | |
7. As dysphagia is frequent in patients with tracheostomy, standardized swallowing assessment should be performed before oral nourishment is initiated. (B) | |
Rehabilitation of cognitive health | |
8. Computer-based learning of attention functions and/or therapy aiming at improvement of cognition should be performed with critically ill patients and in further rehabilitation. (B) | |
9. Interventions for delirium prophylaxis ought to include multimodal sensory, cognitive and emotional stimulation (mobilization, purposeful stimulation and engagement, aids for orientation, contact to family members). (A) | |
10. Interventions for stress reduction (pain, anxiety, sleep, noise), improvement of communication and family care should be applied. (B) | |
11. A prophylactic treatment with Haloperidol for ventilated patients should not be implemented, as there is no effect in comparison to placebo regarding the incidence, severity, duration or outcome of delirium. (B-) | |
Rehabilitation of psychological health | |
12. Critically ill patients with adaptation disorders such as anxiety and depression benefit from psychological interventions. These should be offered already in the ICU and/or early rehabilitation and if possible also to relatives. (B) | |
13. Post-traumatic stress reactions should be treated by interventions such as psychoeducation and psychotherapy. (B) | |
14. Access to professional support and aftercare should be offered in the first 12 months after discharge aiming at mental stabilization. (B) | |
15. ICU diaries ought to be implemented for reducing the risks of symptoms of anxiety, depression, and PTSD in critically ill patients after discharge from the ICU. (A) | |
16. In post-ICU care, ICU diaries ought to be worked on with health care professionals. (A) |
Statement: Diagnosis of PICS
Physical rehabilitation
Early mobilization
Physical therapy
Grade of recommendation: 0 | Level of evidence: OECBM 2 | Quality of evidence: Low Selected reference: [40] |
Grade of recommendation: 0 | Level of evidence: OECBM 2 | Quality of evidence: Low Selected reference: [40] |
Grade of recommendation: 0 | Level of evidence: OECBM 2 | Quality of evidence: Low Selected reference: [41] |
Grade of recommendation: B | Level of evidence: OECBM 2 | Quality of evidence: Moderate Selected reference: [42] |
Dysphagia and removal of tracheostomy tubes
Cognitive rehabilitation
Cognitive therapies
Delirium prevention and therapy
Psychological rehabilitation
Psychotherapy
Grade of recommendation: B | Level of evidence: OECBM 2 | Quality of evidence: Low Selected reference: [66] |
Grade of recommendation: B | Level of evidence: OECBM 2 | Quality of evidence: Low Selected reference: [67] |
Grade of recommendation: B | Level of evidence: OECBM 2 | Quality of evidence: Low Selected reference: [68] |
ICU diaries
Grade of recommendation: A | Level of evidence: OECBM 1 | Quality of evidence: Moderate: Selected reference: [73] |
Discussion
Diagnosis of PICS |
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Which combination and timing of assessments are most valid, reliable, and feasible for detection, report and evaluation of different symptoms of PICS in patients who survive critical illness? |
Rehabilitation of physical health |
Early mobilization Which patients require what type of early mobilization, and how should its intensity be adapted during rehabilitation? What impact does early rehabilitation have on long-term outcomes? Does early mobilization prevent or reduce specific symptoms of PICS? What is the impact of pre-existing frailty on long-term outcome after discharge from ICU? |
Physical therapy What length and frequency of interventions (i.e. strength training etc.) optimize potential effects? Is device-assisted physical therapy (i.e. wheelchair cycle ergometers, electrical stimulation etc.) effective for specific subgroups of patients with PICS? |
Speech-Language-Therapy Do interventions, such as swallowing assessments, FEES, tracheostomy tube management, swallowing therapy lead to improvements of physical symptoms typical for PICS such as diminished coordination of respiration, swallowing and coughing, and/or swallowing function? |
Rehabilitation of cognitive health |
Cognitive therapy Do cognitive therapies (training of attention, computer-based training psychoeducation, virtual reality, goal management training) improve attention, memory, and executive functions in patients with PICS and those at risk for PICS? |
Non-pharmacological delirium prevention and therapy Effect of non-pharmacological interventions (i.e. stress reduction, pain reduction, reduction of sleep deprivation) versus standard or no therapy on cognitive functions or reduction of cognitive PICS symptoms, activities, and participation |
Pharmacological delirium prevention and therapy Effects of pharmacological interventions vs standard or no therapy on delirium reduction regarding incidence, duration, and cognitive outcome |
Rehabilitation of psychological health |
Psychotherapy:When does psychotherapy improve psychological symptoms typical for PICS such as anxiety, depression, and traumatization? |
ICU-diary When is the best time to read diaries, how to reach non-responders/patients who avoid reading their diary, and is there a different impact of diaries written by families compared to those written by healthcare professionals |