Post–Intensive Care Syndrome

From diagnosis to treatment

Background: Patients who have been treated in intensive care units (ICUs) display a multitude of physical, cognitive, and/or mental impairments that are collectively called post–intensive care syndrome (PICS). People with PICS have difficulty returning to everyday life.

Methods: In this narrative review, we present epidemiologic data, risk factors, and approaches to the prevention and treatment of PICS, along with the evidence supporting them. Preliminary findings on the prevalence of PICS and the frequency of treatment for it have been obtained at the PICS outpatient clinic at the Charité—Universitätsmedizin Berlin, where patients are evaluated three months after discharge from an ICU along the three domains of PICS: physical function, cognitive performance, and mental health. These findings yield an overall picture of the everyday reality of post-ICU patient care.

Results: Knowledge of the predisposing factors for PICS (sex, old age, pre-existing mental disorders) and of its precipitating factors (stressful experiences in the ICU, severity of illness, delirium), which may change over the course of treatment, enables clinicians to identify patients at risk of PICS and to pursue preventive strategies while they are still being treated in the ICU. Specialized aftercare consists of a wide variety of multidisciplinary treatments whose efficacy remains to be conclusively demonstrated. These include guidance by a physician, patient education, physiotherapy, psychosocial care, and self-help groups. According to the initial findings of the PICS outpatient clinic at the Charité, Campus Virchow Klinikum, 72% (298/417) of patients suffer from impairment in at least one PICS domain three months after discharge from an ICU. The analysis of treatment frequency revealed that half of all patients visited the PICS outpatient clinic in addition to their family physician’s practice in at least two three-month periods after their ICU discharge.

Conclusion: The specialized, multiprofessional care of patients who have been discharged from an ICU, and of their family members, requires an understanding of the complex pertinent risk factors and courses of illness. It would be desirable for cross-sector care strategies to be established with better integration of rehabilitative services, specialized aftercare facilities, nursing facilities, and primary care practices.

Cite this as: Denke C, Steinecke K, Krampe H, Boehnke DJ, Weiß B, Spies C: Post–intensive care syndrome: From diagnosis to treatment. Dtsch Arztebl Int 2026; 123: 1–7. DOI: 10.3238/arztebl.m2025.0145

Long-term health consequences of critical illness have been known many years and recently attracted special attention in the context of care for patients suffering from long COVID. Advances in intensive care medicine have resulted in increasing numbers of critically ill patients being treated in intensive care units (ICUs) and decreasing mortality rates (1, e1). Following ICU treatment, the primary goal of which is the acute treatment of organ dysfunction, patients are at risk of significant long-term impairment. These conditions are collectively referred to as post–intensive care syndrome (PICS) and defined as physical, mental and/or cognitive disorders which a patient develops for the first time after ICU treatment or which are aggravated after such treatment (2). The reported prevalence rates for PICS and its various symptom domains vary significantly because they depend on:

• ICU treatment-related diagnoses
• Present and past illnesses
• Instruments and times of measurement
• Assessed impairment domains.

An extensive study by Marra et al. (2018) found that 60% of survivors of critical illness suffered from impairment in at least one of the three PICS domains (physical function, cognitive performance, mental health) three and six months after discharge from ICU (3).

PICS is an acronym intended as an umbrella term that encompasses both disease-related and treatment-related impairments in very different symptom domains which require intensive treatment (2). This definition makes it difficult to clearly determine the cause of the symptoms based on diagnostic testing. Overall, PICS can be considered a chronic syndrome that patients may develop starting with the onset of critical illness and related ICU treatment and which can only be diagnosed and classified over its clinical course (4). PICS is not a diagnosis as such, but rather characterized by heterogeneous symptom complexes. The complexity of this syndrome is reflected in the wide variety of ICD-10/ICD-11 codes which are used when classifying its symptoms.

Over time, the multifactorial impairments experienced by survivors of critical illness have a negative impact on their physical and social functioning, economic situation and, ultimately, their quality of life (2, 5). Near relatives of these patients can also develop symptoms, in particular mental health-related problems, which start with the initiation of ICU treatment and the associated stress for family members; PICS-Family (PICS-F) is the term used for this condition (2).

The impairment of physical function is commonly described as Intensive Care Unit-Acquired Weakness (ICU-AW) or Critical Illness Myopathy (CIM)/Critical Illness Polyneuropathy (CIP). The prevalence of this condition varies between 14% and 80% (6, e2). Pain is reported by 14% to 77% of patients (7, e3). Dysphagia (10–50%), hearing loss (4.1%), and loss of vision (4.9%) as well as renal dysfunction are other commonly reported symptoms (8, e4).

The prevalence of cognitive impairment three months and six months after ICU treatment varies among these patients between 40% and 34–55%, respectively (9). Areas most affected are memory performance (13%), executive functions (49%), categorical-semantic verbal fluency (16%), and processing speed (48%) (9, e5, e6, e7). According to uncontrolled prospective observational studies, 20–46% of patients experienced anxiety, 33–40% depression and 7–22% post-traumatic stress disorder (PTSD) (3, e8, e9, e10).

The prevalence rates of PICS-Family also show significant variation. Clinically relevant depressive symptoms, anxiety, PTSD, and complicated grief were reported by 6–48.5%, 15–49.3%, 33.1–49.0%, and 5–46% of family members, respectively (10).

The development of post–intensive care syndrome

Various factors play a role in the development of long-term health effects of critical illness requiring ICU treatment. Furthermore, chronic critical illnesses can occur which, by definition, are persistent, severe, and life-threatening. There is also the possibility that such chronic illnesses require continuous treatment over a prolonged period of time (4). Whether symptoms are classified as PICS, chronic critical illness, or chronic illness depends largely on the patient‘s health status prior to ICU treatment and the courses of acute treatment and rehabilitation (4). It is, however, difficult to establish a definitive diagnosis during the course of the disease given the overlapping symptoms.

Risk factors

Despite the fact that the etiology of PICS is as diverse as the associated domains of impairment (1), numerous risk factors for the development of the syndrome over the course of treatment have now been identified. On the one hand, these factors can be the result of the predisposing health status of critically ill patients or, on the other hand, they can be associated with the acute clinical condition, the course of the illness during the ICU stay, and the treatment (precipitating factors) (Figure) (11).

Figure

Factors that increase the risk of developing post–intensive care syndrome (PICS) prior to treatment and throughout the course of treatment ARDS, acute respiratory distress syndrome; ICU, intensive care unit

A meta-analysis by Lee et al. (2020) identified 60 risk factors, of which 33 were predisposing factors and 27 were precipitating factors (12). Significant risk factors for mental impairment were female sex (odds ratio [OR] = 3.37), previous mental health problems (OR = 9.45) and psychologically stressful experiences in the intensive care unit (OR = 2.59).

Significant risk factors for physical impairment included older age (OR = 2.19), female sex (OR = 1.96), and high disease severity (OR = 2.54) (12).

Delirium was the only significant risk factor identified for cognitive impairment (OR = 2.85) (12).

Further systematic reviews and prospective studies found additional risk factors for all three PICS domains. Pre-existing anxiety disorder or post-traumatic stress disorder, lower levels of education, and alcohol abuse are considered risk factors for mental health problems following an ICU stay (10). Experiencing intensive care treatment is seen as an acutely stressful event (13, e11, e12). At the same time, the long-term physical and cognitive effects and the associated adjustment efforts required of patients are also considered factors contributing to the development of mental disorders (14).

Physical impairments resulting from intensive care unit stays, such as muscle weakness, were also found to be associated with the length of bed rest and duration of treatment (4). In addition, there is evidence from prospective cohort studies highlighting the role of pre-existing cognitive disorders, neurological disorders, ventilation, prolonged sedation, sepsis, and inflammatory responses in the development of cognitive impairment following ICU treatment (15, e5, e12, e13, e14).

Despite the fact that factors predisposing to PICS, such as age, female sex, previous mental illness, or other comorbidities, cannot be modified, they represent important parameters for identifying specific groups at risk of developing PICS.

Precipitating factors reflective of disease severity include pain, delirium, hypoxia, hypo-/hyperglycemia, mechanical ventilation, prolonged immobilization, deep or prolonged sedation, use of muscle relaxants, sepsis, acute respiratory distress syndrome (ARDS), and multiple organ dysfunction syndrome (MODS) (15, 16, e15, e16).

Recent studies analyzed the association between impairments and various inflammatory subphenotypes (hyper- and hypo-inflammatory) in sepsis-associated ARDS as well as markers of acute inflammation and coagulation markers during the acute phase of critical illness (17, e17). The study by Hashem et al. (2022), comparing the hyperinflammatory with the hypo-inflammatory subphenotype of ARDS, found no significant difference in 90-day survival and various domains of impairment between the two subphenotypes after six and twelve months. Apparently, the inflammatory subphenotype of ARDS mostly reflect the acute phase of the disease and its short-term effects, but not the resulting long-term impairments seen in PICS (17).

The risk factors start with acute treatment and continue through to rehabilitation (e.g., lack of documentation of symptoms over the course of rehabilitation treatment). Further aspects of treatment that increase the risk of PICS can be found in the Guideline on Multimodal Rehabilitation for Patients with PICS (18).

Prevention in the acute situation

Precipitating factors can be influenced by taking preventive measures (e18). The ABCDEF bundle is a strategy aimed at achieving optimum symptom control in the acute situation in order to improve the overall outcome of ICU treatment (19, e19). The ABCDEF bundle includes extensive measures

• To control pain, anxiety and sedation
• Use of sedation and weaning protocols
• Early mobilization
• Prevention of delirium
• Management of delirium
• Family engagement.

A multicenter study by Pun et al. (2019), involving over 15 000 patients, showed that consistent application of the bundle achieved improvements in key outcome parameters associated with later impairments (20). Examples include an increased probability of discharge from the ICU (adjusted hazard ratio [AHR] = 1.17) and a lower probability of delirium (AOR = 0.06), readmission to ICU (AOR = 0.54), and discharge outside home (AOR = 0.64) (20). Strict implementation of these preventive measures can help significantly reduce the development of PICS (21, e18, e20).

In addition, psychosocial approaches are used in the acute situation with the aim of stabilizing the patient’s mental state. They minimize stress during the period of acute treatment and offer strategies for successfully coping with physical and mental symptoms (22, e21). ICU diaries are part of this strategy. These diaries are kept by medical and nursing staff and family members for patients undergoing ICU treatment and help to retrospectively clarify missing memories and support coping with the ICU experiences (www.icu-diary.org/diary/start.html) (e22).

Approaches to the treatment of long-term consequences

Typically, intensive care treatment is followed by treatment in a regular ward and/or rehabilitation facility aimed at restoring or improving physical and psychosocial functioning (e23). This is usually followed by care provided by family physicians and, if necessary, specialists (23, e24).

Specialized aftercare facilities and PICS outpatient clinics are increasingly being established to support patients, depending on the severity of their illness, through various phases of rehabilitation and outpatient treatment on their way back to their home environment and, if possible, to the workplace. Cognitive and mental symptoms and organ dysfunctions are identified through interdisciplinary diagnostic assessments and treatment decisions are made based on these findings (23, 24). Here, it should be taken into account that patients’ needs vary significantly over the course of recovery (e25).

First intensive care follow-up facilities were established over a decade ago in the UK and the US (25, 26).While the need for these treatment options has repeatedly been voiced by patients with post-ICU impairments (27, e26, e27), there is a still a lack of randomized controlled trials providing evidence of the effectiveness of these measures (24). High drop-out rates, very heterogeneous patient populations, and monitoring of the clinical course using screening instruments not designed to measure severity could be reasons for the limited evidence available.

The ICU follow-up services/PICS outpatient clinics vary significantly with regard to their structure, the specialist disciplines available, the lengths of care periods and treatment options, as well as diagnostic instruments and diagnostic focus, making it difficult to assess their effectiveness and compare them with one another (24). The majority of studies on the effectiveness of follow-up care options are designed as observational studies; only a few RCTs were conducted (Table 1, eTable 1).In a meta-analysis pooling data from two RCTs, Jensen et al. (2015) showed that specialized ICU follow-up care reduced the risk of new onset of clinically relevant PTBS symptoms after three to six months (risk ratio = 0.49). However, this meta-analysis found no effects on health-related quality of life (HRQoL) and other outcomes (28).

Table 1

Focus areas of treatment for post–intensive care syndrome and findings from randomized controlled interventional studies

Follow-up care focuses on physiotherapy and education, individualized diagnostic evaluation, and treatment planning, for which findings from RCTs have already been published (Table 1). Furthermore, some RCTs found that self-help-supported multi-professional rehabilitative measures, in which family members are also involved, appear to bring about changes in certain domains of impairment (Table 1).

Of the seven RCTs presented in Table 1, four showed significant changes. Of course, increasing the sample size or intensifying the interventions could make these effects more noticeable. These interventions involve one or more of the therapeutic measures presented below.

Education

Education/psychoeducation significantly contributes to mental and physical stabilization. Aside from information about processing mechanisms for critical life events, necessary behavioral adjustments to physical, cognitive, and psychological changes, and socio-medical issues, developing coping strategies for dealing with inner tension, fears, depressive symptoms, changed performance limits or physical function is of particular importance. An observational study and an RCT found significant improvements in PTBS symptoms and both HRQoL and PTBS symptoms, respectively, achieved by these interventions (29, e28). Patients themselves considered access to information about PTBS symptoms to be a key factor in their recovery (e26).

Further medical treatment

Follow-up outpatient medical treatment by intensive care physicians, who, if necessary, perform examinations, provide referrals to specialists in other disciplines, and make adjustments to medication and prescriptions for outpatient treatments, was associated with a significant improvement in HRQoL, a reduction in mental health symptoms, and a reduction in overall impairment (30, 31, e29, e30, e31). The risk of hospital readmission also appears to be reduced by timely follow-up care (32). The holistic approach to treatment plays a central role here (Table 1, eTable 1).

The benefits of integrating follow-up care structures into the provision of intensive care lie in the continuity of care and the expertise of intensive care specialists regarding courses of ICU recovery and risks of renewed critical illness (11).

Physiotherapy

While physiotherapy treatment programs aimed at reconditioning can make a significant contribution to improving physical performance and overall satisfaction with treatment, they usually do not bring about a significant improvement in HRQoL when used as a unimodal treatment approach (33, 34, 35, e32, e33) (Table 1).

Peer Support

The benefits of sharing experiences with others in self-help groups are well supported by qualitative and descriptive data from research into coping with chronic disease (36, 37, e34). According to a systematic review by Haines, self-help resources can reduce the mental distress experienced by patients, both during acute treatment and after a critical illness (36).In addition, these options help to improve perceived self-efficacy as well as social support of affected individuals (36, e34). A qualitative study by McPeake et al. (2021) showed that patients perceived three key aspects as useful:

• Exchange of experiences
• Treatment debriefing
• Altruism (37).

Psychosocial care

Psychosocial care for patients focusses on coping with the experience of critical illness and ICU treatment (27, e26). This includes visiting the ICU, understanding treatment courses and developing coping strategies for dealing with physical symptoms and changed performance limits. In addition, strategies for dealing with clinically relevant symptoms of anxiety and depression can be tailored to the individual needs of patients. Counselling on social medical issues is also a key part of helping patients develop perspectives for their future.

Comprehensive multiprofessional follow-up care includes diagnostic assessment of the diverse domains of impairment over the clinical course and takes these findings into account when making treatment decisions. In addition, self-help options are made available and family members are integrated into the provision of follow-up care. According to the findings of observational studies and controlled interventional studies, this approach is associated with a significant improvement in HRQoL and clinically relevant symptoms of mental disorders (eTable 1) (e29, e30, e31, e35, e36).

Barriers to follow-up care

Despite the need for specialized follow-up care, especially patients with severe impairments and their families face barriers that make it difficult for them to access adequate long-term outpatient follow-up care (38). For example, patients with significant need for care do not return home or they cannot be contacted to arrange follow-up visits due to missing contact addresses or contact data. Furthermore, access to follow-up care services can be limited by cognitive impairments of patients with PICS. Thus, it is necessary to establish closely knit networks between follow-up care facilities and rehabilitation hospitals, specialized care facilities, and primary care physicians so that multi-professional exchange and cross-sector treatment strategies can be realized.

Preliminary findings from the PICS outpatient clinic at Charité

The PICS outpatient clinic of the Department of Anesthesiology and Intensive Care Medicine at Campus Virchow Klinikum (CVK) evolved from the Innofond ERIC project in which the long-term outcome following quality indicator-based, telemedicine-assisted intensive care treatment was one of the outcomes measured (39). In July 2020, this ICU follow-up care facility was established as part of the standard care offering. In this observational study, a standardized diagnostic procedure, comprising all PICS dimensions, was performed three months after discharge from ICU (13). From July 2020 to November 2023, 477 patients were treated for whom 434 (91%) evaluable screening results were available (Table 2, eTable 2). The data analysis revealed impairments in at least 3 PICS dimensions in 298 of the 417 patients (72%). The most commonly identified impairments were physical impairments, detected in 181/355 persons (51%). Mental health symptoms and cognitive impairments were noted in 173/366 (47%) and 112/364 (31%) of patients (Table 2). Of 437/477 persons (92%), treatment frequencies could be analyzed using the patient data management system. 55% of patients presented at the outpatient clinic for the first time or only once, and 30% presented two to three times. One in ten patients visited the PICS outpatient clinic four to six times, and 5% of patients required more visits (7 contacts and more).

Box

Conclusion for clinical practice

Table 2

PICS screening findings in patients of the PICS Outpatient Clinic (Charité Campus Virchow Klinikum) from July 2020 to November 2023

eTable 2

Patient characteristics of the patients of the PICS Outpatient Clinic (Charité Campus Virchow Klinikum) from July 2020 to November 2023

Overall, the findings of the PICS outpatient clinic at Charité showed that the majority of patients still had measurable impairments even three months after discharge from an ICU. Despite receiving care from their family physician, approximately half of these patients sought medium- to long-term multi-professional follow-up care. Consequently, developing and empirically evaluating cross-sector follow-up care services is a task for the health care system to be addressed in the future.

Funding
This study was financially supported by the Innovation Fund of the German Federal Joint Committee (G-BA, Gemeinsamer Bundesauschuss) 2017–2020 ERIC (01NVF16011).

Conflict of interest

The authors declare no conflict of interest.

Manuscript received on 10 February 2025, revised version accepted on 4 August 2025

Translated from the original German by Ralf Thoene, M.D.

Corresponding author
Prof. Dr. med. Claudia Spies

References

1. Paul N, Weiss B: Post-intensive care syndrome after critical illness: An imperative for effective prevention. J Clin Med 2022; 11: 6203

2. Needham DM, Davidson J, Cohen H, et al.: Improving long-term outcomes after discharge from intensive care unit: Report from a stakeholders‘ conference. Crit Care Med 2012; 40: 502–9

3. Marra A, Pandharipande PP, Girard TD, et al.: Co-occurrence of post-intensive care syndrome problems among 406 survivors of critical illness. Crit Care Med 2018; 46: 1393–401

4. Herridge MS, Azoulay É: Outcomes after critical illness. N Engl J Med 2023; 388: 913–24

5. Gupta L, Subair MN, Munjal J, et al.: Beyond survival: Understanding post-intensive care syndrome. Acute Crit Care 2024; 39: 226–33

6. Senger D, Erbguth F.: [Critical illness myopathy and polyneuropathy]. Med Klin Intensivmed Notfmed 2017]; 112: 589–96

7. Meyer-Frießem CH, Malewicz NM, Rath S, et al.: Incidence, time course and influence on quality of life of Intensive care unit-acquired weakness symptoms in long-term intensive care survivors. J Intensive Care Med 2021; 36: 1313–22

8. Heesakkers H, van der Hoeven JG, Corsten S, et al.: Clinical outcomes among patients with 1-year survival following intensive care unit treatment for COVID-19. JAMA 2022; 327: 559–65

9. Mikkelsen ME, Christie JD, Lanken PN, et al.: The adult respiratory distress syndrome cognitive outcomes study: Long-term neuropsychological function in survivors of acute lung injury. Am J Respir Crit Care Med 2012; 185: 1307–15

10. Inoue S, Hatakeyama J, Kondo Y, et al.: Post-intensive care syndrome: Its pathophysiology, prevention, and future directions. Acute Med Surg 2019; 6: 233–46

11. Emsden C, Steinecke K: Post-intensive-care-syndrom: Risikofaktoren, Prävention und Nachsorge. Journal Club AINS 2023; 12: 206–15

12. Lee M, Kang J, Jeong YJ: Risk factors for post-intensive care syndrome: A systematic review and meta-analysis. Aust Crit Care 2020; 33: 287–94

13. Spies CD, Krampe H, Paul N, et al.: Instruments to measure outcomes of post-intensive care syndrome in outpatient care settings—results of an expert consensus and feasibility field test. J Intensive Care Soc 2021; 22: 159–74

14. Kapfhammer HP: [Depressive, anxiety and posttraumatic stress disorders as long-term sequelae of intensive care treatment]. Nervenarzt 2016; 87: 253–63

15. Sasannejad C, Ely EW, Lahiri S: Long-term cognitive impairment after acute respiratory distress syndrome: A review of clinical impact and pathophysiological mechanisms. Crit Care 2019; 23: 352

16. Inoue S, Nakanishi N, Amaya F, et al.: Post-intensive care syndrome: Recent advances and future directions. Acute Med Surg 2024; 11(1): e929

17. Hashem MD, Hopkins RO, Colantuoni E, et al.: Six-month and 12-month patient outcomes based on inflammatory subphenotypes in sepsis-associated ARDS: secondary analysis of SAILS-ALTOS trial. Thorax 2022; 77: 22–30

18. Renner C, Jeitziner MM, Albert M, et al.: Guideline on multimodal rehabilitation for patients with post-intensive care syndrome. Crit Care 2023; 27: 301

19. Barr J, Fraser GL, Puntillo K, et al.: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263–306

20. Pun BT, Balas MC, Barnes-Daly MA, 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

21. Schaller SJ, Anstey M, Blobner M, et al.: Early, goal-directed mobilisation in the surgical intensive care unit: A randomised controlled trial. Lancet 2016; 388: 1377–88

22. Meraner V, Sperner-Unterweger B: [Patients, physicians and nursing personnel in intensive care units: Psychological and psychotherapeutic interventions]. Nervenarzt 2016; 87: 264–8

23. Schaller S, Paul N, Grunow J, Weiss B, Spies C: The post-ICU patient—management of long-term impairments after critical illness. 2020; 20: 275–82.

24. Schofield-Robinson OJ, Lewis SR, Smith AF, McPeake J, Alderson P: Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors. Cochrane Database Syst Rev 2018; 11: Cd012701

25. Griffiths JA, Barber VS, Cuthbertson BH, Young JD: A national survey of intensive care follow-up clinics. Anaesthesia 2006; 61: 950–5

26. Connolly B, Milton-Cole R, Adams C, et al.: Recovery, rehabilitation and follow-up services following critical illness: An updated UK national cross-sectional survey and progress report. BMJ Open 2021; 11: e052214

27. Farley KJ, Eastwood GM, Bellomo R: A feasibility study of functional status and follow-up clinic preferences of patients at high risk of post intensive care syndrome. Anaesth Intensive Care 2016; 44: 413–9

28. Jensen JF, Thomsen T, Overgaard D, Bestle MH, Christensen D, Egerod I: Impact of follow-up consultations for ICU survivors on post-ICU syndrome: A systematic review and meta-analysis. Intensive Care Med 2015; 41: 763–75

29. Peris A, Bonizzoli M, Iozzelli D, et al.: Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients. Crit Care 2011; 15: R41

30. Drewitz KP, Hasenpusch C, Bernardi C, et al.: Piloting an ICU follow-up clinic to improve health-related quality of life in ICU survivors after a prolonged intensive care stay (PINA): Feasibility of a pragmatic randomised controlled trial. BMC Anesthesiol 2023; 23: 344

31. Schmidt K, Worrack S, Von Korff M, et al.: Effect of a primary care management intervention on mental health-related quality of life among survivors of sepsis: A randomized clinical trial. JAMA 2016; 315: 2703–11

32. Bloom SL, Stollings JL, Kirkpatrick O, et al.: Randomized clinical trial of an ICU recovery pilot program for survivors of critical illness. Crit Care Med 2019; 47: 1337–45

33. Cuthbertson BH, Rattray J, Campbell MK, et al.: The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: A pragmatic randomised controlled trial. BMJ 2009; 339: b3723

34. Elliott D, McKinley S, Alison J, et al.: Health-related quality of life and physical recovery after a critical illness: A multi-centre randomised controlled trial of a home-based physical rehabilitation program. Crit Care 2011; 15: R142

35. Jones C, Eddleston J, McCairn A, et al.: Improving rehabilitation after critical illness through outpatient physiotherapy classes and essential amino acid supplement: A randomized controlled trial. J Crit Care 2015; 30: 901–7

36. Haines KJ, Beesley SJ, Hopkins RO, et al.: Peer support in critical care: A systematic review. Crit Care Med 2018; 46: 1522–31

37. McPeake J, Iwashyna TJ, Boehm LM, et al.: Benefits of peer support for intensive care unit survivors: Sharing experiences, care debriefing, and altruism. Am J Crit Care 2021; 30: 145–9

38. Haines KJ, Hibbert E, Leggett N, et al.: Transitions of care after critical illness-challenges to recovery and adaptive problem solving. Crit Care Med 2021; 49: 1923–31

39. Spies CD, Paul N, Adrion C, et al.: Effectiveness of an intensive care telehealth programme to improve process quality (ERIC): A multicentre stepped wedge cluster randomised controlled trial. Intensive Care Med 2023; 49: 191–204

40. Ali Abdelhamid Y, Phillips LK, White MG, Presneill J, Horowitz M, Deane AM: Survivors of intensive care with type 2 diabetes and the effect of shared-care follow-up clinics: The SWEET-AS randomized controlled pilot study. Chest 2021; 159: 174–85

e1. Society of Critical Care: Critical care statistics. 2022. https://sccm.org/communications/critical-care-statistics (last accessed on 30 May 2025).

e2. Fan E, Dowdy DW, Colantuoni E, et al.: Physical complications in acute lung injury survivors: A two-year longitudinal prospective study. Crit Care Med 2014; 42: 849–59

e3. Kemp HI, Laycock H, Costello A, Brett SJ: Chronic pain in critical care survivors: A narrative review. Br J Anaesth 2019; 123: e372–e84

e4. Zielske J, Bohne S, Axer H, Brunkhorst FM, Guntinas-Lichius O: [Dysphagia management of acute and long-term critically ill intensive care patients]. Med Klin Intensivmed Notfmed 2014; 109: 516–25

e5. Pandharipande PP, Girard TD, Jackson JC, et al.: Long-term cognitive impairment after critical illness. N Engl J Med 2013; 369: 1306–16

e6. Rawal G, Yadav S, Kumar R: Post-intensive care syndrome: An overview. J Transl Int Med 2017; 5: 90–2

e7. Hopkins RO, Weaver LK, Pope D, Orme JF, Bigler ED, Larson LV: Neuropsychological sequelae and impaired health status in survivors of severe acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 160: 50–6

e8. Nikayin S, Rabiee A, Hashem MD, et al.: Anxiety symptoms in survivors of critical illness: A systematic review and meta-analysis. Gen Hosp Psychiatry 2016; 43: 23–9

e9. Hatch R, Young D, Barber V, Griffiths J, Harrison DA, Watkinson P: Anxiety, depression and post traumatic stress disorder after critical illness: a UK-wide prospective cohort study. Crit Care 2018; 22: 310

e10. Jackson JC, Pandharipande PP, Girard TD, et al.: Depression, post-traumatic stress disorder, and functional disability in survivors of critical illness in the BRAIN-ICU study: A longitudinal cohort study. Lancet Respir Med 2014; 2: 369–79

e11. Parker AM, Sricharoenchai T, Raparla S, Schneck KW, Bienvenu OJ, Needham DM: Posttraumatic stress disorder in critical illness survivors: A metaanalysis. Crit Care Med 2015; 43: 1121–9

e12. Wade D, Hardy R, Howell D, Mythen M: Identifying clinical and acute psychological risk factors for PTSD after critical care: A systematic review. Minerva Anestesiol 2013; 79: 944–63.

e13. Girard TD, Thompson JL, Pandharipande PP, et al.: Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: A prospective cohort study. Lancet Respir Med 2018; 6: 213–22

e14. Wilcox ME, Brummel NE, Archer K, Ely EW, Jackson JC, Hopkins RO: Cognitive dysfunction in ICU patients: Risk factors, predictors, and rehabilitation interventions. Crit Care Med 2013; 41(9 Suppl 1):S81–98

e15. Duning T, van den Heuvel I, Dickmann A, et al.: Hypoglycemia aggravates critical illness-induced neurocognitive dysfunction. Diabetes Care 2010; 33: 639–44

e16. Girard TD, Jackson JC, Pandharipande PP, et al.: Delirium as a predictor of long-term cognitive impairment in survivors of critical illness. Crit Care Med 2010; 38: 1513–20

e17. Brummel NE, Hughes CG, Thompson JL, et al.: Inflammation and coagulation during critical illness and long-term cognitive impairment and disability. Am J Respir Crit Care Med 2021; 203: 699–706

e18. Hiser SL, Fatima A, Ali M, Needham DM: Post-intensive care syndrome (PICS): Recent updates. J Intensive Care 2023; 11: 23

e19. Marra A, Ely EW, Pandharipande PP, Patel MB: The ABCDEF bundle in critical care. Crit Care Clin 2017; 33: 225–43

e20. Schweickert WD, Pohlman MC, Pohlman AS, et al.: Early physical and occupational therapy in mechanically ventilated, critically ill patients: A randomised controlled trial. Lancet 2009; 373: 1874–82

e21. Deffner T, Rosendahl J, Niecke A: [Psychotraumatological aspects in intensive care medicine]. Med Klin Intensivmed Notfmed 2020; 115: 511–8

e22. Garrouste-Orgeas M, Coquet I, Périer A, et al.: Impact of an intensive care unit diary on psychological distress in patients and relatives. Crit Care Med 2012; 40: 2033–40

e23. Brown SM, Bose S, Banner-Goodspeed V, et al.: Approaches to addressing post-intensive care syndrome among intensive care unit survivors. A narrative review. Ann Am Thorac Soc 2019; 16: 947–56

e24. Svenningsen H, Langhorn L, Ågård AS, Dreyer P: Post-ICU symptoms, consequences, and follow-up: An integrative review. Nurs Crit Care 2017; 22: 212–20

e25. Lee CM, Herridge MS, Matte A, Cameron JI: Education and support needs during recovery in acute respiratory distress syndrome survivors. Crit Care 2009; 13: R153

e26. Prinjha S, Field K, Rowan K: What patients think about ICU follow-up services: A qualitative study. Crit Care 2009; 13: R46

e27. Sevin CM, Bloom SL, Jackson JC, Wang L, Ely EW, Stollings JL: Comprehensive care of ICU survivors: Development and implementation of an ICU recovery center. J Crit Care 2018; 46: 141–8

e28. Zatzick D, Jurkovich G, Rivara FP, et al.: A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors. Annals of Surgery 2013; 257: 390–9

e29. Henderson P, Quasim T, Asher A, et al.: Post-intensive care syndrome following cardiothoracic critical care: Feasibility of a complex intervention. J Rehabil Med 2021; 53: jrm00206

e30. Sayde GE, Stefanescu A, Hammer R: Interdisciplinary treatment for survivors of critical illness due to COVID-19: Expanding the post-intensive care recovery model and impact on psychiatric outcomes. J Acad Consult Liaison Psychiatry 2023; 64: 226–35

e31. Khan BA, Lasiter S, Boustani MA: CE: critical care recovery center: An innovative collaborative care model for ICU survivors. Am J Nurs 2015; 115: 24–31; quiz 4, 46

e32. McWilliams DJ, Atkinson D, Carter A, Foëx BA, Benington S, Conway DH: Feasibility and impact of a structured, exercise-based rehabilitation programme for intensive care survivors. Physiother Theory Pract 2009; 25: 566–71

e33. Major ME, Dettling-Ihnenfeldt D, Ramaekers SPJ, Engelbert RHH, van der Schaaf M: Feasibility of a home-based interdisciplinary rehabilitation program for patients with post-intensive care syndrome: The REACH study. Crit Care 2021; 25: 279

e34. Boehm LM, Drumright K, Gervasio R, Hill C, Reed N: Implementation of a patient and family-centered intensive care unit peer support program at a veterans affairs hospital. Crit Care Nurs Clin North Am 2020; 32: 203–10

e35. McPeake J, Shaw M, Iwashyna TJ, Daniel M, et al.: Intensive care syndrome: Promoting independence and return to employment (InS:PIRE). Early evaluation of a complex intervention. PLoS One 2017; 12: e0188028

e36. Henderson P, Quasim T, Shaw M, et al.: Evaluation of a health and social care programme to improve outcomes following critical illness: A multicentre study. Thorax 2023; 78(2): 160–8