1. Weaning and De-escalation of Life-Sustaining Therapies

Systematic reduction of vasopressors, ventilator support, and antibiotics as physiological stability returns is crucial to minimize iatrogenic harm and restore patient autonomy.

A. Vasopressor Weaning Protocol

• Entry Criteria: MAP ≥ 65 mm Hg for at least 2 hours on norepinephrine ≤ 0.05 µg/kg/min; demonstrating improving lactate clearance (>10%/h) and adequate urine output (>0.5 mL/kg/h).
• Tapering Algorithm: Reduce infusion by 10–20% every 30–60 minutes if MAP remains ≥ 65 mm Hg. Hold the taper or revert to the previous dose if MAP falls below 60 mm Hg or lactate begins to rise.
• Transition: Once off intravenous support, assess for persistent orthostasis. If present, consider oral agents like midodrine to facilitate mobilization.

B. Mechanical Ventilation Liberation

• Daily Spontaneous Awakening Trials (SAT): Pause sedation daily to assess neurologic function and readiness for weaning, aiming for a Richmond Agitation-Sedation Scale (RASS) score of −1 to +1.
• Spontaneous Breathing Trials (SBT): If a patient passes the SAT, proceed to an SBT using a T-piece or minimal pressure support (≤ 7 cm H₂O) for 30–120 minutes with FiO₂ ≤ 40% and PEEP ≤ 5 cm H₂O.
• Extubation Criteria: Successful SBT completion plus stable gas exchange (PaO₂/FiO₂ > 150), an effective cough to clear secretions, and an intact mental status.

C. Antimicrobial De-escalation

• Reassessment at 48–72 hours: Review culture data and clinical response. Narrow the antibiotic spectrum to target identified pathogens or discontinue therapy if a non-infectious cause is confirmed.
• Typical Durations: Aim for 5–7 days for uncomplicated bacteremia or pneumonia. Extend to 10–14 days only if there is a deep-seated infection, incomplete source control, or profound immunosuppression.
• Biomarker Guidance: A procalcitonin level < 0.25 ng/mL or a >80% drop from its peak value can support the safe discontinuation of antibiotics, particularly in respiratory infections.

2. Conversion to Enteral Medication Regimens

Transitioning from intravenous to oral or enteral therapy as soon as feasible preserves gut integrity, reduces the risk of central line-associated bloodstream infections (CLABSI), and is a key step in discharge planning.

A. GI Function Assessment

• Assess for return of bowel function by checking for bowel sounds, performing a non-distended abdominal exam, and ensuring gastric residual volumes are < 500 mL.
• The presence of hemodynamic stability on low-dose vasopressors (e.g., norepinephrine ≤ 0.1 µg/kg/min) is generally considered acceptable for initiating trophic enteral feeds.

B. Enteral Formulation Selection & Administration

3. Prevention and Management of Post-ICU Syndrome (PICS)

Early identification of at-risk patients and consistent implementation of bundle-based interventions are effective strategies to reduce the long-term cognitive, physical, and psychological impairments associated with critical illness.

A. High-Risk Patient Identifiers

• Age > 65 years
• ICU length of stay > 7 days
• Duration of mechanical ventilation > 48 hours
• Presence of delirium for > 2 days
• High cumulative doses of sedatives, especially benzodiazepines

B. The ABCDEF Bundle

The ABCDEF bundle is a multidisciplinary, evidence-based approach to harmonizing ICU care practices to improve outcomes for critically ill patients.

4. Medication Reconciliation and Discharge Planning

A structured, pharmacist-led process is essential to prevent medication errors, optimize patient adherence, and ensure a safe and effective handoff to the next level of care.

A. Reconciliation Workflow

1. Collection: A best possible medication history (pre-admission list) is collected at ICU admission.
2. Documentation: All in-ICU medication changes (initiations, discontinuations, dose adjustments) are documented daily.
3. Reconciliation: A final, formal reconciliation is performed at discharge to resolve any discrepancies, omissions, or duplications between the pre-admission and current medication lists.

B. Patient and Caregiver Education

• Provide clear, written medication schedules, pill organizers, and information on mobile app reminders.
• Educate on “red flag” symptoms that warrant immediate contact with a healthcare provider, such as new weakness, altered cognition, or signs of infection.
• Discuss the potential for PICS symptoms (anxiety, memory problems, fatigue) and normalize the experience.

C. Handoff Communication Tools

Utilize a standardized handoff template, such as SBAR, within the electronic health record to ensure all critical information is conveyed.

• Situation: Patient is being discharged after recovery from septic shock.
• Background: Summarize sepsis etiology, key interventions (e.g., vasopressors, ventilation), and hospital course.
• Assessment: Current clinical status, key unresolved issues, and medication list.
• Recommendation: Specific follow-up appointments, pending tests, and therapy goals.

5. Long-Term Follow-Up and Rehabilitation Programs

Ongoing, multidisciplinary care is vital for addressing late-emerging sequelae of critical illness and tracking key recovery metrics over time.

A. Post-Critical Illness Clinics

Specialized clinics provide a structured environment for follow-up. They are typically scheduled 1–3 months post-discharge and staffed by a team including an intensivist, pharmacist, rehabilitation specialist, and psychologist.

B. Monitoring for Sequelae

• Cognition: Screen with the Montreal Cognitive Assessment (MoCA) or Mini-Mental State Examination (MMSE) at each visit.
• Physical Function: Assess with objective measures like the 6-Minute Walk Test and handgrip dynamometry.
• Emotional Health: Use validated screening tools such as the Patient Health Questionnaire-9 (PHQ-9) for depression and the Generalized Anxiety Disorder-7 (GAD-7) for anxiety.

C. Quality Improvement Metrics

Key metrics to track the success of a post-sepsis recovery program include the 30-day hospital readmission rate, the proportion of patients returning to baseline Activities of Daily Living (ADLs), and patient-reported quality of life (QoL) scores.