Follow-up program after intensive care unit discharge

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On the other hand, hypercapnic acidosis stimulates translocation of the ReIB antiinflammatory gene, and possibly reduces the translocation of p65 by inhibiting the canonic NF-kB pathway (B). Hypercapnic acidosis prevents apoptosis produced by mechanical overdistension, by inhibiting the MAPK ASK-1-JNK/p38 pathway, and reducing the levels of ASK-1, p38, JNK and caspase 3 (C). Hypercapnic acidosis delays alveolar edema clearance by inducing endocytosis of the Na+-K+-ATPase pump (D). ADAM-17: ADAM metallopeptidase 17; ASK-1: apoptosis signal-regulating kinase-1; EGFR: epidermal growth factor receptor; ERK: extracellular signal-regulated kinase; MAPK: mitogen-activated protein kinase; NF-kB: nuclear factor kappa B; PKA: protein kinase A. Courtesy of Contreras M. Curr Opin Anesthesiol 2015, 28:26–37.<a class="elsevierStyleCrossRef" href="#bib0690">69</a> Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. 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"apellidos" => "Estenssoro" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Clínica Olivos, SMG, Buenos Aires, Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Comité de Seguimiento y Rehabilitación, Sociedad Argentina de Terapia Intensiva (SATI), Argentina" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital San Martín de La Plata, La Plata, Argentina" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital Italiano de Buenos Aires, Buenos Aires, Argentina" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Clínica Basilea, Buenos Aires, Argentina" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Hospital Juan A. Fernández, Buenos Aires, Argentina" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Hospital Alejandro Posadas, Buenos Aires, Argentina" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Programa de seguimiento al alta de la unidad de cuidados intensivos" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 615 "Ancho" => 2167 "Tamanyo" => 116568 ] ] "descripcion" => array:1 [ "en" => "Flow-diagram of the Follow-up Program." ] ] ] "textoCompleto" => "IntroductionOver the last few years, the long-term consequences of critical disease have become more and more importance, due to the growing increase of life expectancy and the evolution of healthcare technologies that contribute to more patients being admitted to intensive care units (ICU) who survive the experience. These survivors suffer from important functional, psychological, and neurocognitive effects that have an impact on their health-related quality of life.<a class="elsevierStyleCrossRef" href="#bib0340">1</a> These effects were called PICS, which stands for post-intensive care syndrome, at the Conference of the Medical Society of Critical Care held back in the year 2010.<a class="elsevierStyleCrossRef" href="#bib0345">2</a> PICS develops quickly following the critical disease and it can last for up to 5 years<a class="elsevierStyleCrossRef" href="#bib0350">3</a> or even more after the acute period of hospitalization. This syndrome affects both the patients who had the disease and their families, which has been referred to as family PICS,<a class="elsevierStyleCrossRef" href="#bib0355">4</a> and is defined as the psychological consequences of the family member or care giver of a critically ill patient.Below we can find a description of the areas most impacted by the PICS that can be classified as physical (functional), mental, and neurocognitive.The physical complications after the ICU discharge are frequent and they can be classified as pulmonary and extrapulmonary, and they are maybe the main determinants, among other results, of the place of referral after the ICU discharge. In patients evaluated using pulmonary tests, a mild restrictive pattern was observed (that became normal 6 months after discharge) as well as the presence of an alteration in carbon monoxide diffusion, which improved over time, but it was not responsible for the fatigue patients exhibited.<a class="elsevierStyleCrossRef" href="#bib0340">1</a>The most common extrapulmonary consequence is muscle weakness, associated with reduced muscle mass, strength and endurance. The study conducted by Hermans et al.<a class="elsevierStyleCrossRef" href="#bib0360">5</a> it confirmed that ICU acquired weakness (ICUAW) was associated with less probability of weaning from mechanical ventilation (hazard ratio [HR], 0.709 [0.549–0.888]; P=.009), surviving the ICU (HR, 0.698 [0.553–0.861]; P=.008) and the hospital (HR, 0.680 [0.514–0.871]; P=.007) and higher mortality rate per year (30.6% vs. 17.2%; P=.015) compared to those who did not show muscle weakness. The risk of mortality per year was even greater if weakness was there even at ICU discharge (P=.001). Contracture-induced joint rigidity during the ICU stay is present in around 60% of the patients and it is a determinant factor in their capacity to walk independently after being discharged from hospital. Neuropathy entrapment, peripheral nerve damage, heterotopic ossifications, sexual dysfunction, dysphonia, voice changes, and cosmetic issues such as bed sores, transient alopecia, striations and scars are common complications that have an impact on the patient's functionality. They can be defined as the performance of Activities of Daily Living (ADL) of self-care and other Instrumental Activities of Daily Living (IADL) associated with autonomy, independence and competence. Chelluri et al.<a class="elsevierStyleCrossRef" href="#bib0365">6</a> observed that, a year after discharge, most of these patients showed some degree of autonomy in their basic ADL and still greater autonomy in the IADL. Similar results are described in a follow-up study conducted in Argentina<a class="elsevierStyleCrossRef" href="#bib0370">7</a> in which 51% of the patients still had some degree of dependence 3 months after leaving the ICU, while 33% were still dependent one year later.Finally, coming back to work or prior activities fully is perhaps the most relevant functional determinant factor for a patient's life after ICU discharge. This result involves not only the patient's physical recovery, but also their full psychological and neurocognitive recovery. In the study conducted by Herridge et al.,<a class="elsevierStyleCrossRef" href="#bib0340">1</a> only 49% of the patients came back to work within a year after ICU discharge; similar results were found in Argentina.<a class="elsevierStyleCrossRef" href="#bib0365">6</a>On the other hand, acknowledging psychological disorders as symptoms of anxiety, depression, post-traumatic stress syndrome (PTSD)<a class="elsevierStyleCrossRef" href="#bib0375">8</a> is crucial since all these disorders have a negative impact on health-related quality of life and they delay the come back to work. The presence of depression also increases the risk of suicide. Jones et al.<a class="elsevierStyleCrossRef" href="#bib0380">9</a> described a large number of symptoms and psychological disorders in ICU survivors, such as anxiety, depression, guilt, fear of death, swinging moods, irritability, nightmares, agoraphobia, panic attacks, social isolation, etc. The symptoms of depression that occurred the year after ICU discharge are common,<a class="elsevierStyleCrossRef" href="#bib0385">10</a> and they affect 28% (8%–57%) of the patients, a much higher incidence rate compared to the general population (7%–8%) and to those who suffered acute myocardial infarctions (14%) and maybe it is even greater since most studies excluded patients with a psychiatric history. The symptoms of anxiety occur in 24% (from 23 to 48%) of ICU survivors and PTSD in 22% (from 8 to 51%) of the critically ill patient populations. One in every 4 survivors will suffer from it, so its incidence rate is greater than that of the general population and similar to the one of those exposed to major traumas (3.5%). Evolution of the psychological symptoms over time varies: depressive symptoms improve within the first year, the symptoms of anxiety can persist beyond the first year and PTSD seems to remain stable. Over time, the problem tends to become chronic. The early diagnosis and treatment of PTSD can reduce its progression to chronicity.Brain dysfunction at the ICU is one of the most common forms of organ failure that affects critically ill patients and occurs in its acute form as delirium. Not only acute brain dysfunction is common here, but also the brain dysfunction that occurs after the critical disease in the form of neurocognitive impairment that may last for months and years and prevents coming back to the previous functioning level.The cognitive functions more commonly affected after ICU discharge are attention, memory and executive functions.<a class="elsevierStyleCrossRef" href="#bib0390">11</a> Like psychological alterations, the neurocognitive ones can only be identified at the ICU discharge if they are properly tested, since in most cases they are not evident at first sight as it would be the case with physical alterations. Above all cognitive disorders are relevant in young patients who survive their ICU stay. Different studies have shown that neurocognitive impairment affects between 20% and 80% of ICU survivors, depending on the diagnostic tests used and the population assessed. Memory, attention and concentration disorders are present in 78% of patients one year after discharge. At the same time, speed processing and executive functions are also altered. During the BRAIN ICU study,<a class="elsevierStyleCrossRef" href="#bib0395">12</a> we saw that 40% of the patients showed results that were consistent with moderate brain trauma and 26% a similar pattern to that of Alzheimer's disease. This pattern persisted in 24% and 34% of the patients at one year, respectively. In sum, cognitive impairment among ICU survivors affects over one third of the patients who were on mechanical ventilation.The presence of persistent chronic pain after the critical disease has been described in several studies. It can be present for over 11 years after ICU discharge, and one third of the patients require professional treatment to alleviate it<a class="elsevierStyleCrossRef" href="#bib0400">13</a> since it affects quality of life and ADL.<a class="elsevierStyleCrossRef" href="#bib0405">14</a>Nutritional (caloric and protein) deficiency sustained by patients at ICUs involves weight loss which, upon discharge, is around 20%. Recovery is slow and only 70% recover within a year of discharge.<a class="elsevierStyleCrossRef" href="#bib0340">1</a> During stay in the critical area around 2% of the lean muscle mass is lost per day, which is associated with protein and energy deficiencies. Recovering from weight loss is difficult, since patients suffer from reduction of appetite due to multiple causes such as depression, dyspnea, weakness, taste disorders, and/or swallowing disorders. The ICU stay-induced lack of teeth is another limiting factor to be able to recover from weight loss. In turn, nutritional deficiency conditions the survivors’ physical and functional rehabilitation.Quality of life among ICU survivors is significantly reduced in the months and years to come compared to the general population.<a class="elsevierStyleCrossRef" href="#bib0410">15</a> The impact on quality of life is associated with the above-mentioned physical, psychological and cognitive complications, along with chronic pain and the individuals’ social and family support. In turn, mortality in ICU survivors is different from that shown by the general population adjusted by sex and age. In their study, Williams et al.<a class="elsevierStyleCrossRef" href="#bib0415">16</a> conducted a 17- year follow-up of ICU survivor patients after their discharge and they proved that one year mortality was greater compared to the group of survivors (standardized mortality ratio [SMR]=2.90; 95%CI: 2.73–3.08) and it remained greater than that of the general population in each year for the following 15 years of the follow-up (SMR=2.01; 95%CI: 1.64–2.46).The effects of critical disease do not seem to derive directly from the characteristics of the disease that caused the patient to be admitted at the ICU or from its severity. This has been a cause for concern over the last 10 years among the international scientific community and several research lines have been developed to try to identify the consequences of critical disease and its possible risk factors. In addition, several randomized controlled trials (RCT) have been conducted to evaluate the effect that physical, psychological and neurocognitive rehabilitation has on improving the quality of life and physical and the psychological functionality among this group of patients. These trials have revealed variable results, they have been negative in some trials<a class="elsevierStyleCrossRefs" href="#bib0340">1,2,8–34</a> and positive in others.<a class="elsevierStyleCrossRefs" href="#bib0340">1–4,21–25</a> The last review published by the Cochrane Collaboration,<a class="elsevierStyleCrossRef" href="#bib0510">35</a> whose objective was to evaluate the long-term results of an ICU discharge rehabilitation program, revealed inconclusive results, partly due to the variability in the tools used to measure each domain and the results assessed in each trial. The conclusions from the review conducted by Jensen et al.<a class="elsevierStyleCrossRef" href="#bib0515">36</a> are similar; all the authors emphasize the need for standardizing the interventions and measuring the results in future trials.Requiring a post-intensive therapy multidisciplinary treatment in this group of patients is significantly greater than in the rest of the population<a class="elsevierStyleCrossRefs" href="#bib0520">37–39</a>; therefore, the use of healthcare resources and expenses is significant here.<a class="elsevierStyleCrossRef" href="#bib0535">40</a> The UK National Institute for Health and Care suggests an evaluation and follow-up program for patients that survive the ICU in their NICE guidelines (National Institute for Health and Care Excellence),<a class="elsevierStyleCrossRef" href="#bib0540">41</a> since between 10% and 40% of the patients who survive hospitalization suffer from re-hospitalizations within 30 and 180 days of hospital discharge which is associated with an increase of mortality and healthcare costs, in addition to being an objective of quality in some healthcare systems. In vulnerable populations such as the elderly,<a class="elsevierStyleCrossRef" href="#bib0545">42</a> psychiatric patients, heart failure,<a class="elsevierStyleCrossRef" href="#bib0550">43</a> who receive multiple drug treatments,<a class="elsevierStyleCrossRef" href="#bib0555">44</a> and chronic conditions<a class="elsevierStyleCrossRef" href="#bib0560">45</a> such as chronic obstructive pulmonary disease (COPD),<a class="elsevierStyleCrossRef" href="#bib0565">46</a> the post-hospitalization follow-up has proven to have a significant impact on the reduction of the number of re-hospitalization, and as a consequence, in the reduction of costs. However, this has not been generalized to all hospitalized patients, that is, post-hospitalization follow-up would not be justified for the entire population at hospital discharge, but only for those patients with increased risk of suffering from re-hospitalization. The patients who survive critical disease with requirements of mechanical ventilation make up a sub-group that is vulnerable to suffer from re-hospitalization,<a class="elsevierStyleCrossRef" href="#bib0570">47</a> since their quality of life is especially deteriorated as well as their functionality.<a class="elsevierStyleCrossRef" href="#bib0365">6</a> There are some trials that justify the implementation of follow-up programs in this sub-group with aimed at reducing re-hospitalizations,<a class="elsevierStyleCrossRefs" href="#bib0575">48,49</a> and the costs of the program are justified by their results.<a class="elsevierStyleCrossRef" href="#bib0585">50</a>The absence of a follow-up program makes the routine, close monitoring of patients at ICU discharge difficult, thus preventing the early detection of complications and their feasibility of treatment in an attempt to avoid new periods of hospitalization.The goal of the present document is to collect basic measures of results and the tools validated in Spanish included in a Follow-up Program that would allow the evaluation of patients at risk of presenting PICS at hospital discharge. This document considers the possibility of assessing additional results; however, its main goal is to outline a minimum evaluation standard of the most important results that can be accessed by healthcare professionals in Iberian America.MethodsThe Comité de Seguimiento y Rehabilitación de la Sociedad Argentina de Terapia Intensiva (Follow-up and Rehabilitation Committee of the Argentine Society of Intensive Care, SATI) summoned different inter-society committees involved with the issue of follow-up of survivors after ICU discharge in an attempt to design the guidelines of the Follow-up Program in patients at risk of developing PICS. The call was accepted by the Chapter of Kinesiology, the Nutrition Committee, the Critical Pneumology Committee, and the Mental Health Committee.A detailed bibliographic search was conducted in each area; then, five meetings and 3 discussion forums were held (according to the three PICS spheres: the physical, the psychological and the neurocognitive) among the different committee members in order to achieve consensus on the characteristics of the Follow-up Program. Randomized and controlled trials were included and selected during the bibliographic search for rehabilitation protocols upon discharge from ICU to assess the existing evidence and make the corresponding recommendation for each domain. The recommendations were made in accordance with the GRADE system.It was decided to include the following topics in the document (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> and <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Population meeting the inclusion criteria in the Follow-up Program</li><li class="elsevierStyleListItem" id="lsti0010">•Follow-up Frequency</li><li class="elsevierStyleListItem" id="lsti0015">•Personnel in charge of the Follow-up Program</li><li class="elsevierStyleListItem" id="lsti0020">•Basic domains to be assessed in the Follow-up Program and recommended tools for their evaluation</li><li class="elsevierStyleListItem" id="lsti0025">∘Survival</li><li class="elsevierStyleListItem" id="lsti0030">∘Physical Function</li><li class="elsevierStyleListItem" id="lsti0035">∘Mental Health</li><li class="elsevierStyleListItem" id="lsti0040">∘Pain</li><li class="elsevierStyleListItem" id="lsti0045">∘Cognitive Function</li><li class="elsevierStyleListItem" id="lsti0050">∘Quality of life</li><li class="elsevierStyleListItem" id="lsti0055">∘Nutrition</li><li class="elsevierStyleListItem" id="lsti0060">•Additional domains to be assessed in the Follow-up Program</li><li class="elsevierStyleListItem" id="lsti0065">∘Pharmacological therapy at ICU discharge</li><li class="elsevierStyleListItem" id="lsti0070">∘Swallowing</li><li class="elsevierStyleListItem" id="lsti0075">∘Assessment of pulmonary function</li><li class="elsevierStyleListItem" id="lsti0080">•Duration of the Follow-up Program</li></ul><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Population meeting the inclusion criteria in the Follow-up ProgramThis program was designed to follow up ICU patients that show at least 2 of the following criteria:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0085">–APACHE II score >14.</li><li class="elsevierStyleListItem" id="lsti0090">–Frailty upon admittance at the ICU<a class="elsevierStyleCrossRef" href="#bib0590">51</a>: according to the Clinical Frailty Scale CSHA (Clinical Frailty Scale, from the Canadian Study of Health and Aging).<a class="elsevierStyleCrossRef" href="#bib0595">52</a> The patients that show mild frailty when they are admitted may be included in the program (for their description, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>).</li><li class="elsevierStyleListItem" id="lsti0095">–Duration of invasive mechanical ventilation (IMV) or non-invasive mechanical ventilation (NIMV) greater than 7 days.</li><li class="elsevierStyleListItem" id="lsti0100">–Patients who cannot walk with assistance or show significant weakness at ICU discharge.</li><li class="elsevierStyleListItem" id="lsti0105">–ICU stays over 10 days.</li><li class="elsevierStyleListItem" id="lsti0110">–Patients who according to the opinion of their attending physician show indication of follow-up.</li><li class="elsevierStyleListItem" id="lsti0115">–Patients with a diagnosis of prior severe cognitive impairment or any condition that prevents rehabilitation will be excluded.</li></ul>In patients referred to rehabilitation or geriatric centers it will be possible to conduct the evaluation via phone call/email.Patients who meet the inclusion criteria for the Follow-up Program at ICU discharge should receive the follow-up sheet (see <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and the rehabilitation Manual. This manual was developed by Jones's<a class="elsevierStyleCrossRef" href="#bib0600">53</a> group at St Helens and Knowsley Hospital and it was translated by the SATI Follow-up and Rehabilitation Committee with the authorization of Christina Jones (see the follow-up manual in Spanish available at <a id="intr0010" class="elsevierStyleInterRef" href="https://www.sati.org.ar/index.php/areas-o/comites-o/comite-de-seguimiento-y-rehabilitacion-o/comite-de-seguimiento-y-rehabilitacion-produccion-academica">https://www.sati.org.ar/index.php/areas-o/comites-o/comite-de-seguimiento-y-rehabilitacion-o/comite-de-seguimiento-y-rehabilitacion-produccion-academica</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>RecommendationBased on the trials included, it is not possible to establish a recommendation about the population to be included in the follow-up (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Here the recommendation from our expert panel's: the patient should meet at least 2 of the aforementioned criteria to be included in the program. However, the follow-up is orientated to patients with a logical possibility of rehabilitation, that is, patients with effects so severe that cannot improve over time will be excluded, as well as those that, at hospital discharge, are almost in the exact same condition as before the ICU admission. This differentiation, though complex, is crucial to make an adequate selection of patients.Follow-up frequencyThe first meeting between the patient and the follow-up team should be held within the first month after hospital discharge to assess the different domains and eventually establish an early treatment. Patients showing alterations in the domains evaluated should be referred to the corresponding specialist, and they can have an appointment 6 months after hospital discharge. Patients that show no alterations can have an appointment 12 months after the discharge. Follow-up frequency can increase in case the attending team deems it necessary.RecommendationBased on the trials included, it is not possible to establish a recommendation about the frequency of the follow-up (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Our expert panel's recommendation is this: the patient can be given an appointment within a month after hospital discharge and, depending on the alterations observed it will be the subsequent frequency including a appointment one year after discharge.Personnel in charge of the Follow-up ProgramThe team in charge of the patient's follow-up at ICU discharge should know the complications associated with PICS and be capable of evaluating the different domains. This team should be made up of at least one physician and one kinesiologist. There is little evidence<a class="elsevierStyleCrossRef" href="#bib0605">54</a> that it would be beneficial for the attending physician to be trained in the critical area. Ideally, a psychologist and a nutritionist should join the team, but that will depend on the possibilities of each institution.RecommendationBased on the trials included, it is not possible to establish a recommendation about the personnel in charge of the follow-up (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Our expert panel's recommendation is this: the management of the PICS should be conducted via a multidisciplinary team led by a physician, preferably one trained in the critical area, and one kinesiologist. Ideally, a psychologist and a nutritionist could join the team.Basic domains to be assessed in the Follow-up Program and recommended tools for their evaluationAll the evaluations mentioned below are tests validated in Argentina or into Spanish language that can be applied by healthcare personnel not specialized in a specific area.SurvivalSurvival evaluation can be conducted via phone call or in person.RecommendationBased on the trials included, it is not possible to establish a recommendation about the impact of the follow-up programs on the patients’ survival at UCI discharge (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Experts’ recommendation: we consider that follow-up programs are useful for the assessment of survival, but data are insufficient to evaluate their impact.Physical functionPhysical function is one of the most compromised spheres at ICU discharge and it should be assessed during follow-up. There are several tests available and the following ones are the most highly recommended:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0120">–Six-minute Walk Test (6MWTM). The 6MWTM<a class="elsevierStyleCrossRef" href="#bib0610">55</a> evaluates comprehensively the response of the respiratory, cardiovascular, metabolic, musculoskeletal and neurosensory systems that an individual develops during exercise. This test can only be conducted in patients that can walk (for further details, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>). In those patients who cannot walk, the Katz index will be used here.</li><li class="elsevierStyleListItem" id="lsti0125">–Katz Index (KI): KI<a class="elsevierStyleCrossRef" href="#bib0615">56</a> evaluates the people's dependence/independence in 6 ADL: bathing (sponge, shower or bathtub), dressing, toileting, transferring, continence, and feeding. If the patient shows some degree of dependence in any of the ADL, motor rehabilitation will be indicated (for further details, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>).</li></ul>Another option for those who wish to make a more detailed evaluation is the following ones:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0130">–Test Timed Up and Go<a class="elsevierStyleCrossRef" href="#bib0620">57</a> (TUG): it requires the patients to get up from a chair, walk, turn around and walk back until they sit down again, while the examiner times how long it takes them to complete the test (for further details, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>).</li></ul>RecommendationBased on the trials included, it is not possible to establish a recommendation about the impact of the follow-up programs on the patients’ physical function (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).Experts’ recommendation: follow-up programs are recommended for assessing and rehabilitating physical function at ICU discharge. Patients showing a significant reduction of their physical function as evidenced by their dependence on any of the ADL, evaluated by the KI, or by their impossibility to walk by 6MWTM, should be referred to motor rehabilitation.Mental healthAccording to the most common complications found in this area, it is recommended to evaluate anxiety, depression and PTSD during follow-up after ICU discharge.<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0135">–Depression: to evaluate depression the score Hospital Anxiety and Depression Scale<a class="elsevierStyleCrossRef" href="#bib0625">58</a> (HADS) or the Beck Depression Inventory-II (BDI-II) can be used. The HADS, which is most commonly used, consists of 17 items. Scores over 7 points would be indicative of referral to psychiatry. The BDI-II<a class="elsevierStyleCrossRef" href="#bib0630">59</a> has a score that goes from 0 to 63; scores over 14 or 20 would be indicative of referral to psychiatry (for further details, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>).</li><li class="elsevierStyleListItem" id="lsti0140">–Anxiety: The Beck Anxiety Inventory (BAI)<a class="elsevierStyleCrossRef" href="#bib0635">60</a> assesses anguish or panic disorders and generalized anxiety with a score that goes from 0 to 63. Values over 11 would be indicative of referral to psychiatry (for further details, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>).</li><li class="elsevierStyleListItem" id="lsti0145">–PTSD: there are different tools to evaluate PTSD, among these we have the Impact of Event Scale<a class="elsevierStyleCrossRef" href="#bib0640">61</a> (IES) and the Impact of Event Scale-revised <a class="elsevierStyleCrossRef" href="#bib0645">62</a> (IES-R). The IES is made up of 15 items and 2 subscales that evaluate 2 of the 3 components of PTSD: intrusive thoughts and avoidance. The IES-R incorporates 7 new items (for a total of 22 items) and assesses the third component: the state of hyperarousal. Its use is not recommended for the diagnosis of PTSD; however, cut-off points are specified and suggest specific interviews. Scores ≥24 would be indicative of a clinical problem; scores ≥33 would be indicative of a probable PTSD diagnosis; and scores ≥37 would be indicative of a serious problem (for further details, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>).</li></ul>RecommendationBased on the trials included, it is not possible to establish a recommendation about the impact of the follow-up programs on the patients’ mental function (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).Experts’ recommendation: follow-up programs are recommended for assessing and rehabilitating mental function at ICU discharge. In patients showing depression confirmed through the HADS>7 or BDI-II>14–20, or anxiety confirmed by BAI with scores over 11 or PTSD confirmed by the EIE-R scale with scores over 24, referral to the area of psychiatry should be indicated.PainThe evaluation of pain should be included in the follow-up program since it is a frequent, limiting symptom in this group of patients. To evaluate pain question number 4 from the quality of life score Euroqol EQ-5D-3L should be used (see assessment of quality of life).RecommendationBased on the trials included, it is not possible to establish a recommendation about the impact of the follow-up programs on the patients’ pain (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Experts’ recommendation: follow-up programs are recommended to assess and treat pain at ICU discharge. Patients showing pain after answering question number 4 from the Euroqol EQ-5D-3L score on quality of life (see assessment of quality of life) should be referred to the corresponding specialist.Cognitive functionAssessing the cognitive function is a complex task and it requires the participation of specialists trained in this area. However, the early detection of cognitive disorders through simple tools can be useful in order to indicate early a timely referral to those specialized teams. We recommend the Montreal Cognitive Assessment<a class="elsevierStyleCrossRef" href="#bib0650">63</a> (MOCA) test for the assessment of the cognitive function by personnel that is not specialized in this field. This is a simple test that allows training in its application (for further details, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>).For those who wish to conduct a more thorough assessment, they can use the Repeatable Battery for the Assessment of Neuropsychological Status Update (RBANS® Update<a class="elsevierStyleCrossRef" href="#bib0655">64</a>) test, taking into consideration that its use is not cost-free.RecommendationBased on the trials included, it is not possible to establish a recommendation about the impact of the follow-up programs on the patients’ cognitive function (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Experts’ recommendation: follow-up programs are recommended to assess and rehabilitate cognitive function at ICU discharge. Patients showing cognitive deficiencies assessed by the MOCA test with values under 17 points should be referred to a specialist in cognitive therapy for their rehabilitation.Quality of lifeHealth-related quality of life questionnaires are tools to measure the physical, social and mental condition of a subject. The questionnaire recommended to assess the quality of life is Euroqol EQ-5D-3L<a class="elsevierStyleCrossRef" href="#bib0660">65</a> – a simple, generic tool with multiple-choice answers. It is widely accepted, and its use has spread to different patient populations admitted to the ICU. This questionnaire has been validated to be used via phone call and it has proven to be a reliable measuring tool with family members (in an indirect way). It allows us to make comparisons with the general population, since there is such a thing as the Argentine population's criteria.<a class="elsevierStyleCrossRef" href="#bib0665">66</a> A brief description appears in <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>. Questionnaire SF-36 can also be used, it has been translated into Spanish and it has proven to be a reliable tool to use in the population after ICU discharge. It allows more thorough assessments as it is a more comprehensive test.RecommendationBased on the trials included, it is not possible to establish a recommendation about the impact of the follow-up programs on the patients’ quality of life (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).Experts’ recommendation: follow-up programs are recommended to assess and rehabilitate quality of life at ICU discharge. The assessment can be conducted with either questionnaire, the EQ-5D 3L or the SF-36.NutritionAt ICU discharge patients generally show a deficient nutritional condition which justifies assessment. Validation of the Malnutrition Screening Tool (MST) has recently been published to be used within rehabilitation programs.<a class="elsevierStyleCrossRef" href="#bib0670">67</a> This tool takes into account weight loss and its cause and classifies patients as patients at nutritional risk or as patients who are not at nutritional risk.RecommendationBased on the trials included, it is not possible to establish a recommendation about the impact of the follow-up programs on the patients’ nutritional condition (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).Experts’ recommendation: follow-up programs are recommended to assess the nutritional condition at ICU discharge. Patients showing values ≥2 should be referred to the specialist for follow-up purposes (for further details, see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>). In addition, feeding through nasogastric tube or the ostomy bag is an indication for follow-up for the nutrition team.<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the domains to be evaluated during the follow-up, along with the tests validated in Spanish that can be used for its evaluation and the cut points often used to indicate referral to a specialist.Additional domains to be assessed in the Follow-up ProgramPharmacological therapy at the ICU dischargeThe detailed assessment of the pharmacological therapy received by the patient at hospital discharge is relevant in an attempt to adjust the drugs and their doses to the actual situation of the discharged patient.SwallowingIn patients with swallowing difficulties (coughing, wet voice, difficulty swallowing certain textures) it is possible to perform an evaluation of swallowing at the patient's bedside or request a video-deglutition examination to diagnose it properly and eventually treat it.Assessment of pulmonary functionPatients showing stridor or dyspnea at minimal or moderate efforts should be referred to the pulmonologist, so that they can conduct diagnostic studies to rule out lesions of the airways, that are so common in this population.Duration of the Follow-up ProgramThe time of the follow-up will vary from patient to patient. Stabilization of functions is the most relevant criterion to terminate the follow-up. Identifying the aforementioned stabilization will not always be easy to diagnose. The tests conducted during the follow-up will be, without doubt, a useful tool to assess the domains that are considered more important for the patients’ quality of life; if the results of the test do no vary substantially between one visit and the next, its termination could be considered.RecommendationBased on the trials included, it is not possible to establish a recommendation about the duration of the follow-up in patients at ICU discharge (see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).Experts’ recommendation: a minimum duration of one year of follow-up is recommended after ICU discharge.ConclusionsLongitudinal follow-up offices allow a multidisciplinary approach to PICS, whose goal is the early identification of alterations in physical and mental health as well as to discuss with family members goals of re-hospitalizations and palliative care, and other aspects. The adequate selection of the population to be included in the program, personalized follow-up and multidisciplinary approach are some key aspects of this program. None of the follow-up measures proposed has evidence of quality, which means that it was only possible to make experts’ recommendations in all the cases.FundingThis study has not been funded totally or partially.Conflicts of interestThe authors declare no conflicts of interest whatsoever." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1186044" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1105784" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1186045" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1105785" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Population meeting the inclusion criteria in the Follow-up Program" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Recommendation" ] ] ] 1 => array:3 [ "identificador" => "sec0025" "titulo" => "Follow-up frequency" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Recommendation" ] ] ] 2 => array:3 [ "identificador" => "sec0035" "titulo" => "Personnel in charge of the Follow-up Program" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Recommendation" ] ] ] 3 => array:3 [ "identificador" => "sec0045" "titulo" => "Basic domains to be assessed in the Follow-up Program and recommended tools for their evaluation" "secciones" => array:14 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Survival" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Recommendation" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Physical function" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Recommendation" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Mental health" ] 5 => array:2 [ "identificador" => "sec0075" "titulo" => "Recommendation" ] 6 => array:2 [ "identificador" => "sec0080" "titulo" => "Pain" ] 7 => array:2 [ "identificador" => "sec0085" "titulo" => "Recommendation" ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Cognitive function" ] 9 => array:2 [ "identificador" => "sec0095" "titulo" => "Recommendation" ] 10 => array:2 [ "identificador" => "sec0100" "titulo" => "Quality of life" ] 11 => array:2 [ "identificador" => "sec0105" "titulo" => "Recommendation" ] 12 => array:2 [ "identificador" => "sec0110" "titulo" => "Nutrition" ] 13 => array:2 [ "identificador" => "sec0115" "titulo" => "Recommendation" ] ] ] 4 => array:3 [ "identificador" => "sec0120" "titulo" => "Additional domains to be assessed in the Follow-up Program" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0125" "titulo" => "Pharmacological therapy at the ICU discharge" ] 1 => array:2 [ "identificador" => "sec0130" "titulo" => "Swallowing" ] 2 => array:2 [ "identificador" => "sec0135" "titulo" => "Assessment of pulmonary function" ] ] ] 5 => array:3 [ "identificador" => "sec0140" "titulo" => "Duration of the Follow-up Program" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0145" "titulo" => "Recommendation" ] ] ] ] ] 6 => array:2 [ "identificador" => "sec0150" "titulo" => "Conclusions" ] 7 => array:2 [ "identificador" => "sec0155" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0160" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-03" "fechaAceptado" => "2018-12-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1105784" "palabras" => array:3 [ 0 => "Post-intensive care syndrome" 1 => "Follow-up" 2 => "Follow-up clinic" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1105785" "palabras" => array:3 [ 0 => "Síndrome post terapia intensiva" 1 => "Seguimiento" 2 => "Programa de seguimiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionPatient follow-up after intensive care unit (ICU) discharge allows the early recognition of complications associated to post-intensive care syndrome (PICS). The aim of this project is to standardize outcome variables in a follow-up program for patients at risk of suffering PICS. MethodsThe Rehabilitation and Patient Follow-up Committee of the Argentine Society of Intensive Care Medicine (Sociedad Argentina de Terapia Intensiva, SATI) requested the collaboration of different committees to design the present document. A thorough search of the literature on the issue, together with pre-scheduled meetings and web-based discussion encounters were carried out. After comprehensive evaluation, the recommendations according to the GRADE system included in the follow-up program were: frequency of controlled visits, appointed healthcare professionals, basic domains of assessment and recommended tools of evaluation, validated in Spanish, and entire duration of the program. ConclusionThe measures herein suggested for patient follow-up after ICU discharge will facilitate a basic approach to diagnosis and management of the long-term complications associated to PICS." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónEl seguimiento de pacientes al alta de la unidad de cuidados intensivos (UCI) permite el reconocimiento precoz de las complicaciones asociadas al síndrome post terapia intensiva (SPTI). El objetivo de este estudio es la estandarización de medidas básicas de resultado incluidas en un programa de seguimiento de pacientes en riesgo de presentar SPTI. MétodosEl comité de Seguimiento y Rehabilitación luego de la Enfermedad Crítica de la Sociedad Argentina de Terapia Intensiva (SATI) convocó a diferentes comités para la redacción del presente documento. Se realizó una búsqueda bibliográfica, junto con reuniones y foros de discusión. Las recomendaciones incluidas en el programa de seguimiento según el sistema GRADE son: frecuencia de seguimiento, profesionales encargados del programa, dominios básicos a evaluar, herramientas recomendadas para su evaluación validadas al español y duración del programa. ConclusiónLas medidas recomendadas para el seguimiento de pacientes permiten establecer los lineamientos básicos para la identificación y tratamiento precoz de las complicaciones asociadas al SPTI." "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Busico M, das Neves A, Carini F, Pedace M, Villalba D, Foster C, et al. Programa de seguimiento al alta de la unidad de cuidados intensivos. Med Intensiva. 2019;43:243–254." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0170" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 615 "Ancho" => 2167 "Tamanyo" => 116568 ] ] "descripcion" => array:1 [ "en" => "Flow-diagram of the Follow-up Program." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1865 "Ancho" => 2295 "Tamanyo" => 324995 ] ] "descripcion" => array:1 [ "en" => "Follow-up sheet." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1102 "Ancho" => 3333 "Tamanyo" => 301442 ] ] "descripcion" => array:1 [ "en" => "GRADE system-based quality of evidence." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "The table shows the domains to be assessed during follow-up together with the tests validated into Spanish and the cut-off scores for every test that are indicative of referral to the specialist.ADL: activities of daily life; BAI: Beck Anxiety Inventory; BDI-II: Beck Depression Inventory-II; IES-R: Impact of Event Scale-revised; EQ5D: Euroqol EQ-5D; HADS: Hospital Anxiety and Depression Scale; MOCA: Montreal Cognitive Assessment; MST: Malnutrition Screening Tool; SF-36: Short Form 36." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Domains \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Test \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cut-off point for referral \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Interview \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="top">Physical function</td><td class="td" title="table-entry " align="left" valign="top">Índice de Katz \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inability to perform ADL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Test de caminata de 6 minutos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Inability to walk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="top">Mental function</td><td class="td" title="table-entry " align="left" valign="top">HADS \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score >7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BDI-II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score >14–20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BAI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score >11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IES-R \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score >24 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EQ5D question #3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Moderate pain \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cognitive function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MOCA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score <17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Quality of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">EQ5D SF-36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– – \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nutrition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">MST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Score ≥2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2022614.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Domains included in the Follow-Up Program." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Recommendations according to the GRADE system and based on randomized controled follow-up studies at ICU discharge. Evidence is categorized as very low, low, moderate, or high.GRADE: Grading of Recommendations Assessment, Development and Evaluation." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Items \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Follow-up population \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frequency of follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Professionals in charge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Physical function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Very low evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mental function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Very low evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cognitive function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Quality of life \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Very low evidence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nutrition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of the program \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No recommendation \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2022615.png" ] ] ] ] "descripcion" => array:1 [ "en" => "GRADE-based recommendation for the Follow-up Program." ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 1273427 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:67 [ 0 => array:3 [ "identificador" => "bib0340" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "One-year outcomes in survivors of the acute respiratory distress syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. 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Special article

Follow-up program after intensive care unit discharge

Programa de seguimiento al alta de la unidad de cuidados intensivos

M. Busicoa,b,

Corresponding author

marinabusico@yahoo.com.ar

Corresponding author.

, A. das Nevesb,c, F. Carinib,d, M. Pedaceb,d, D. Villalbab,e, C. Fosterb,f, J. García Urrutiab,g, M. Garbarinib,d, S. Jerebb,g, V. Sachah, E. Estenssorob,c

a Clínica Olivos, SMG, Buenos Aires, Argentina

b Comité de Seguimiento y Rehabilitación, Sociedad Argentina de Terapia Intensiva (SATI), Argentina

c Hospital San Martín de La Plata, La Plata, Argentina

d Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

e Clínica Basilea, Buenos Aires, Argentina

f Hospital Juan A. Fernández, Buenos Aires, Argentina

g Hospital Alejandro Posadas, Buenos Aires, Argentina

h Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Over the last few years&#44; the long-term consequences of critical disease have become more and more importance&#44; due to the growing increase of life expectancy and the evolution of healthcare technologies that contribute to more patients being admitted to intensive care units &#40;ICU&#41; who survive the experience&#46; These survivors suffer from important functional&#44; psychological&#44; and neurocognitive effects that have an impact on their health-related quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">1</span></a> These effects were called PICS&#44; which stands for post-intensive care syndrome&#44; at the Conference of the Medical Society of Critical Care held back in the year 2010&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">2</span></a> PICS develops quickly following the critical disease and it can last for up to 5 years<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">3</span></a> or even more after the acute period of hospitalization&#46; This syndrome affects both the patients who had the disease and their families&#44; which has been referred to as family PICS&#44;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">4</span></a> and is defined as the psychological consequences of the family member or care giver of a critically ill patient&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Below we can find a description of the areas most impacted by the PICS that can be classified as physical &#40;functional&#41;&#44; mental&#44; and neurocognitive&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The physical complications after the ICU discharge are frequent and they can be classified as pulmonary and extrapulmonary&#44; and they are maybe the main determinants&#44; among other results&#44; of the place of referral after the ICU discharge&#46; In patients evaluated using pulmonary tests&#44; a mild restrictive pattern was observed &#40;that became normal 6 months after discharge&#41; as well as the presence of an alteration in carbon monoxide diffusion&#44; which improved over time&#44; but it was not responsible for the fatigue patients exhibited&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The most common extrapulmonary consequence is muscle weakness&#44; associated with reduced muscle mass&#44; strength and endurance&#46; The study conducted by Hermans et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">5</span></a> it confirmed that ICU acquired weakness &#40;ICUAW&#41; was associated with less probability of weaning from mechanical ventilation &#40;hazard ratio &#91;HR&#93;&#44; 0&#46;709 &#91;0&#46;549&#8211;0&#46;888&#93;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;009&#41;&#44; surviving the ICU &#40;HR&#44; 0&#46;698 &#91;0&#46;553&#8211;0&#46;861&#93;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;008&#41; and the hospital &#40;HR&#44; 0&#46;680 &#91;0&#46;514&#8211;0&#46;871&#93;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;007&#41; and higher mortality rate per year &#40;30&#46;6&#37; vs&#46; 17&#46;2&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;015&#41; compared to those who did not show muscle weakness&#46; The risk of mortality per year was even greater if weakness was there even at ICU discharge &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;001&#41;&#46; Contracture-induced joint rigidity during the ICU stay is present in around 60&#37; of the patients and it is a determinant factor in their capacity to walk independently after being discharged from hospital&#46; Neuropathy entrapment&#44; peripheral nerve damage&#44; heterotopic ossifications&#44; sexual dysfunction&#44; dysphonia&#44; voice changes&#44; and cosmetic issues such as bed sores&#44; transient alopecia&#44; striations and scars are common complications that have an impact on the patient&#39;s functionality&#46; They can be defined as the performance of Activities of Daily Living &#40;ADL&#41; of self-care and other Instrumental Activities of Daily Living &#40;IADL&#41; associated with autonomy&#44; independence and competence&#46; Chelluri et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">6</span></a> observed that&#44; a year after discharge&#44; most of these patients showed some degree of autonomy in their basic ADL and still greater autonomy in the IADL&#46; Similar results are described in a follow-up study conducted in Argentina<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">7</span></a> in which 51&#37; of the patients still had some degree of dependence 3 months after leaving the ICU&#44; while 33&#37; were still dependent one year later&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally&#44; coming back to work or prior activities fully is perhaps the most relevant functional determinant factor for a patient&#39;s life after ICU discharge&#46; This result involves not only the patient&#39;s physical recovery&#44; but also their full psychological and neurocognitive recovery&#46; In the study conducted by Herridge et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">1</span></a> only 49&#37; of the patients came back to work within a year after ICU discharge&#59; similar results were found in Argentina&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">6</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">On the other hand&#44; acknowledging psychological disorders as symptoms of anxiety&#44; depression&#44; post-traumatic stress syndrome &#40;PTSD&#41;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">8</span></a> is crucial since all these disorders have a negative impact on health-related quality of life and they delay the come back to work&#46; The presence of depression also increases the risk of suicide&#46; Jones et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">9</span></a> described a large number of symptoms and psychological disorders in ICU survivors&#44; such as anxiety&#44; depression&#44; guilt&#44; fear of death&#44; swinging moods&#44; irritability&#44; nightmares&#44; agoraphobia&#44; panic attacks&#44; social isolation&#44; etc&#46; The symptoms of depression that occurred the year after ICU discharge are common&#44;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">10</span></a> and they affect 28&#37; &#40;8&#37;&#8211;57&#37;&#41; of the patients&#44; a much higher incidence rate compared to the general population &#40;7&#37;&#8211;8&#37;&#41; and to those who suffered acute myocardial infarctions &#40;14&#37;&#41; and maybe it is even greater since most studies excluded patients with a psychiatric history&#46; The symptoms of anxiety occur in 24&#37; &#40;from 23 to 48&#37;&#41; of ICU survivors and PTSD in 22&#37; &#40;from 8 to 51&#37;&#41; of the critically ill patient populations&#46; One in every 4 survivors will suffer from it&#44; so its incidence rate is greater than that of the general population and similar to the one of those exposed to major traumas &#40;3&#46;5&#37;&#41;&#46; Evolution of the psychological symptoms over time varies&#58; depressive symptoms improve within the first year&#44; the symptoms of anxiety can persist beyond the first year and PTSD seems to remain stable&#46; Over time&#44; the problem tends to become chronic&#46; The early diagnosis and treatment of PTSD can reduce its progression to chronicity&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Brain dysfunction at the ICU is one of the most common forms of organ failure that affects critically ill patients and occurs in its acute form as delirium&#46; Not only acute brain dysfunction is common here&#44; but also the brain dysfunction that occurs after the critical disease in the form of neurocognitive impairment that may last for months and years and prevents coming back to the previous functioning level&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The cognitive functions more commonly affected after ICU discharge are attention&#44; memory and executive functions&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">11</span></a> Like psychological alterations&#44; the neurocognitive ones can only be identified at the ICU discharge if they are properly tested&#44; since in most cases they are not evident at first sight as it would be the case with physical alterations&#46; Above all cognitive disorders are relevant in young patients who survive their ICU stay&#46; Different studies have shown that neurocognitive impairment affects between 20&#37; and 80&#37; of ICU survivors&#44; depending on the diagnostic tests used and the population assessed&#46; Memory&#44; attention and concentration disorders are present in 78&#37; of patients one year after discharge&#46; At the same time&#44; speed processing and executive functions are also altered&#46; During the BRAIN ICU study&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">12</span></a> we saw that 40&#37; of the patients showed results that were consistent with moderate brain trauma and 26&#37; a similar pattern to that of Alzheimer&#39;s disease&#46; This pattern persisted in 24&#37; and 34&#37; of the patients at one year&#44; respectively&#46; In sum&#44; cognitive impairment among ICU survivors affects over one third of the patients who were on mechanical ventilation&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The presence of persistent chronic pain after the critical disease has been described in several studies&#46; It can be present for over 11 years after ICU discharge&#44; and one third of the patients require professional treatment to alleviate it<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">13</span></a> since it affects quality of life and ADL&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Nutritional &#40;caloric and protein&#41; deficiency sustained by patients at ICUs involves weight loss which&#44; upon discharge&#44; is around 20&#37;&#46; Recovery is slow and only 70&#37; recover within a year of discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">1</span></a> During stay in the critical area around 2&#37; of the lean muscle mass is lost per day&#44; which is associated with protein and energy deficiencies&#46; Recovering from weight loss is difficult&#44; since patients suffer from reduction of appetite due to multiple causes such as depression&#44; dyspnea&#44; weakness&#44; taste disorders&#44; and&#47;or swallowing disorders&#46; The ICU stay-induced lack of teeth is another limiting factor to be able to recover from weight loss&#46; In turn&#44; nutritional deficiency conditions the survivors&#8217; physical and functional rehabilitation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Quality of life among ICU survivors is significantly reduced in the months and years to come compared to the general population&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">15</span></a> The impact on quality of life is associated with the above-mentioned physical&#44; psychological and cognitive complications&#44; along with chronic pain and the individuals&#8217; social and family support&#46; In turn&#44; mortality in ICU survivors is different from that shown by the general population adjusted by sex and age&#46; In their study&#44; Williams et al&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">16</span></a> conducted a 17- year follow-up of ICU survivor patients after their discharge and they proved that one year mortality was greater compared to the group of survivors &#40;standardized mortality ratio &#91;SMR&#93;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;90&#59; 95&#37;CI&#58; 2&#46;73&#8211;3&#46;08&#41; and it remained greater than that of the general population in each year for the following 15 years of the follow-up &#40;SMR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;01&#59; 95&#37;CI&#58; 1&#46;64&#8211;2&#46;46&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The effects of critical disease do not seem to derive directly from the characteristics of the disease that caused the patient to be admitted at the ICU or from its severity&#46; This has been a cause for concern over the last 10 years among the international scientific community and several research lines have been developed to try to identify the consequences of critical disease and its possible risk factors&#46; In addition&#44; several randomized controlled trials &#40;RCT&#41; have been conducted to evaluate the effect that physical&#44; psychological and neurocognitive rehabilitation has on improving the quality of life and physical and the psychological functionality among this group of patients&#46; These trials have revealed variable results&#44; they have been negative in some trials<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">1&#44;2&#44;8&#8211;34</span></a> and positive in others&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">1&#8211;4&#44;21&#8211;25</span></a> The last review published by the Cochrane Collaboration&#44;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">35</span></a> whose objective was to evaluate the long-term results of an ICU discharge rehabilitation program&#44; revealed inconclusive results&#44; partly due to the variability in the tools used to measure each domain and the results assessed in each trial&#46; The conclusions from the review conducted by Jensen et al&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">36</span></a> are similar&#59; all the authors emphasize the need for standardizing the interventions and measuring the results in future trials&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Requiring a post-intensive therapy multidisciplinary treatment in this group of patients is significantly greater than in the rest of the population<a class="elsevierStyleCrossRefs" href="#bib0520"><span class="elsevierStyleSup">37&#8211;39</span></a>&#59; therefore&#44; the use of healthcare resources and expenses is significant here&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">40</span></a> The UK National Institute for Health and Care suggests an evaluation and follow-up program for patients that survive the ICU in their NICE guidelines &#40;National Institute for Health and Care Excellence&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">41</span></a> since between 10&#37; and 40&#37; of the patients who survive hospitalization suffer from re-hospitalizations within 30 and 180 days of hospital discharge which is associated with an increase of mortality and healthcare costs&#44; in addition to being an objective of quality in some healthcare systems&#46; In vulnerable populations such as the elderly&#44;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">42</span></a> psychiatric patients&#44; heart failure&#44;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">43</span></a> who receive multiple drug treatments&#44;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">44</span></a> and chronic conditions<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">45</span></a> such as chronic obstructive pulmonary disease &#40;COPD&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">46</span></a> the post-hospitalization follow-up has proven to have a significant impact on the reduction of the number of re-hospitalization&#44; and as a consequence&#44; in the reduction of costs&#46; However&#44; this has not been generalized to all hospitalized patients&#44; that is&#44; post-hospitalization follow-up would not be justified for the entire population at hospital discharge&#44; but only for those patients with increased risk of suffering from re-hospitalization&#46; The patients who survive critical disease with requirements of mechanical ventilation make up a sub-group that is vulnerable to suffer from re-hospitalization&#44;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">47</span></a> since their quality of life is especially deteriorated as well as their functionality&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">6</span></a> There are some trials that justify the implementation of follow-up programs in this sub-group with aimed at reducing re-hospitalizations&#44;<a class="elsevierStyleCrossRefs" href="#bib0575"><span class="elsevierStyleSup">48&#44;49</span></a> and the costs of the program are justified by their results&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">50</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The absence of a follow-up program makes the routine&#44; close monitoring of patients at ICU discharge difficult&#44; thus preventing the early detection of complications and their feasibility of treatment in an attempt to avoid new periods of hospitalization&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The goal of the present document is to collect basic measures of results and the tools validated in Spanish included in a Follow-up Program that would allow the evaluation of patients at risk of presenting PICS at hospital discharge&#46; This document considers the possibility of assessing additional results&#59; however&#44; its main goal is to outline a minimum evaluation standard of the most important results that can be accessed by healthcare professionals in Iberian America&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Methods</span><p id="par0080" class="elsevierStylePara elsevierViewall">The Comit&#233; de Seguimiento y Rehabilitaci&#243;n de la Sociedad Argentina de Terapia Intensiva &#40;Follow-up and Rehabilitation Committee of the Argentine Society of Intensive Care&#44; SATI&#41; summoned different inter-society committees involved with the issue of follow-up of survivors after ICU discharge in an attempt to design the guidelines of the Follow-up Program in patients at risk of developing PICS&#46; The call was accepted by the Chapter of Kinesiology&#44; the Nutrition Committee&#44; the Critical Pneumology Committee&#44; and the Mental Health Committee&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">A detailed bibliographic search was conducted in each area&#59; then&#44; five meetings and 3 discussion forums were held &#40;according to the three PICS spheres&#58; the physical&#44; the psychological and the neurocognitive&#41; among the different committee members in order to achieve consensus on the characteristics of the Follow-up Program&#46; Randomized and controlled trials were included and selected during the bibliographic search for rehabilitation protocols upon discharge from ICU to assess the existing evidence and make the corresponding recommendation for each domain&#46; The recommendations were made in accordance with the GRADE system&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">It was decided to include the following topics in the document &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> and <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Population meeting the inclusion criteria in the Follow-up Program</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Follow-up Frequency</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Personnel in charge of the Follow-up Program</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0110" class="elsevierStylePara elsevierViewall">Basic domains to be assessed in the Follow-up Program and recommended tools for their evaluation</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8728;</span><p id="par0115" class="elsevierStylePara elsevierViewall">Survival</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8728;</span><p id="par0120" class="elsevierStylePara elsevierViewall">Physical Function</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8728;</span><p id="par0125" class="elsevierStylePara elsevierViewall">Mental Health</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8728;</span><p id="par0130" class="elsevierStylePara elsevierViewall">Pain</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8728;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Cognitive Function</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8728;</span><p id="par0140" class="elsevierStylePara elsevierViewall">Quality of life</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8728;</span><p id="par0145" class="elsevierStylePara elsevierViewall">Nutrition</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Additional domains to be assessed in the Follow-up Program</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8728;</span><p id="par0155" class="elsevierStylePara elsevierViewall">Pharmacological therapy at ICU discharge</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">&#8728;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Swallowing</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">&#8728;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Assessment of pulmonary function</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Duration of the Follow-up Program</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Population meeting the inclusion criteria in the Follow-up Program</span><p id="par0175" class="elsevierStylePara elsevierViewall">This program was designed to follow up ICU patients that show at least 2 of the following criteria&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">&#8211;</span><p id="par0180" class="elsevierStylePara elsevierViewall">APACHE II score &#62;14&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">&#8211;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Frailty upon admittance at the ICU<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">51</span></a>&#58; according to the Clinical Frailty Scale CSHA &#40;Clinical Frailty Scale&#44; from the Canadian Study of Health and Aging&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">52</span></a> The patients that show mild frailty when they are admitted may be included in the program &#40;for their description&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">&#8211;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Duration of invasive mechanical ventilation &#40;IMV&#41; or non-invasive mechanical ventilation &#40;NIMV&#41; greater than 7 days&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">&#8211;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Patients who cannot walk with assistance or show significant weakness at ICU discharge&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">&#8211;</span><p id="par0200" class="elsevierStylePara elsevierViewall">ICU stays over 10 days&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">&#8211;</span><p id="par0205" class="elsevierStylePara elsevierViewall">Patients who according to the opinion of their attending physician show indication of follow-up&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8211;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Patients with a diagnosis of prior severe cognitive impairment or any condition that prevents rehabilitation will be excluded&#46;</p></li></ul></p><p id="par0215" class="elsevierStylePara elsevierViewall">In patients referred to rehabilitation or geriatric centers it will be possible to conduct the evaluation via phone call&#47;email&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Patients who meet the inclusion criteria for the Follow-up Program at ICU discharge should receive the follow-up sheet &#40;see <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and the rehabilitation Manual&#46; This manual was developed by Jones&#39;s<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">53</span></a> group at St Helens and Knowsley Hospital and it was translated by the SATI Follow-up and Rehabilitation Committee with the authorization of Christina Jones &#40;see the follow-up manual in Spanish available at <a id="intr0010" class="elsevierStyleInterRef" href="https://www.sati.org.ar/index.php/areas-o/comites-o/comite-de-seguimiento-y-rehabilitacion-o/comite-de-seguimiento-y-rehabilitacion-produccion-academica">https&#58;&#47;&#47;www&#46;sati&#46;org&#46;ar&#47;index&#46;php&#47;areas-o&#47;comites-o&#47;comite-de-seguimiento-y-rehabilitacion-o&#47;comite-de-seguimiento-y-rehabilitacion-produccion-academica</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Recommendation</span><p id="par0225" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the population to be included in the follow-up &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0230" class="elsevierStylePara elsevierViewall">Here the recommendation from our expert panel&#39;s&#58; the patient should meet at least 2 of the aforementioned criteria to be included in the program&#46; However&#44; the follow-up is orientated to patients with a logical possibility of rehabilitation&#44; that is&#44; patients with effects so severe that cannot improve over time will be excluded&#44; as well as those that&#44; at hospital discharge&#44; are almost in the exact same condition as before the ICU admission&#46; This differentiation&#44; though complex&#44; is crucial to make an adequate selection of patients&#46;</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Follow-up frequency</span><p id="par0235" class="elsevierStylePara elsevierViewall">The first meeting between the patient and the follow-up team should be held within the first month after hospital discharge to assess the different domains and eventually establish an early treatment&#46; Patients showing alterations in the domains evaluated should be referred to the corresponding specialist&#44; and they can have an appointment 6 months after hospital discharge&#46; Patients that show no alterations can have an appointment 12 months after the discharge&#46; Follow-up frequency can increase in case the attending team deems it necessary&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Recommendation</span><p id="par0240" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the frequency of the follow-up &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Our expert panel&#39;s recommendation is this&#58; the patient can be given an appointment within a month after hospital discharge and&#44; depending on the alterations observed it will be the subsequent frequency including a appointment one year after discharge&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Personnel in charge of the Follow-up Program</span><p id="par0250" class="elsevierStylePara elsevierViewall">The team in charge of the patient&#39;s follow-up at ICU discharge should know the complications associated with PICS and be capable of evaluating the different domains&#46; This team should be made up of at least one physician and one kinesiologist&#46; There is little evidence<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">54</span></a> that it would be beneficial for the attending physician to be trained in the critical area&#46; Ideally&#44; a psychologist and a nutritionist should join the team&#44; but that will depend on the possibilities of each institution&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Recommendation</span><p id="par0255" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the personnel in charge of the follow-up &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">Our expert panel&#39;s recommendation is this&#58; the management of the PICS should be conducted via a multidisciplinary team led by a physician&#44; preferably one trained in the critical area&#44; and one kinesiologist&#46; Ideally&#44; a psychologist and a nutritionist could join the team&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Basic domains to be assessed in the Follow-up Program and recommended tools for their evaluation</span><p id="par0265" class="elsevierStylePara elsevierViewall">All the evaluations mentioned below are tests validated in Argentina or into Spanish language that can be applied by healthcare personnel not specialized in a specific area&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Survival</span><p id="par0270" class="elsevierStylePara elsevierViewall">Survival evaluation can be conducted via phone call or in person&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Recommendation</span><p id="par0275" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the impact of the follow-up programs on the patients&#8217; survival at UCI discharge &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0280" class="elsevierStylePara elsevierViewall">Experts&#8217; recommendation&#58; we consider that follow-up programs are useful for the assessment of survival&#44; but data are insufficient to evaluate their impact&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Physical function</span><p id="par0285" class="elsevierStylePara elsevierViewall">Physical function is one of the most compromised spheres at ICU discharge and it should be assessed during follow-up&#46; There are several tests available and the following ones are the most highly recommended&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8211;</span><p id="par0290" class="elsevierStylePara elsevierViewall">Six-minute Walk Test &#40;6MWTM&#41;&#46; The 6MWTM<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">55</span></a> evaluates comprehensively the response of the respiratory&#44; cardiovascular&#44; metabolic&#44; musculoskeletal and neurosensory systems that an individual develops during exercise&#46; This test can only be conducted in patients that can walk &#40;for further details&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46; In those patients who cannot walk&#44; the Katz index will be used here&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8211;</span><p id="par0295" class="elsevierStylePara elsevierViewall">Katz Index &#40;KI&#41;&#58; KI<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">56</span></a> evaluates the people&#39;s dependence&#47;independence in 6 ADL&#58; bathing &#40;sponge&#44; shower or bathtub&#41;&#44; dressing&#44; toileting&#44; transferring&#44; continence&#44; and feeding&#46; If the patient shows some degree of dependence in any of the ADL&#44; motor rehabilitation will be indicated &#40;for further details&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46;</p></li></ul></p><p id="par0300" class="elsevierStylePara elsevierViewall">Another option for those who wish to make a more detailed evaluation is the following ones&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8211;</span><p id="par0305" class="elsevierStylePara elsevierViewall">Test Timed Up and Go<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">57</span></a> &#40;TUG&#41;&#58; it requires the patients to get up from a chair&#44; walk&#44; turn around and walk back until they sit down again&#44; while the examiner times how long it takes them to complete the test &#40;for further details&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Recommendation</span><p id="par0310" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the impact of the follow-up programs on the patients&#8217; physical function &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Experts&#8217; recommendation&#58; follow-up programs are recommended for assessing and rehabilitating physical function at ICU discharge&#46; Patients showing a significant reduction of their physical function as evidenced by their dependence on any of the ADL&#44; evaluated by the KI&#44; or by their impossibility to walk by 6MWTM&#44; should be referred to motor rehabilitation&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Mental health</span><p id="par0320" class="elsevierStylePara elsevierViewall">According to the most common complications found in this area&#44; it is recommended to evaluate anxiety&#44; depression and PTSD during follow-up after ICU discharge&#46;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8211;</span><p id="par0325" class="elsevierStylePara elsevierViewall">Depression&#58; to evaluate depression the score Hospital Anxiety and Depression Scale<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">58</span></a> &#40;HADS&#41; or the Beck Depression Inventory-II &#40;BDI-II&#41; can be used&#46; The HADS&#44; which is most commonly used&#44; consists of 17 items&#46; Scores over 7 points would be indicative of referral to psychiatry&#46; The BDI-II<a class="elsevierStyleCrossRef" href="#bib0630"><span class="elsevierStyleSup">59</span></a> has a score that goes from 0 to 63&#59; scores over 14 or 20 would be indicative of referral to psychiatry &#40;for further details&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8211;</span><p id="par0330" class="elsevierStylePara elsevierViewall">Anxiety&#58; The Beck Anxiety Inventory &#40;BAI&#41;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">60</span></a> assesses anguish or panic disorders and generalized anxiety with a score that goes from 0 to 63&#46; Values over 11 would be indicative of referral to psychiatry &#40;for further details&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8211;</span><p id="par0335" class="elsevierStylePara elsevierViewall">PTSD&#58; there are different tools to evaluate PTSD&#44; among these we have the Impact of Event Scale<a class="elsevierStyleCrossRef" href="#bib0640"><span class="elsevierStyleSup">61</span></a> &#40;IES&#41; and the Impact of Event Scale-revised <a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">62</span></a> &#40;IES-R&#41;&#46; The IES is made up of 15 items and 2 subscales that evaluate 2 of the 3 components of PTSD&#58; intrusive thoughts and avoidance&#46; The IES-R incorporates 7 new items &#40;for a total of 22 items&#41; and assesses the third component&#58; the state of hyperarousal&#46; Its use is not recommended for the diagnosis of PTSD&#59; however&#44; cut-off points are specified and suggest specific interviews&#46; Scores &#8805;24 would be indicative of a clinical problem&#59; scores &#8805;33 would be indicative of a probable PTSD diagnosis&#59; and scores &#8805;37 would be indicative of a serious problem &#40;for further details&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46;</p></li></ul></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Recommendation</span><p id="par0340" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the impact of the follow-up programs on the patients&#8217; mental function &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Experts&#8217; recommendation&#58; follow-up programs are recommended for assessing and rehabilitating mental function at ICU discharge&#46; In patients showing depression confirmed through the HADS<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>7 or BDI-II<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>14&#8211;20&#44; or anxiety confirmed by BAI with scores over 11 or PTSD confirmed by the EIE-R scale with scores over 24&#44; referral to the area of psychiatry should be indicated&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Pain</span><p id="par0350" class="elsevierStylePara elsevierViewall">The evaluation of pain should be included in the follow-up program since it is a frequent&#44; limiting symptom in this group of patients&#46; To evaluate pain question number 4 from the quality of life score Euroqol EQ-5D-3L should be used &#40;see assessment of quality of life&#41;&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Recommendation</span><p id="par0355" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the impact of the follow-up programs on the patients&#8217; pain &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Experts&#8217; recommendation&#58; follow-up programs are recommended to assess and treat pain at ICU discharge&#46; Patients showing pain after answering question number 4 from the Euroqol EQ-5D-3L score on quality of life &#40;see assessment of quality of life&#41; should be referred to the corresponding specialist&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Cognitive function</span><p id="par0365" class="elsevierStylePara elsevierViewall">Assessing the cognitive function is a complex task and it requires the participation of specialists trained in this area&#46; However&#44; the early detection of cognitive disorders through simple tools can be useful in order to indicate early a timely referral to those specialized teams&#46; We recommend the Montreal Cognitive Assessment<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">63</span></a> &#40;MOCA&#41; test for the assessment of the cognitive function by personnel that is not specialized in this field&#46; This is a simple test that allows training in its application &#40;for further details&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">For those who wish to conduct a more thorough assessment&#44; they can use the Repeatable Battery for the Assessment of Neuropsychological Status Update &#40;RBANS<span class="elsevierStyleSup">&#174;</span> Update<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">64</span></a>&#41; test&#44; taking into consideration that its use is not cost-free&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Recommendation</span><p id="par0375" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the impact of the follow-up programs on the patients&#8217; cognitive function &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">Experts&#8217; recommendation&#58; follow-up programs are recommended to assess and rehabilitate cognitive function at ICU discharge&#46; Patients showing cognitive deficiencies assessed by the MOCA test with values under 17 points should be referred to a specialist in cognitive therapy for their rehabilitation&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Quality of life</span><p id="par0385" class="elsevierStylePara elsevierViewall">Health-related quality of life questionnaires are tools to measure the physical&#44; social and mental condition of a subject&#46; The questionnaire recommended to assess the quality of life is Euroqol EQ-5D-3L<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">65</span></a> &#8211; a simple&#44; generic tool with multiple-choice answers&#46; It is widely accepted&#44; and its use has spread to different patient populations admitted to the ICU&#46; This questionnaire has been validated to be used via phone call and it has proven to be a reliable measuring tool with family members &#40;in an indirect way&#41;&#46; It allows us to make comparisons with the general population&#44; since there is such a thing as the Argentine population&#39;s criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">66</span></a> A brief description appears in <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#46; Questionnaire SF-36 can also be used&#44; it has been translated into Spanish and it has proven to be a reliable tool to use in the population after ICU discharge&#46; It allows more thorough assessments as it is a more comprehensive test&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Recommendation</span><p id="par0390" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the impact of the follow-up programs on the patients&#8217; quality of life &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">Experts&#8217; recommendation&#58; follow-up programs are recommended to assess and rehabilitate quality of life at ICU discharge&#46; The assessment can be conducted with either questionnaire&#44; the EQ-5D 3L or the SF-36&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Nutrition</span><p id="par0400" class="elsevierStylePara elsevierViewall">At ICU discharge patients generally show a deficient nutritional condition which justifies assessment&#46; Validation of the Malnutrition Screening Tool &#40;MST&#41; has recently been published to be used within rehabilitation programs&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">67</span></a> This tool takes into account weight loss and its cause and classifies patients as patients at nutritional risk or as patients who are not at nutritional risk&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Recommendation</span><p id="par0405" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the impact of the follow-up programs on the patients&#8217; nutritional condition &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> and <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><p id="par0410" class="elsevierStylePara elsevierViewall">Experts&#8217; recommendation&#58; follow-up programs are recommended to assess the nutritional condition at ICU discharge&#46; Patients showing values &#8805;2 should be referred to the specialist for follow-up purposes &#40;for further details&#44; see <a class="elsevierStyleCrossRef" href="#sec0165">supplementary data</a>&#41;&#46; In addition&#44; feeding through nasogastric tube or the ostomy bag is an indication for follow-up for the nutrition team&#46;</p><p id="par0415" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the domains to be evaluated during the follow-up&#44; along with the tests validated in Spanish that can be used for its evaluation and the cut points often used to indicate referral to a specialist&#46;</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Additional domains to be assessed in the Follow-up Program</span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Pharmacological therapy at the ICU discharge</span><p id="par0420" class="elsevierStylePara elsevierViewall">The detailed assessment of the pharmacological therapy received by the patient at hospital discharge is relevant in an attempt to adjust the drugs and their doses to the actual situation of the discharged patient&#46;</p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Swallowing</span><p id="par0425" class="elsevierStylePara elsevierViewall">In patients with swallowing difficulties &#40;coughing&#44; wet voice&#44; difficulty swallowing certain textures&#41; it is possible to perform an evaluation of swallowing at the patient&#39;s bedside or request a video-deglutition examination to diagnose it properly and eventually treat it&#46;</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Assessment of pulmonary function</span><p id="par0430" class="elsevierStylePara elsevierViewall">Patients showing stridor or dyspnea at minimal or moderate efforts should be referred to the pulmonologist&#44; so that they can conduct diagnostic studies to rule out lesions of the airways&#44; that are so common in this population&#46;</p></span></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Duration of the Follow-up Program</span><p id="par0435" class="elsevierStylePara elsevierViewall">The time of the follow-up will vary from patient to patient&#46; Stabilization of functions is the most relevant criterion to terminate the follow-up&#46; Identifying the aforementioned stabilization will not always be easy to diagnose&#46; The tests conducted during the follow-up will be&#44; without doubt&#44; a useful tool to assess the domains that are considered more important for the patients&#8217; quality of life&#59; if the results of the test do no vary substantially between one visit and the next&#44; its termination could be considered&#46;</p><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Recommendation</span><p id="par0440" class="elsevierStylePara elsevierViewall">Based on the trials included&#44; it is not possible to establish a recommendation about the duration of the follow-up in patients at ICU discharge &#40;see <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0445" class="elsevierStylePara elsevierViewall">Experts&#8217; recommendation&#58; a minimum duration of one year of follow-up is recommended after ICU discharge&#46;</p></span></span></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Conclusions</span><p id="par0450" class="elsevierStylePara elsevierViewall">Longitudinal follow-up offices allow a multidisciplinary approach to PICS&#44; whose goal is the early identification of alterations in physical and mental health as well as to discuss with family members goals of re-hospitalizations and palliative care&#44; and other aspects&#46; The adequate selection of the population to be included in the program&#44; personalized follow-up and multidisciplinary approach are some key aspects of this program&#46; None of the follow-up measures proposed has evidence of quality&#44; which means that it was only possible to make experts&#8217; recommendations in all the cases&#46;</p></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Funding</span><p id="par0455" class="elsevierStylePara elsevierViewall">This study has not been funded totally or partially&#46;</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Conflicts of interest</span><p id="par0460" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest whatsoever&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Patient follow-up after intensive care unit &#40;ICU&#41; discharge allows the early recognition of complications associated to post-intensive care syndrome &#40;PICS&#41;&#46; The aim of this project is to standardize outcome variables in a follow-up program for patients at risk of suffering PICS&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The Rehabilitation and Patient Follow-up Committee of the Argentine Society of Intensive Care Medicine &#40;Sociedad Argentina de Terapia Intensiva&#44; SATI&#41; requested the collaboration of different committees to design the present document&#46; A thorough search of the literature on the issue&#44; together with pre-scheduled meetings and web-based discussion encounters were carried out&#46; After comprehensive evaluation&#44; the recommendations according to the GRADE system included in the follow-up program were&#58; frequency of controlled visits&#44; appointed healthcare professionals&#44; basic domains of assessment and recommended tools of evaluation&#44; validated in Spanish&#44; and entire duration of the program&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The measures herein suggested for patient follow-up after ICU discharge will facilitate a basic approach to diagnosis and management of the long-term complications associated to PICS&#46;</p></span>"
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        "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducci&#243;n</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El seguimiento de pacientes al alta de la unidad de cuidados intensivos &#40;UCI&#41; permite el reconocimiento precoz de las complicaciones asociadas al s&#237;ndrome post terapia intensiva &#40;SPTI&#41;&#46; El objetivo de este estudio es la estandarizaci&#243;n de medidas b&#225;sicas de resultado incluidas en un programa de seguimiento de pacientes en riesgo de presentar SPTI&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">M&#233;todos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El comit&#233; de Seguimiento y Rehabilitaci&#243;n luego de la Enfermedad Cr&#237;tica de la Sociedad Argentina de Terapia Intensiva &#40;SATI&#41; convoc&#243; a diferentes comit&#233;s para la redacci&#243;n del presente documento&#46; Se realiz&#243; una b&#250;squeda bibliogr&#225;fica&#44; junto con reuniones y foros de discusi&#243;n&#46; Las recomendaciones incluidas en el programa de seguimiento seg&#250;n el sistema GRADE son&#58; frecuencia de seguimiento&#44; profesionales encargados del programa&#44; dominios b&#225;sicos a evaluar&#44; herramientas recomendadas para su evaluaci&#243;n validadas al espa&#241;ol y duraci&#243;n del programa&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusi&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Las medidas recomendadas para el seguimiento de pacientes permiten establecer los lineamientos b&#225;sicos para la identificaci&#243;n y tratamiento precoz de las complicaciones asociadas al SPTI&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Busico M&#44; das Neves A&#44; Carini F&#44; Pedace M&#44; Villalba D&#44; Foster C&#44; et al&#46; Programa de seguimiento al alta de la unidad de cuidados intensivos&#46; Med Intensiva&#46; 2019&#59;43&#58;243&#8211;254&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Flow-diagram of the Follow-up Program&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The table shows the domains to be assessed during follow-up together with the tests validated into Spanish and the cut-off scores for every test that are indicative of referral to the specialist&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ADL&#58; activities of daily life&#59; BAI&#58; Beck Anxiety Inventory&#59; BDI-II&#58; Beck Depression Inventory-II&#59; IES-R&#58; Impact of Event Scale-revised&#59; EQ5D&#58; Euroqol EQ-5D&#59; HADS&#58; Hospital Anxiety and Depression Scale&#59; MOCA&#58; Montreal Cognitive Assessment&#59; MST&#58; Malnutrition Screening Tool&#59; SF-36&#58; Short Form 36&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Domains&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cut-off point for referral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Interview&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Physical function</td><td class="td" title="table-entry  " align="left" valign="top">&#205;ndice de Katz&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inability to perform ADL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Test de caminata de 6 minutos&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Inability to walk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="top">Mental function</td><td class="td" title="table-entry  " align="left" valign="top">HADS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Score &#62;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BDI-II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Score &#62;14&#8211;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BAI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Score &#62;11&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Score &#60;17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Quality of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EQ5D<br>SF-36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;<br>&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Score &#8805;2&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Recommendations according to the GRADE system and based on randomized controled follow-up studies at ICU discharge&#46; Evidence is categorized as very low&#44; low&#44; moderate&#44; or high&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">GRADE&#58; Grading of Recommendations Assessment&#44; Development and Evaluation&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No recommendation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No recommendation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No recommendation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No recommendation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No recommendation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No recommendation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No recommendation&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2019.03.009

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