key: cord-0700143-tvu4a5g6 authors: Moonen, Hanneke Pierre Franciscus Xaverius; Strookappe, Bert; van Zanten, Arthur Raymond Hubert title: Physical recovery of COVID‐19 pneumosepsis intensive care survivors compared with non‐COVID pneumosepsis intensive care survivors during post–intensive care hospitalization: The RECOVID retrospective cohort study date: 2021-09-02 journal: JPEN J Parenter Enteral Nutr DOI: 10.1002/jpen.2242 sha: 884d8e6a308bf25c521dfdf0cae1c87ef42dc068 doc_id: 700143 cord_uid: tvu4a5g6 BACKGROUND: Coronavirusdisease 2019 (COVID‐19) pneumosepsis survivors are at a high risk of developing intensive care unit (ICU)–acquired weakness (ICUAW) because of high incidence of acute respiratory distress syndrome and the common need for prolonged invasive ventilation. It remains unknown whether regular postpneumosepsis physical rehabilitation strategies are suitable for this extraordinary patient category. METHODS: We retrospectively compared the physical recovery of COVID‐19 and non‐COVID pneumosepsis ICU survivors during post‐ICU hospitalization, defined as the difference in performance on the Medical Research Council Sum‐Score (MRC‐SS), Chelsea Critical Care Physical Assessment tool (CPAx), and percentage of predicted handgrip strength (POP‐HGS). An analysis of covariance model was built using age, sex, Barthel index, body mass index, admission Acute Physiology And Chronic Health Evaluation II score, adequacy of protein delivery during ICU stay, and ward length of stay as covariates. RESULTS: Thirty‐five COVID‐19 ICU patients could be compared with 21 non‐COVID pneumosepsis ICU survivors. All patients scored ≤48 on the MRC‐SS at ICU discharge, indicating ICUAW. When controlling for covariates, COVID‐19 patients performed worse on all physical assessments upon ICU discharge, but had improved more at hospital discharge on the MRC‐SS (ɳ(2) = 0.214, P =.002) and CPAx (ɳ(2) = 0.153, P =.011). POP‐HGS remained lower in COVID‐19 patients throughout hospital stay. CONCLUSION: COVID‐19 ICU survivors are vulnerable to ICUAW, but they show better tendency towards physical rehabilitation than non‐COVID pneumosepsis ICU survivors during the post‐ICU hospitalization period regarding MRC‐SS and CPAx. COVID‐19 ICU patients might benefit from early, more intensive physical therapy. survivors during the post-ICU hospitalization period regarding MRC-SS and CPAx. COVID-19 ICU patients might benefit from early, more intensive physical therapy. Covid19, ICU-acquired weakness, pneumonia, recovery, sepsis Coronavirus disease2019 ICU survivors are at high risk for intensive care unit-acquired weakness, which is well known to have immense personal and societal consequences. As the group of COVID-19 ICU survivors is quickly growing worldwide, insight into their requirements for optimal physical rehabilitation and methods of assessing these is of paramount importance. in the ICU population. However, it has been suggested that the lesserknown Chelsea Critical Care Physical Assessment tool (CPAx) might provide benefits, especially in the COVID-19 ICU population, as it is a more holistic measurement tool concerning functional recovery and incorporating respiratory functioning. 5 In this retrospective cohort study, we aim to compare the (course of) physical functioning of COVID-19 pneumosepsis survivors to non-COVID pneumosepsis survivors at ICU and hospital discharge based on several physical performance scores. Our results may shed light on the optimum method for assessing physical performance in this large group of patients, as well as help to identify the physical therapy approach they will likely require. We performed a retrospective cohort study in the ICU of the Gelderse Vallei Hospital, a University-affiliated teaching hospital in Ede, the Netherlands. All ICU patients at our hospital receive standardized early rehabilitation therapy each weekday from ICU admission to hospital discharge. This is a progressive multistep program adapted from the pro- IBM SPSS statistics 27 (IBM Corp, Armonk, NY, USA) was used for all analyses. Continuous values are reported as mean and bias corrected and accelerated bootstrap 95% CI to facilitate comparisons between data with a difference in distribution between the cohorts and to minimize the effect of outliers. Discrete data are presented as numbers (percentages). Normality of the data was visually assessed using the quantile-quantile plot. When inconclusive, the Shapiro-Wilk test was adhered. Differences between groups were assessed using independent samples of t-tests for continuous data or chi-squared tests for categorical data. When test assumptions were not met, Mann-Whitney U tests or Fisher's exact tests were used, respectively. An analysis of covariance (ANCOVA) model was built assessing the association between the admission diagnosis (COVID-19 or non-COVID pneumosepsis) and the difference between physical assessment scores upon ICU and hospital discharge. Empirically, age, sex, and ward LOS were added into the model as covariates. In addition, parameters with a significant difference between the means (COVID-19 vs non-COVID In accordance with previous research, we observed that COVID-19 ICU patients are prone to ICUAW at ICU and hospital discharge, MRC-SS is a well-validated, relatively easy bedside method to establish muscle strength, which is sensitive to identify ICUAW, and reliably predicts hospital mortality, days on a ventilator, ICULOS, and HLOS with excellent interrater reliability. [12] [13] [14] In our study, ICUAW resolved in more COVID-19 than non-COVID patients during the post-ICU hospitalization period, although not significantly, likely due to lack of power. Although the MRC-SS is widely used, it is limited in that it focuses solely on assessment of muscle strength. CPAx was developed as a holistic approach to assessing physical functioning, including respiratory function. 15 The CPAx is an outcome measure designed to assess 10 domains of physical ability in the post-ICU patient: respiratory function, cough, bed mobility, supine to sitting on the edge of the bed, dynamic sitting, sit to stand, standing balance, transferring from bed to chair, stepping, and grip strength. Use of CPAx is not yet ubiquitous; however, it has been translated into several languages and correlates well to other methods such as MRC-SS. [15] [16] [17] [18] [19] Taken together, the advantages of CPAx has experts to advocate for its use specifically in the functional assessment of post-ICU COVID-19 patients. 5 In contrast to the MRC-SS and the CPAx, the change in POP-HGS between ICU and hospital discharge in our study was not different for COVID-19 patients compared with non-COVID pneumosepsis patients. In the past, HGS has been shown to correlate with MRC-SS; however, it has not consistently been shown to predict outcome across the heterogenic ICU population. 12 This may be due to the lack of discriminatory power of HGS, as a HGS of 0 kg has previously been shown to be associated with acceptable or even normal MRC-SS measurements. 12 In addition, our study may have been underpowered to detect a significant change in HGS. Our results are subject to the limitations of a retrospective approach. Because of ethical considerations, we were only able to include anonymized records of patients who had previously consented to collection of data in the context of a prospective trial. The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Hanneke Pierre Franciscus Xaverius Moonen contributed to the conception of the research, data acquisition, data analysis, and interpretation and writing of the final manuscript. Bert Strookappe contributed to the conception of the research, data acquisition, data interpretation, and revision of the final manuscript. Arthur Raymond Hubert van Zanten contributed to the conception of the research, data interpretation, and revision of the final manuscript. The ethics committee of Gelderse Vallei Hospital has approved this study. The patients or their legal representatives had previously given informed consent to use all the characteristics and parameters in the context of the BIAC-19, the RECOVER-energy ICU, or the MIC studies. The relevant sections of the respective databases were merged for data analysis. No additional information was gathered. Therefore, we considered the previously obtained informed consent to cover the extended analysis as proposed. Not applicable. Arthur Raymond Hubert van Zanten MDPhD https://orcid.org/0000-0001-6276-7192 COVID-19 Consortium. Intensive care unit acquired muscle weakness in COVID-19 patients Post-intensive care syndrome and COVID-19: crisis after a crisis? Heart Lung Early mobilization and physical exercise in patients with COVID-19: a narrative literature review Intensive care unit-acquired weakness: unanswered questions and targets for future research Chelsea physical assessment tool for evaluating functioning in post-intensive care unit COVID-19 patients Physiotherapy in the intensive care unit: an evidence-based, expert driven, practical statement and rehabilitation recommendations Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial Report of a joint FAO/WHO/UNU Expert Consultation Ageand gender-specific normative data of grip and pinch strength in a healthy adult Swiss population Acute Functional Outcomes in Critically Ill COVID-19 Patients Medical Research Council-sum score: a tool for evaluating muscle weakness in patients with post-intensive care syndrome Global muscle strength but not grip strength predicts mortality and length of stay in a general population in a surgical intensive care unit Interobserver agreement of medical research council sum-score and handgrip strength in the intensive care unit Respiratory weakness is associated with limb weakness and delayed weaning in critical illness The Chelsea critical care physical assessment tool (CPAx): validation of an innovative new tool to measure physical morbidity in the general adult critical care population; an observational proof-of-concept pilot study Translation and crosscultural adaptation of the Chelsea Critical Care Physical Assessment tool into Danish German version of the Chelsea Critical Care Physical Assessment Tool (CPAx-GE): translation, cross-cultural adaptation, validity, and reliability Chinesisation, adaptation and validation of the Chelsea Critical Care Physical Assessment Tool in critically ill patients: a cross-sectional observational study Cross-cultural adaptation and inter-rater reliability of the Swedish version of the Chelsea critical care assessment tool (CPAX-Swe) in critically ill patients SUPPORTING INFORMATION Additional supporting information may be found in the online version of the article at the publisher's website.