
Am Fam Physician. 2021;103(10):590-596
Published online February 2, 2021.
Author disclosure: No relevant financial affiliations.
More than 5 million patients in the United States are admitted to intensive care units (ICUs) annually, and an increasing percentage of patients treated in the ICU survive to hospital discharge. Because these patients require follow-up in the outpatient setting, family physicians should be prepared to provide ongoing care and screening for post-ICU complications. Risk factors for complications after ICU discharge include previous ICU admissions, preexisting mental illness, greater number of comorbidities, and prolonged mechanical ventilation or higher opioid exposure while in the ICU. Early nutritional support and mobilization in the ICU decrease the risk of complications. After ICU discharge, patients should be screened for depression, anxiety, insomnia, and cognitive impairment using standardized screening tools. Physicians should also inquire about weakness, fatigue, neuropathy, and functional impairment and perform a targeted physical examination and laboratory evaluation as indicated; treatment depends on the underlying cause. Exercise regimens are beneficial for reducing several post-ICU complications. Patients who were treated for COVID-19 in the ICU may require additional instruction on reducing the risk of virus transmission. Telemedicine and telerehabilitation allow patients with COVID-19 to receive effective care without increasing exposure risk in communities, hospitals, and medical offices.
More than 5 million patients in the United States are admitted to intensive care units (ICUs) annually.1 Mortality rates among these patients decreased by 35% between 1988 and 2012, despite increasing illness severity and increasing patient age; current mortality rates are estimated at 10% to 29%.1 Because a greater number of patients are surviving to ICU discharge and require follow-up in the outpatient setting, family physicians should be prepared to provide ongoing care and screening for post-ICU complications.
Clinical recommendation | Evidence rating | Comments |
---|---|---|
Patients should be screened for weakness after ICU discharge and referred for physical rehabilitation when appropriate.5–8 | B | Small randomized controlled trials and professional guideline |
Patients should be screened for cognitive impairment after ICU discharge.20–22 | C | Observational and retrospective cohort studies |
Patients should be screened for depression, anxiety,and posttraumatic stress disorder after ICU discharge.5,24,25 | C | Prospective cohort studies |
Partners and family members of patients discharged from the ICU should be screened for depression, anxiety, and posttraumatic stress disorder.27,28 | C | Prospective cohort studies |
With no universally accepted guidelines, the timing and frequency of post-ICU follow-up should be individualized and based on the patient's comorbidities and severity of illness. Although about 20 medical centers in the United States have post-ICU transition clinics,2 there is no evidence that such programs decrease readmission or mortality rates.3
Although the term post-ICU syndrome has been used to describe the various complications reported in ICU survivors (Table 14 ), there is no universally accepted definition for such a syndrome. Family physicians must be familiar with the complications that can occur after discharge (e.g., physical and psychological impairments), including in patients recovering from COVID-19.

Complication | Potential causes | Evaluation |
---|---|---|
Amenorrhea | Hypothalamic amenorrhea secondary to severe weight loss or major illness | Gonadotropin-releasing hormone, luteinizing hormone, follicle-stimulating hormone, estrogen, and human chorionic gonadotropin measurements |
Anxiety | Generalized anxiety disorder, PTSD | Anxiety screening tool, such as General Anxiety Disorder-7 (available at https://www.mdcalc.com/gad-7-general-anxiety-disorder-7) |
Deconditioning | Anemia, critical illness myopathy or poly-neuropathy, muscle atrophy, malnutrition, drug therapy | CBC, iron panel, serum chemistries, serial body weight measurements |
Depressed mood | Major depressive disorder, familial anxiety or depression, frustration with slow recovery, drug therapy, PTSD | Depression screening tool, such as the Patient Health Questionnaire (available at https://www.aafp.org/afp/2018/1015/p508.html) |
Fatigue | Anemia, insomnia, depression, muscle atrophy, poor nutrition, drug therapy, hypoxia | CBC, iron panel, serum chemistries, serial body weight measurements, physical therapy, sleep/depression questionnaire, oxygen saturation |
Hair loss | Telogen effluvium secondary to severe weight loss or major illness | Thyroid-stimulating hormone measurement, CBC, ferritin measurement, antinuclear antibody testing to rule out other causes |
Impaired memory, poor concentration, nightmares, hallucinations, distressing flashbacks, hyperarousal | PTSD | Primary Care PTSD Screen |
Insomnia | Depression, anxiety disorders, PTSD | Sleep/depression questionnaire |
Mobility issues | Critical illness myopathy or polyneuropathy, joint pain, joint stiffness, muscle weakness, deconditioning | Physical therapy, neurology consultation |
Peripheral neuropathy, numbness, paresthesia | Critical illness polyneuropathy, iatrogenic causes (e.g., needle injury) | Neurology consultation, electromyography, nerve conduction velocity studies |
Reduced appetite | Altered taste, swallowing difficulties, weakness of the pharyngeal muscles, drug therapy, psychological condition precluding patients from feeding themselves | Swallowing study |
Shortness of breath | Newly acquired cardiopulmonary pathologies (e.g., pulmonary embolism, heart failure) or worsening pre-ICU pulmonary or cardiovascular disease; anemia, neuropathy, muscle atrophy, psychological factors | Imaging studies (e.g., chest radiography, chest computed tomography) if warranted, CBC, iron panel, reticulocyte count, pulmonary function tests, electrocardiography, echocardiography |
Stridor | Tracheal stenosis | Magnetic resonance imaging of the neck or upper endoscopy |
Physical Considerations
DECONDITIONING
One year after ICU discharge, more than 20% of patients without functional limitations before admission experience some difficulty in completing activities of daily living.5 The National Institute for Health and Care Excellence recommends reassessing patients' physical function two to three months following discharge.6 Exercise and self-help rehabilitation programs improve muscle function and cardiopulmonary function after critical illness.7,8 Patients with deconditioning should be instructed on starting a home exercise regimen or referred to physical therapy.
CRITICAL ILLNESS POLYNEUROPATHY
Patients treated in the ICU are at risk of critical illness (or ICU-acquired) polyneuropathy, a disease of the peripheral nerves secondary to axonal degeneration. This condition is caused by complex and poorly understood processes that include microcirculatory abnormalities, metabolic derangements, and other factors.9–11 Critical illness polyneuropathy is diagnosed by the presence of limb weakness and unexplained difficulty in weaning from mechanical ventilation. Sepsis, prolonged mechanical ventilation, hyperglycemia, and multiorgan failure increase the risk of critical illness polyneuropathy.9,10
Although nerve function usually begins to improve when major medical issues are resolved, weakness and numbness may persist in severe cases. There is little evidence for physical rehabilitation or pharmacologic interventions in the treatment of critical illness polyneuropathy, but early mobilization in the ICU may improve mobility and muscle strength. 12,13 For painful polyneuropathy, gabapentin (Neurontin), pregabalin (Lyrica), or serotonin-norepinephrine reuptake inhibitors should be considered.
CRITICAL ILLNESS MYOPATHY
Critical illness (or ICU-acquired) myopathy also presents as muscle weakness and difficulty weaning from mechanical ventilation. The pathophysiology of critical illness myopathy is believed to be similar to that of critical illness polyneuropathy.10,11 Electromyography and nerve conduction velocity studies can assist with distinguishing between these two clinically similar diseases. Muscle biopsy is considered the diagnostic standard for critical illness myopathy.12 Unlike critical illness polyneuropathy, critical illness myopathy may improve with exercise. Early mobilization and physical therapy have the greatest evidence of benefit.10,11
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