key: cord-0696414-3g1x4hnp
authors: Parker, Alexander J.; Humbir, Anita; Tiwary, Pooja; Mishra, Monalisa; Shanmugam, Mohan; Bhatia, Kailash; Duncan, Alastair; Sharma, Manu-Priya; Kitchen, Gareth; Brij, Seema; Wilde, Siobhan; Martin, Andrew D.; Wilson, Anthony; Brandwood, Craig
title: Recovery after critical illness in COVID-19 ICU survivors
date: 2021-03-19
journal: Br J Anaesth
DOI: 10.1016/j.bja.2021.03.005
sha: 43c549e74f6676de8d1c515922fc1f0c5f116307
doc_id: 696414
cord_uid: 3g1x4hnp

nan

Editor -Coronavirus disease (COVID-19) has placed an enormous strain on intensive care units (ICUs) in the UK with mortality rates of around 40% 1 . Invasively ventilated ICU survivors have frequently required prolonged critical care, but to date there have been limited reports on recovery and rehabilitation in these patients. Case series have mainly focussed on all hospitalised patients, including patients with less severe disease 2, 3 . Studies in critically ill populations have been limited to functional status assessments or have focussed on the residual radiological features in these patients 4, 5 .

Our dedicated ICU COVID-19 follow-up clinic has assessed all patients cared for during the first wave of the UK COVID-19 pandemic. We report our findings for invasively ventilated patients from this multidisciplinary assessment of patient recovery and rehabilitation. Our institution's research and innovation department determined that this project did not require ethical approval. Information governance safeguards were approved by our institution's Caldicott guardian.

Face-to-face review was undertaken by a critical care consultant with input from physiotherapists, occupational therapists, dieticians and critical care nurses. Patients completed quality of life, anxiety, depression and post-traumatic stress surveys by telephone prior to review, and chest radiograph, pulmonary function tests and measures of muscle strength in the clinic. Subjective and objective measures of dyspnoea were recorded.

Between 17 March and 31 May 2020, 110 patients were admitted to our ICU with confirmed or probable COVID pneumonitis: 60/110 (54.5%) were invasively ventilated, of whom 40 (66.7%) survived to ICU discharge and 38 (63.3%) were discharged home. Of these, 36/38 patients (95%) attended the follow-up clinic. Detailed patient characteristics and ICU care can be found in table S1 in the online supplementary material.

Neuromuscular blocking agent (NMBA) infusion was used in 26/36 (72%); 15/36 (42%) required prone positioning.; 20/36 (56%) required tracheostomy to facilitate weaning from the ventilator and 2/36 (6%) required transfer to another unit for Extracorporeal Membrane Oxygenation (ECMO). Median length of stay in our ICU was 25 [IQR 14 -34] days. Patients were seen in clinic 10.9 (SD 2.4) weeks after hospital discharge. Table 1 provides an overview of the rehabilitation and recovery metrics assessed.

The majority of patients (83%) had complete resolution of their radiographic findings and normal oxygen saturations both at rest on exertion in a 60 s sit to stand test. Pulmonary function tests identified a mild restrictive defect with normal KCO. However, there was a marked reduction in grip strength measurements in comparison to a healthy population reference range of similar age and sex 6 . From a functional perspective, scores were reduced in all SF-36 domains with the largest reductions in role limitations due to impairment in physical health. We found that 20% of patients who responded reported clinically significant anxiety and depression symptoms and 57% of patients had clinically significant post-traumatic stress symptoms.

Our findings offer insight into the early recovery of invasively ventilated COVID-19 patients. Respiratory findings occurred similar to early follow-up of other acute respiratory distress syndrome (ARDS) survivors in which patients often display a mild restrictive pattern on spirometry and compromised diffusion capacity (TLCO) 7 . We suggest respiratory muscle weakness is the major contributor to these abnormalities in view of the radiological findings, marked reduction in grip strength, and patient reported physical limitation and dyspnoea. Anecdotally, our experience has been that intubated patients with COVID-19 frequently desaturate during spontaneous breathing trials and sedation weaning. This has led to prolonged use of neuromuscular blockade, increased sedation regimes and frequent use of prone positioning, which may have contributed to the muscle weakness observed.

A Swiss study 8 of critically ill patients recovering from COVID-19 who were followed up at 4 months reported marked desaturation (to 90%) during six-minute walk tests. We did not observe this phenomenon during sit to stand exercises; this is J o u r n a l P r e -p r o o f surprising as only 70% of the Swiss cohort had been invasively ventilated, and they were seen after a longer period of recovery (4 months vs 2-3 months) and had better spirometry results. The differences may reflect the different exercise regimes used.

Our patients reported marked reduction in all SF-36 domains, in particular in role limitation due to impairment in physical health. This pattern is well established in ARDS survivors, 9 and is more marked in our population possibly due to the earlier timing of follow up and perhaps the expectations of our patients, who were young and in good physical health prior to their critical illness.

Post-traumatic stress syndrome is a recognised phenomenon following critical illness with rates of 29% amongst ARDS survivors at one year 7 . Our rate of 57% is much higher, which is concerning. This may in part reflect our small sample size, selfreporting bias and the earlier timing of our follow up. COVID-19 ICU survivors will need continued follow up and support to characterise these psychological sequelae and to help mitigate the effects of this significant life event.

'Long Covid' has been used to describe symptoms in people reporting long-term effects following COVID-19, but we would urge caution in applying this diagnosis to ICU survivors who may simply be experiencing the symptoms and recovery typical of many ARDS survivors.

We have observed significant physical weakness in critically ill patients recovering from COVID-19, highlighting the need for ongoing physical rehabilitation in this patient group. Detailed analysis of both ICU care and follow up of COVID-19 patients may allow identification of the most favourable management strategies of patients with severe COVID-19 in order to mitigate long-term sequelae.

A limitation of this study is that it is a single centre review, therefore our findings may not reflect the outcomes of patients cared for in other ICUs. Furthermore, the number of survivors in whom we report data is relatively small. However, our admission characteristics and detailed descriptors of ICU stay allow other units to make a comparison with their own data. Our results may assist in health service planning and ongoing care and support requirements for an ever-increasing number of mechanically ventilated COVID-19 survivors.

AW, MS and AP drafted the manuscript. AP and AW had full access to the data and undertook the data extraction and analysis. All authors contributed to the paper conception, revision of the manuscript and manual data collection. Data are given as n (%) or mean (SD) unless otherwise stated. FEV1 = forced expiratory volume in 1 s, FVC = forced vital capacity. TLCO = diffusion capacity for carbon monoxide, KCO = carbon monoxide transfer coefficient. CPAx score (Chelsea Critical Care Physical Assessment Tool): 10 commonly assessed components of physical ability, each graded on a six-point scale from 0 (complete dependency) to 5 (complete independence). Borg rating of perceived exertion: 0 to 10 scale (0 = rest, 10 = extreme exertion). SF-36 = short form 36: a 36 item self-reporting tool which measures both physical health (physical function, physical role function, bodily pain, and general health) and mental health (vitality, social function, emotional function, and mental health). Each domain is scored from 0 (poor health) to 100 (excellent health). HADS = hospital anxiety and depression scale; a 14-item self-reported screening tool each item is rated 0-3 with total scores of 11+ associated with clinical anxiety and depression. PTSS-14 = post-traumatic stress symptoms 14, a 14-item self-report screening tool; each item is rated 1 (never) to 7 (always) with a total score ranging from 14 to 98.

Comprehensive health assessment three months after recovery from acute COVID-19

et alPatient outcomes after hospitalisation with COVID-19 and implications for follow-up: results from a prospective UK cohort

Quality of life, functional status, and persistent symptoms after intensive care of COVID-19 patients

Chest CT in COVID-19 pneumonia: what are the findings in mid-term follow-up?

Hand Grip Strength: age and gender stratified normative data in a population-based study

What's Next After ARDS: Long-Term Outcomes