Post-Intensive Care Syndrome (PICS)

What post-intensive care syndrome is

More people survive critical illness than ever before. But surviving the ICU is often the start of a long recovery. The term PICS was introduced by critical care experts to describe the new or worsened impairments that remain after hospital discharge. They fall into three areas, and many people have problems in more than one.

Symptoms of PICS

Physical problems

• ICU-acquired weakness: profound weakness of the arms and legs from muscle loss and nerve damage during critical illness (critical illness myopathy and polyneuropathy). Muscle mass can fall rapidly during the first week of critical illness.
• severe fatigue and low stamina
• shortness of breath, especially after ARDS or pneumonia
• difficulty swallowing and a hoarse voice after a breathing tube
• joint stiffness, pain and numbness
• weight loss, hair loss and sleep problems
• loss of balance and falls

Cognitive problems

• poor short-term memory
• trouble concentrating and following conversations
• slower thinking and difficulty planning or multitasking

Cognitive impairment after ICU is common. In some studies, a large minority of survivors still had problems a year later comparable to mild dementia or a moderate brain injury. Delirium in the ICU is one of the strongest predictors.

Mental health problems

• anxiety
• depression
• post-traumatic stress disorder, often linked to frightening memories or hallucinations from the ICU, such as feeling trapped, unable to speak or attacked

Many survivors remember little of the real events but vivid, disturbing delusional memories.

PICS in family members (PICS-F)

Spouses, parents and children of ICU patients can develop anxiety, depression, complicated grief and PTSD, both during the ICU stay and for months after. Caregiving after discharge adds strain. Family members are encouraged to seek support for themselves too.

Causes and risk factors

PICS results from the illness itself and from the effects of intensive treatment:

• Severe illness: sepsis, acute respiratory distress syndrome (ARDS), major trauma, cardiac arrest, severe COVID-19
• Mechanical ventilation, especially for more than a few days
• Delirium during the ICU stay
• Prolonged bed rest and sedation
• Low blood oxygen, low blood pressure or low blood sugar during illness
• Inflammation affecting muscles, nerves and the brain
• Pre-existing problems, such as frailty, depression or anxiety

Diagnosis

There is no single test for PICS. A post-ICU clinic, primary care doctor or rehabilitation team assesses each area:

• muscle strength, walking speed and a 6-minute walk test
• swallowing assessment if eating is difficult
• cognitive screening tests such as the Montreal Cognitive Assessment (MoCA)
• questionnaires for anxiety, depression and PTSD
• review of medicines, nutrition, sleep and daily function

The NICE guideline on rehabilitation after critical illness recommends assessing physical and non-physical problems before discharge from the ICU and again 2 to 3 months later.

Treatment and recovery

Physical rehabilitation

Physical and occupational therapy rebuild strength, balance and endurance, starting in the hospital and continuing at home, in rehab centers or outpatient programs. Pulmonary rehabilitation helps breathlessness. Speech-language therapy helps swallowing and voice.

Cognitive rehabilitation

Memory aids, planners, routines and structured cognitive exercises help with everyday tasks. Returning to work is often best done gradually, with adjusted duties.

Mental health care

Trauma-focused talking therapies, cognitive behavioral therapy and, where needed, antidepressants treat anxiety, depression and PTSD. ICU survivor peer support groups help many people make sense of their experience.

Post-ICU follow-up clinics

Specialist clinics, available at some hospitals, bring doctors, nurses, therapists and psychologists together to review recovery, adjust medicines and coordinate care. Ask your ICU team whether one is available.

What helps at home

• Build activity gradually. Expect good and bad days.
• Eat enough protein and calories to rebuild muscle. A dietitian can help.
• Keep a sleep routine and limit daytime naps.
• Read an ICU diary if one was kept, or ask the ICU team to explain what happened, which can help fill memory gaps.
• Manage medicines with a pill organizer and written schedule.
• Do not drive until strength, reaction time and concentration have recovered, and your doctor agrees.

Prevention in the ICU

ICUs reduce PICS risk with the ABCDEF bundle promoted by the Society of Critical Care Medicine:

• Assess, prevent and manage pain
• Both spontaneous awakening and breathing trials
• Choice of sedation, using the lightest effective level
• Delirium: assess, prevent and manage
• Early mobility and exercise
• Family engagement, with relatives involved in care and decisions

ICU diaries written by staff and family can reduce later PTSD symptoms.

Outlook

Recovery is gradual. Many survivors see their biggest gains in the first 6 to 12 months, but some physical, cognitive or emotional problems last for years. Younger age, shorter ICU stays, less delirium and good support predict better recovery. Knowing that these problems are common and have a name helps patients and families seek the right help.

Frequently asked questions

What are the symptoms of post-intensive care syndrome?

Symptoms include severe muscle weakness, fatigue, breathlessness, swallowing difficulty, poor memory and concentration, anxiety, depression, nightmares and flashbacks. They appear after an ICU stay and can affect one or all three areas: physical, cognitive and mental health. They are new or clearly worse than before the illness.

How long does post-intensive care syndrome last?

It varies. Many people improve steadily over 6 to 12 months, especially with rehabilitation. Some problems, particularly fatigue, cognitive difficulties and PTSD, can persist for years. Regular follow-up helps identify problems that need targeted treatment rather than waiting for them to pass.

How common is PICS?

PICS is common. A large proportion of ICU survivors who needed mechanical ventilation or were treated for sepsis have at least one new physical, cognitive or mental health problem months after discharge. The risk is highest after long stays, delirium and severe illness.

Can family members get PICS?

Yes. PICS-Family (PICS-F) describes anxiety, depression, PTSD and complicated grief in relatives of ICU patients. Being involved in care in the ICU, open communication with staff and support after discharge can reduce the risk. Family members should seek help for their own symptoms.

Is PICS the same as PTSD?

No. PTSD is one part of PICS, affecting mental health. PICS is broader and also includes physical problems, such as ICU-acquired weakness, and cognitive problems, such as memory loss. A survivor can have PICS without PTSD, or PTSD alongside other PICS problems.