Psychosocial, Behavioral & Cognitive · Topic 6 of 7

Post-Intensive Care Syndrome

Psychosocial · ICU survivorship

Post-Intensive Care Syndrome

New physical, cognitive or mental-health impairment after critical illness affects most ICU survivors; the ABCDEF bundle, every patient every day, is the prevention.

Key numbers

Most ICU survivors have a PICS problem56% at 12 months

01 · The numberMost ICU survivors have a PICS problem

After respiratory failure or shock, one or more PICS problems (new cognitive impairment, ADL disability or depression) were present in 64% of survivors at 3 months and 56% at 12 months.

02 · DoApply the ABCDEF bundle every day

The SCCM ICU Liberation (ABCDEF) bundle applies to every ICU patient daily: Assess, prevent and manage pain; Both awakening and breathing trials; Choice of analgesia and sedation; Delirium assess, prevent, manage; Early mobility; Family engagement.

03 · RiskICU delirium predicts lasting cognitive impairment

Delirium during the ICU stay is the strongest predictor of persistent cognitive dysfunction after critical illness, so delirium prevention is cognitive-PICS prevention (detail in the Delirium sheet).

What it is

Core idea

New impairment after critical illness, persisting post-discharge must knowPost-intensive care syndrome (PICS) = new or worsening physical, cognitive or mental-health impairment arising after critical illness and persisting beyond the hospital stay; PICS-F describes the same effect on family members.

Causes & risk factors

Why it happens

PICS risk: ventilation, delirium, immobility, frailtyPICS risk rises with mechanical ventilation, multiorgan failure, delirium, immobility, corticosteroids and neuromuscular blockers, longer ICU stay, premorbid cognitive or mental illness and frailty; more education is protective.

Engage the family to limit PICS-FFamily engagement is the F of the bundle; family PICS risk rises with limited ICU visiting, poor communication with ICU clinicians, perceiving the patient as near death, and lack of social support.

Diagnosis & monitoring

Work-up

Screen for delirium with a validated toolAssess critically ill adults regularly for delirium with a validated tool such as the CAM-ICU or ICDSC; prevention and treatment are covered in the Delirium sheet.

Management

Orders

Pair daily awakening and breathing trialsThe B of the bundle pairs a daily spontaneous awakening trial with a spontaneous breathing trial to shorten ventilation and sedative exposure (protocol details in Liberation from Mechanical Ventilation).

Prefer dexmedetomidine or propofol over benzodiazepinesFor ventilated adults, use propofol or dexmedetomidine rather than benzodiazepines; SCCM 2025 suggests dexmedetomidine over propofol when light sedation or less delirium is the priority.

Mobilize early and give enhanced rehabilitationSCCM 2025 suggests enhanced mobilization and rehabilitation over usual care; mobilization within 24–72 hours of ICU admission is linked to more ventilator-free days, shorter stay and greater strength at discharge.

Screen all three domains after dischargeScreen survivors and caregivers for physical, cognitive and mental-health deficits after the ICU and refer to rehabilitation and mental-health support; dedicated follow-up clinics have mixed trial results.

Red flags & don'ts

Avoid harm

ICU-acquired weakness: the main physical problem complicationICU-acquired weakness is the most common physical manifestation of PICS, affecting 25–75% of mechanically ventilated patients; fatigue, chronic pain and dysphagia also persist (see ICU-Acquired Weakness).

Depression, anxiety and PTSD after the ICU complicationThe mental-health domain of PICS is depression, anxiety and post-traumatic stress disorder; screen survivors with HADS (anxiety and depression), PHQ-9 or GAD-7, and IES-R for PTSD symptoms.

Cognitive deficits: executive function, attention, language complicationCognitive PICS includes executive dysfunction, attention, language and visuospatial deficits — from mild forgetfulness to dementia-level impairment — lasting months to years; screen with the MoCA once delirium has resolved.

The rules

Know these

Complete bundle use improves survival and deliriumIn the ICU Liberation Collaborative (> 15,000 adults), complete ABCDEF performance was linked to lower 7-day hospital death, next-day ventilation, coma, delirium, restraint use, ICU readmission and discharge to a facility, with a dose-response.

PICS in the patient or in the family?

Commonly confused

Domains	Physical, cognitive and mental health
Typical problems	ICU-acquired weakness, cognitive deficits, depression, anxiety, PTSD
Risk factors	Mechanical ventilation, delirium, immobility, multiorgan failure
ICU-phase prevention	ABCDEF bundle

More detail

Reference

Show 5 reference facts

Co-occurring PICS problems in two or more domains are less common: 25% at 3 months and 21% at 12 months; all three domains in only 4–6%.

ICU diaries are safe and valued, but evidence is inconsistent: they may ease anxiety or depression in some survivors and PTSD symptoms in relatives; pair them with access to psychological support.

Up to 23% of ICU survivors still have dysphagia 6 months after discharge; involve speech-language pathology early.

SCCM 2025 could not recommend for or against antipsychotics to treat ICU delirium or benzodiazepines to treat ICU anxiety, and conditionally suggests melatonin for ICU patients.

Higher-intensity active mobilization has not improved long-term outcomes over standard early mobilization and carried more adverse events; early, consistent mobilization is the goal.

Pearl

PICS prevention starts in the ICU: A-B-C-D-E-F, for every patient, every day.

Sources · Needham DM et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders' conference. Crit Care Med 2012;40:502–509 (abstract) · Post-intensive care syndrome: a state-of-the-art review. Singapore Med J 2026 · Marra A et al. Co-occurrence of post-intensive care syndrome problems among 406 survivors of critical illness. Crit Care Med 2018;46:1393–1401 · Pun BT et al. Caring for critically ill patients with the ABCDEF bundle: results of the ICU Liberation Collaborative in over 15,000 adults. Crit Care Med 2019;47:3–14 · Devlin JW et al. SCCM Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption (PADIS). Crit Care Med 2018;46:e825–e873 · Lewis K et al. A focused update to the SCCM PADIS guidelines (anxiety, agitation/sedation, delirium, immobility, sleep). Crit Care Med 2025 (and executive summary) · SCCM ICU Liberation Bundle (A–F) — elements and implementation for every ICU patient · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).