# Interventions to Prevent or Mitigate Post-Intensive Care Syndrome (PICS) in Adult ICU Survivors: A Systematic Review and Network Meta-Analysis

## TL;DR

This study reviews interventions to help ICU survivors avoid post-intensive care syndrome, finding early physical therapy and sedation protocols most promising but with low certainty.

## Contribution

The study provides a network meta-analysis comparing interventions for post-intensive care syndrome, identifying early rehabilitation and sedation protocols as potentially most effective.

## Key findings

- No intervention significantly reduced mortality compared to usual care in ICU survivors.
- Early physical therapy and occupational therapy ranked highest in probabilistic effectiveness.
- Evidence certainty was very low to low due to bias, imprecision, and heterogeneity.

## Abstract

This systematic review and network meta-analysis (NMA) aimed to determine the comparative effectiveness of interventions aimed at preventing or mitigating post-intensive care syndrome (PICS) in adult intensive care unit (ICU) survivors by synthesizing all available evidence. Multiple electronic databases were queried to identify randomized controlled trials (RCTs) assessing pharmacological or non-pharmacological therapies designed to prevent or treat post-intensive care syndrome. The primary end point for this analysis was all-cause mortality. To compare the relative efficacy of these interventions, a Bayesian network meta-analysis (NMA) was performed using a random-effects model, and interventions were ranked probabilistically using the surface under the cumulative ranking curve (SUCRA), and the certainty of evidence was assessed using the Confidence in Network Meta-Analysis (CINeMA) framework. Twelve randomized controlled trials involving 2,649 patients and seven distinct interventions were included, yet no intervention demonstrated a statistically significant reduction in mortality compared to usual care as all comparisons had wide credible intervals (CrIs) indicating substantial uncertainty, although a probabilistic ranking identified early physical therapy (PT) and occupational therapy (OT) as having the highest probability of being the most effective intervention for reducing mortality, followed by a spontaneous awakening trial (SAT) and spontaneous breathing trial (SBT) protocol, with the overall certainty of the evidence judged as very low to low due to serious risk of bias, imprecision, and statistical heterogeneity. Based on evidence of low certainty, no single intervention can be definitively recommended to reduce mortality in survivors with post-intensive care syndrome. However, a preliminary evidence-based hierarchy suggests that strategies combining early rehabilitation and protocolized sedation weaning are most promising. High-quality, head-to-head comparative effectiveness trials are urgently needed to provide more definitive guidance.