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Pharmacy Practice in Focus: Health Systems
Pharmacists Can Help Treat Post-Intensive Care Syndrome
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Managing transitions of care is vital to discontinue use of unnecessary drugs and minimize medication errors.
Post-Intensive Care Syndrome (PICS) comprises a series of ailments that patients experience upon discharge from the hospital following care for a critical illness.1,2
These ailments may be a new occurrence or worsening of a cognitive, mental, or physical health issue. From pain to anxiety and depression to difficulty concentrating and remembering, the manifestation of PICS varies.
The overall population of critical care patients who experience PICS is unknown; however, with improved survival rates and increased ventilator users, many discharged patients experience at least 1 problem associated with PICS. These patients often have trouble returning to their pre-illness state, with some never fully recovering. Resolution of symptoms is dependent upon both the patient and the symptom, with time frames of a few weeks to several years.
PICS can appear in any patient, regardless of demographics or environment. Severity of symptoms also differs, although some risk factors have been defined. Remaining within the intensive care unit (ICU), especially while intubated and sedated, is a major risk factor for developing PICS, which can also result from dysregulated blood glucose, respiratory distress syndrome, prolonged delirium, and sepsis while in the hospital.
Unfortunately, PICS is not exclusive to the patient and can similarly be experienced by caregivers. The patient’s family can develop anxiety, depression, and post-traumatic stress disorder, and maintenance of their well-being is a crucial objective. PICS can, however, be prevented, or at least managed, through close monitoring and interventions. Caregivers, family, and the medical team, including pharmacists, can involve themselves in the patient’s critical care journey to improve the care and prognosis of PICS.
Prevention
In terms of prevention, there are many factors to consider. Certain drugs used in the ICU have been found to be associated with PICS.1 Also, blood glucose levels are an important laboratory value to monitor in patients in the ICU because hyperglycemia has been found to be associated with increased morbidity and mortality.3
Generally, insulin is used to manage blood glucose levels if they become elevated. The clinical guidelines recommend targeting a glucose goal of approximately 140 mg/dL to 180 mg/dL.4 If glucose levels go beyond the recommended target, that is an indication to optimize the insulin dose.
Medications for the treatment of delirium that are a concern in the development of PICS. Antipsychotics not only have weak evidence in the prevention and treatment of delirium but, when used in the ICU, they also can potentially precipitate effects of delirium or other adverse effects and increase the patient’s chances of developing PICS.5 The best way to prevent delirium is through early mobilization. Another concern is that antipsychotics and other medications initiated in the ICU are often continued erroneously during transitions of care.
Disease States
In terms of comorbidities, pain and sedation are associated with an increased risk of developing PICS. When an individual is sedated for a long period of time, the likelihood of delirium increases, so light sedation using nonbenzodiazepines for the shortest amount of time is preferable. Also, in terms of pain management, nonopioid analgesics are preferred over opioid analgesics because opioids can also cause central nervous system depression and prolonged immobilization.
Monitoring these conditions closely is vital because any improvement in a patient’s status may warrant a dose reduction. Furthermore, pain should be monitored using validated pain scales, such as the Behavioral Pain Scale and the Critical-Care Pain Observation Tool. Monitoring pain helps improve patient experience and quality of life after discharge because individuals who recall pain in the ICU often develop chronic pain.6 Finally, in terms of monitoring sedation, the Richmond Agitation and Sedation Scale or another validated sedation assessment tool should be used.
Transitions of Care
Transitions of care (TOC) are an important aspect of prevention because medication errors during TOC are common.1 TOC can get complicated for a patient, especially if they are discharged with many different medications. Pharmacists can help by making sure that the medications prescribed to the patient are appropriate for the outpatient setting. Pharmacists can also screen for and discontinue any unnecessary medications to reduce the pill burden for patients. In addition, pharmacists can educate patients about the importance of medication adherence and how nonadherence can lead to the disease state worsening.
Treatment
Patients who develop PICS are treated based on their symptoms. If their minds are affected, they can be started on medications and therapy. If their physical states are affected, they may initiate exercise and physical therapy. If quality of life is affected, occupational therapy is an option.2
There are many avenues through which patients with PICS can heal, and PICS clinics are a promising way to start. These clinics are a developing idea in North America but are well established in Europe.7
Traditionally, the clinics include multidisciplinary teams that support patients who have shown at least 1 risk factor for PICS. These teams often include nurses, occupational and physical therapists, physicians, and social workers, but pharmacists can also play a big role by reviewing medications and counseling on adherence and proper use. Through pharmacists’ efforts, therapies can be optimized and mistakes such as potential interactions or unnecessary medications that fell through the cracks during TOC can be corrected.8
PICS clinics provide an invaluable opportunity to comfort and educate patients, continue care, and provide patients the opportunity to comment on and share their ICU and post-ICU experiences, empowering them in their care.
Conclusion
Patients requiring ICU care can experience impairments in normal bodily functions that make it difficult to perform self-care and participate in daily activities. This can have a detrimental effect on mental health and overall well-being, which can lead to a greater risk of hospitalization, institutionalization, and mortality.
It is critical to manage PICS with education, follow-up, and medication to lower the rate of these incidences and provide patients with a better quality of life once discharged from the ICU. Health care providers should participate in TOC to minimize the risks of medication error and discontinue unnecessary medications using proper guidelines and protocols. Health care providers should be aware of the risks of and treatments for PICS, not only to better serve patients, but also to help educate caregivers and family members so that they may continue to provide care outside the health care setting.
Winston Su, Olivia Wierciszewski, Kapil Rawal, and Chidambaranathan Sambath are PharmD candidates at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway.
Deepali Dixit, PharmD, BCPS, BCCCP, FCCM, is a clinical associate professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey.
REFERENCES
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