Post Intensive Care Syndrome: Symptoms, Types, Causes and Treatment

Surviving a critical illness and an intensive care unit (ICU) stay is a milestone, but for many patients and their families, the journey does not end at discharge. Post Intensive Care Syndrome (PICS) is a constellation of health problems that can persist for months or even years, affecting physical, cognitive, and psychological well-being. Understanding PICS is crucial for patients, families, and healthcare professionals to recognize, manage, and ideally prevent its long-term consequences.

Symptoms of Post Intensive Care Syndrome

Post Intensive Care Syndrome manifests in a range of symptoms that can affect every aspect of a survivor’s life. These symptoms can be subtle or severe, and often overlap, making recovery challenging and multifaceted.

Symptom	Description	Impact	Source(s)
Physical	Weakness, fatigue, pain, mobility issues	Daily function	2,4,5,7,8,9
Cognitive	Memory loss, attention deficits, confusion	Independence	2,3,4,5,7,8
Psychological	Anxiety, depression, PTSD, sleep disturbances	Quality of life	1,2,4,5,6,7,8,9

Table 1: Key Symptoms of PICS

Physical Symptoms

Physical impairments are among the most common and visible features of PICS. Patients may experience profound muscle weakness (ICU-acquired weakness), persistent fatigue, pain, and difficulty with mobility. These issues are often a result of prolonged bed rest, sedative medications, and the severity of the critical illness itself. Even after discharge, survivors may find daily activities—like walking, dressing, or climbing stairs—challenging. In some cases, these physical limitations can last for years and may never completely resolve 2,4,5,7,8,9.

Cognitive Symptoms

Cognitive dysfunction, sometimes referred to as "ICU brain," encompasses a range of problems including memory loss, attention deficits, difficulty with problem-solving, and mental slowness. These deficits can interfere with a person's ability to work, manage finances, or maintain relationships. Delirium during the ICU stay is a major risk factor for long-term cognitive decline. Some patients may develop symptoms resembling dementia, even if they were cognitively intact before their ICU admission 2,3,4,5,7,8.

Psychological Symptoms

Psychological distress is a core component of PICS. Anxiety, depression, and post-traumatic stress disorder (PTSD) are common, sometimes co-occurring, and can dramatically affect quality of life. Insomnia and nightmares are also reported. These symptoms are not limited to patients; family members (termed PICS-F) may also suffer significant psychological challenges, especially if they were involved in decision-making or witnessed distressing events 1,4,5,6,7,8,9.

Types of Post Intensive Care Syndrome

PICS is a broad syndrome, but it also encompasses distinct types and related conditions, affecting not only patients but also their families and even children.

Type	Definition	Who is Affected	Source(s)
PICS	Physical, cognitive, and psychological issues	ICU survivors	2,4,5,7,8
PICS-F	Psychological symptoms in family members	Family/decision-makers	1,5,12
PICS-p	PICS in pediatric patients	Children	8

Table 2: Types of PICS

Classic PICS (Adult Patients)

Traditional PICS refers to the collection of new or worsening physical, cognitive, and psychological health problems that arise after a critical illness and persist beyond hospital discharge. These may be single or multi-domain, and the constellation of symptoms can vary widely from person to person 2,4,5,7,8.

PICS-F (Family)

Family members can also suffer from the aftermath of an ICU experience. Termed PICS-F, this variant includes anxiety, depression, PTSD, and complicated grief among caregivers and family decision-makers. The emotional burden can be severe, especially when the ICU experience was traumatic or resulted in the death of a loved one 1,5,12.

PICS-p (Pediatric Patients)

Children who survive critical illnesses face unique challenges, as their brains and bodies are still developing. PICS-p refers to the physical, cognitive, and psychological sequelae in pediatric patients. The effects can be compounded by the child’s pre-existing conditions and the stage of development at the time of ICU admission 8.

Causes of Post Intensive Care Syndrome

The development of PICS is multifactorial, involving a complex interplay of patient-specific and ICU-related factors.

Cause	Mechanism/Trigger	Risk Group	Source(s)
ICU-acquired weakness	Immobility, muscle breakdown	Prolonged ICU stays	2,4,8
Delirium	Inflammation, sedation, hypoxia	Elderly, severe illness	2,6,8
Mental trauma	Stressful ICU events, fear	Patients/families	1,6,8,12
Disease severity	Organ failure, comorbidities	Critically ill, older age	2,6,8
Pre-existing conditions	Prior mental/physical illness	All with prior illness	1,6

Table 3: Causes of PICS

ICU-Acquired Physical Impairments

Prolonged immobility and inflammation during critical illness can lead to muscle wasting and ICU-acquired weakness. Mitochondrial dysfunction, impaired regeneration, and medication side effects (e.g., steroids, neuromuscular blockers) also contribute 2,4,8.

Delirium and Cognitive Decline

Delirium—a state of acute confusion common in the ICU—is a leading risk factor for long-term cognitive impairment. It is triggered by infection, hypoxia, metabolic disturbances, sedative medications, and sleep deprivation. Delirium’s impact on the brain can persist long after the underlying cause resolves 2,6,8.

Psychological Distress and Trauma

The ICU environment can be extremely stressful. Patients may experience terror, hallucinations, or nightmares, while families can be traumatized by witnessing suffering or having to make life-and-death decisions. A negative ICU experience or prior mental health issues greatly increase the risk of psychological symptoms post-discharge 1,6,8,12.

Disease Severity and Pre-Existing Conditions

Severe organ failure, longer ICU stays, advanced age, and pre-existing mental or physical health problems all elevate the likelihood of developing PICS. Some patients have a genetic or biological predisposition that makes them more vulnerable 1,2,6,8.

Treatment of Post Intensive Care Syndrome

Managing PICS requires a comprehensive, multidisciplinary approach that addresses all domains of the syndrome—physical, cognitive, and psychological. Early intervention and prevention are also key.

Treatment	Focus Area	Approach/Intervention	Source(s)
Early Rehabilitation	Physical	Mobilization, physical therapy	8,9,13
Delirium Prevention	Cognitive	ABCDEFGH bundle, minimize sedation	8,9
Psychological Support	Psychological	Counseling, ICU diaries, family involvement	1,9,12,13
Multidisciplinary Care	All	Rehabilitation teams, follow-up clinics	5,9,13
Family Interventions	Family (PICS-F)	Proactive communication, support groups	1,12

Table 4: Treatment Approaches for PICS

Early Rehabilitation and Physical Therapy

Early mobilization—even while patients are still in the ICU—can help prevent or reduce physical impairments. Physical therapy should continue after discharge, focusing on restoring strength, endurance, and function. Additional interventions include cycling, neuromuscular stimulation, and appropriate nutrition. Swallowing assessments are important to prevent aspiration 8,9,13.

Delirium Prevention and Cognitive Recovery

Prevention and early treatment of delirium are critical. The ABCDEFGH bundle (which includes assessment and management of pain, spontaneous awakening and breathing trials, choice of sedation, delirium monitoring, early mobility, family engagement, and good handoff communication) is recommended. Cognitive rehabilitation, such as attention training and memory exercises, can aid recovery 8,9.

Psychological Support and ICU Diaries

Integrating psychological care during and after ICU stays helps address anxiety, depression, and PTSD. ICU diaries—written by staff and family to help patients reconstruct their ICU experience—have shown promise in reducing psychological distress. Involving families in care, providing information, and offering counseling can improve outcomes for both patients and their loved ones 1,9,12,13.

Multidisciplinary and Long-Term Care

A coordinated approach involving physicians, nurses, physical therapists, occupational therapists, psychologists, and social workers is essential. Regular assessments for PICS symptoms should be performed throughout the recovery journey. Access to specialized rehabilitation clinics and follow-up programs supports sustained improvement 5,9,13.

Family-Focused Interventions (PICS-F)

Supporting family members with clear communication, involvement in care planning, and access to mental health resources can mitigate PICS-F. Structured family conferences and proactive information sharing are key; however, not all interventions are beneficial, and some—like condolence letters—may inadvertently worsen outcomes, highlighting the need for evidence-based approaches 1,12.

Conclusion

Post Intensive Care Syndrome is a complex, multifaceted condition that affects not only ICU survivors but also their families and, in some cases, children. It can lead to profound and lasting physical, cognitive, and psychological challenges.

Key Takeaways:

• PICS includes physical, cognitive, and psychological symptoms that may last for years 2,4,5,7,8.
• Types of PICS extend to family members (PICS-F) and children (PICS-p) 1,5,8,12.
• Major causes include ICU-acquired weakness, delirium, trauma, disease severity, and pre-existing health issues 1,2,4,6,8.
• Treatment is most effective when multidisciplinary, proactive, and individualized, focusing on early rehabilitation, delirium prevention, psychological support, and family engagement 1,5,8,9,12,13.

Awareness, early recognition, and comprehensive care are vital for improving the long-term outcomes of those affected by PICS and supporting their families on the road to recovery.