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Am Fam Physician. 2021;103(10):590-596

Published online February 2, 2021.

This clinical content conforms to AAFP criteria for CME.

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.

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.

ComplicationPotential causesEvaluation
AmenorrheaHypothalamic amenorrhea secondary to severe weight loss or major illnessGonadotropin-releasing hormone, luteinizing hormone, follicle-stimulating hormone, estrogen, and human chorionic gonadotropin measurements
AnxietyGeneralized anxiety disorder, PTSDAnxiety screening tool, such as General Anxiety Disorder-7 (available at https://www.mdcalc.com/gad-7-general-anxiety-disorder-7)
DeconditioningAnemia, critical illness myopathy or poly-neuropathy, muscle atrophy, malnutrition, drug therapyCBC, iron panel, serum chemistries, serial body weight measurements
Depressed moodMajor depressive disorder, familial anxiety or depression, frustration with slow recovery, drug therapy, PTSDDepression screening tool, such as the Patient Health Questionnaire (available at https://www.aafp.org/afp/2018/1015/p508.html)
FatigueAnemia, insomnia, depression, muscle atrophy, poor nutrition, drug therapy, hypoxiaCBC, iron panel, serum chemistries, serial body weight measurements, physical therapy, sleep/depression questionnaire, oxygen saturation
Hair lossTelogen effluvium secondary to severe weight loss or major illnessThyroid-stimulating hormone measurement, CBC, ferritin measurement, antinuclear antibody testing to rule out other causes
Impaired memory, poor concentration, nightmares, hallucinations, distressing flashbacks, hyperarousalPTSDPrimary Care PTSD Screen
InsomniaDepression, anxiety disorders, PTSDSleep/depression questionnaire
Mobility issuesCritical illness myopathy or polyneuropathy, joint pain, joint stiffness, muscle weakness, deconditioningPhysical therapy, neurology consultation
Peripheral neuropathy, numbness, paresthesiaCritical illness polyneuropathy, iatrogenic causes (e.g., needle injury)Neurology consultation, electromyography, nerve conduction velocity studies
Reduced appetiteAltered taste, swallowing difficulties, weakness of the pharyngeal muscles, drug therapy, psychological condition precluding patients from feeding themselvesSwallowing study
Shortness of breathNewly acquired cardiopulmonary pathologies (e.g., pulmonary embolism, heart failure) or worsening pre-ICU pulmonary or cardiovascular disease; anemia, neuropathy, muscle atrophy, psychological factorsImaging studies (e.g., chest radiography, chest computed tomography) if warranted, CBC, iron panel, reticulocyte count, pulmonary function tests, electrocardiography, echocardiography
StridorTracheal stenosisMagnetic 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.

In general, patients should be screened for weakness at follow-up and referred for physical rehabilitation when appropriate.58

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.911 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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