key: cord-0722813-fkwgq5mr authors: Wiertz, Carolina M.H.; Vints, Wouter A.J.; Maas, Geert. J.C.M.; Rasquin, Sascha M.C.; van Horn, Yvette Y.; Dremmen, Martijn P.M.; Hemmen, Bena; Verbunt, Jeanine A. title: COVID-19: patient characteristics in the first phase of post-intensive care rehabilitation date: 2021-02-04 journal: Arch Rehabil Res Clin Transl DOI: 10.1016/j.arrct.2021.100108 sha: 2fc2173226fc969862d5edf291c2cec565945332 doc_id: 722813 cord_uid: fkwgq5mr Objective To describe clinical characteristics of post-ICU COVID-19 patients, admitted for inpatient rehabilitation. Design A cross-sectional design Setting Inpatient rehabilitation care in the Netherlands Participants All post-ICU COVID-19 patients admitted to the rehabilitation centre between April 2 and May 13, 2020 were invited to participate in the study. Included were patients above 18 years old, needing inpatient rehabilitation after ICU treatment for COVID-19. Intervention Not applicable Main outcomes measures The following information was collected in the first week of inpatient rehabilitation care: 1. Demographics, 2. ICU-stay parameters, 3. Medical, physical and functional characteristics, 4. Self-reported symptoms. Results Sixty patients participated with the mean age of 59.9 and the majority being men(75%). Most important findings for rehabilitation: in the first week after discharge to the rehabilitation centre 38.3% of all patients experienced exercise-induced oxygen desaturation, in 72.7% muscle weakness was present in all major muscle groups and 21.7% had a reduced mobility in one or both shoulders. Furthermore 40% suffered from dysphagia and 39.2% reported symptoms of anxiety. Conclusion Post-ICU COVID-19 patients, display physical and anxiety symptoms as reported in other post-ICU patient groups. However this study showed some remarkable clinical characteristics of post-ICU COVID-19 patients. Rehabilitation programs need to anticipate on this. Long-term follow-up studies are necessary. Previous studies showed that critical illness can have a major impact on all areas of participation 6, 7 . The impairments in physical, cognitive, and/or mental health resulting from critical illness are described as post intensive care syndrome (PICS) 8 . One year after ICU discharge 56% of all patients suffer from one or more problems related to PICS 9 . Identification of PICS and rehabilitation needs may help prevent chronic disability 10 . In addition to PICS, post-ICU COVID-19 patients might be prone to (irreversible) pulmonary dysfunctions. Although long-term data on pulmonary consequences in COVID-19 patients is not yet available, clinical characteristics might be similar to those seen with severe acute respiratory syndrome (SARS) or acute respiratory distress syndrome (ARDS). SARS and ARDS patients suffered a spectrum of residual symptoms such as ICU-acquired weakness (ICU-AW), moderate to severe dyspnoea, reduced exercise capacity, fatigue, multi-organ impairment and cognitive and mental health problems [11] [12] [13] [14] . At this moment information on long-term characteristics of post-ICU COVID-19 patients is still incomplete. Information about physical, mental and cognitive health, in the acute phase after ICU discharge is needed to assess whether current multidisciplinary rehabilitation programmes are suitable for this patient group. Therefore the aim of this study is to describe clinical characteristics of post-ICU COVID-19 patients in the first week after admission for inpatient rehabilitation. This cross-sectional study was performed at Adelante Zorggroep, a rehabilitation centre in the South of the Netherlands. Inclusion criteria were patients; 1. aged 18 or older, 2. being referred for inpatient rehabilitation after ICU treatment for COVID-19 subsequent to ICU and hospital-discharge and 3. functioning independently before their COVID-19 infection. Excluded were all patients that did not fulfilled the inclusion criteria. COVID-19 was diagnosed during hospital admission. All post-ICU COVID-19 patients admitted to the rehabilitation centre between April 2 and May 13, 2020 were invited to participate in the study. We started including from the first patient that was admitted to the rehabilitation centre. Twenty five beds were available for post-ICU COVID-19 patients. One of the wards was completely isolated as a quarantine ward. As soon as patients tested negative for COVID-19, they were transferred to another ward within the rehabilitation centre. Zuyderland METC (METCZ20200086) and the Local Ethics Commission Adelante approved this study. Participants consented to medical record data related to their admission being used for research purpose. Data collection ICU-specific data were collected retrospectively, attained from medical transfer letters. All other data were collected in the first week after admission. Medical and functional characteristics and self-reported symptoms were collected on the first day and physical characteristics were collected during the first week following admission to the rehabilitation centre, as part of standard clinical care. In case of any missing or uncertain records data were considered lost. The following information was collected: 17 . Thus for these muscles HHD was performed. The following muscle groups were assessed with the HHD: shoulder abduction, elbow flexion, wrist extension, hip flexion and knee extension, bilateral. HHD values were measured in Newton and percentages of the norm, compared to healthy subjects of the same sex, age and weight 18, 19 . As in previous studies, muscle weakness was defined as <80% of the norm score 20, 21 . Sensory impairment was identified with the Erasmus modified Nottingham Sensory Assessment (NSA) 22, 23 . ROM was extracted from: cervical spine, shoulders, elbows, wrists, hips, knees and ankles. We defined contracture as a recorded ROM that did not reach the full range 24 . Functional characteristics: Activities of daily living (ADL) function was assessed by the Barthel index (BI). The BI is a well-established instrument that consists of 10 items measuring the extent to which a person can perform basic ADL activities independently 25, 26 . Self-reported symptoms: Those indicating complaints of fear, dyspnoea or fatigue, were scored on a numeric rating scale (NRS) ranging from 0 to 10, with 0 indicating a total absence of any complaints and 10 indicating the worst imaginable fear, fatigue or dyspnoea 27, 28 . Fear, dyspnoea and fatigue were scored separately. Because several patients had restricted possibility to fill in self-reported questionnaires in the first week of inpatient rehabilitation, the NRS was chosen instead of self-reported questionnaires. Descriptive statistics were used to summarize the data; results are reported as means and standard deviations (SD) in case of a normal distribution, or medians and interquartile ranges (IQR) in case of a non-normal distribution of the data. Categorical variables were summarized as counts and percentages. No imputation was made for missing data. Statistical analysis was performed using SPSS, 26.0 a . Between April 2 and May 13, 2020, sixty patients were admitted for inpatient rehabilitation. Everyone provided informed consent about the use of their medical data and were included. The demographic characteristics are shown in Table 1 . ICU stay-specific parameters are shown in Table 2 . In seven patients (11.7%) tracheostomy tube placement had been necessary in the ICU due to a problematic weaning process. However in six the tube could be removed before admission to the rehabilitation centre. Just one person was transferred to the rehabilitation centre with a tracheostomy tube due to severe dysphagia. Five patients (8.3%) needed CRRT on the ICU. In two CRRT could be stopped and in three CRRT was converted to haemodialysis during their ICU stay. Of the three latter patients, one became independent of haemodialysis while still on the ICU, one was first transferred to a hospital ward for geriatric rehabilitation and was transferred to the rehabilitation centre at the moment haemodialysis could be stopped. The third patient was admitted to the rehabilitation centre while still dependent on haemodialysis. Thromboembolic complications were present in 14 patients (23.3%), one had PE as well as a stroke. Two patients developed a cardiac arrest due to massive PE on the ICU. One patient was transferred to the rehabilitation centre with a postinfectious encephalitis. Medical and functional characteristics are shown in Table 3 . On admission to the rehabilitation centre 20 persons (33.3%) still required nasal oxygen therapy because of low saturation (<93%) in rest. However in 38.3% of all patients exercise-induced hypoxemia (<90%) was noted. Twenty-four (40.0%) were admitted with dysphagia needing tube feeding or adapted feeding consistency. Furthermore, six patients (10%) received adapted feeding consistency due to severe fatigue. Pressure sores were seen mostly on face, sacrum and heels. Physical characteristics are described in Table 4 contractures were present. All of them had a reduced ROM in one or both shoulders, sometimes in combination with one or more other joints. In 16.6% a sensory neuropathy was present, varying in location. In five cases reduced sensibility was associated with a drop foot. Self-reported symptoms are given in pandemic, in the Netherlands, an incidence of thromboembolic complications of 49-59% was found in ICU patients 39, 40 . In the present study population the number of rehabilitation patients that needed ECMO or CRRT and/or had suffered thromboembolic complications was lower than in studies that describe these numbers in a population of ICU patients before discharge. That could be due the fact that patients with multi-organ failure and/or thromboembolic events have lower odds of surviving ICU-stay 37, 39, 40 . At the moment of admission to the rehabilitation centre 33% of the patients still depended on oxygen therapy. An exercise-induced hypoxemia (<90%) was noted in 38.3% of all patients. It remains unclear why some post-ICU COVID-19 patients experience exertional hypoxemia, while others do not. Recent lung pathological reports in COVID-19 found three main histological patterns: reactive epithelial changes and diffuse alveolar damage, pulmonary microthrombi and interstitial fibrosis 41 . Further research is needed to find out in which degree these changes, might contribute to long-term (exertional) hypoxemia and impaired cardiopulmonary function. Previous studies on SARS and ARDS reported a wide range (6 to 58%) of patients with a affected lung function 14, 42 . Even though spirometry indicates a good recovery in terms of lung volumes, the diffusing capacity and exercise capacity seem to stay reduced 6-12 months after hospital or ICU discharge 14, 42 . In case of an exercise-induced hypoxemia, oxygen therapy is indicated in patients with a blood oxygen saturation below 88-90% or a relative reduction of 2-5% during exercise lasting for 0.5-5.0 minute 43 . Oxygen therapy will help patients meet elevated metabolic demands, prevent hypoxemia and reduce pulmonary dynamic hyperinflation 44 . In this way trainings-possibilities are increased 43, 44 . In summary we recommend a heightened awareness of exertional hypoxemia in COVID-19 patients and the need to provide appropriate oxygen therapy and gradually increase exercise intensity over time starting with Borg scale ≤4, while monitoring oxygen saturation 44, 45 . The MRC and HHD values obtained in this population showed that patients have severely reduced muscle force compared with reference values. A serious shoulder weakness in almost all patients was found, with a median shoulder abduction strength of 35.0% of the norm. Weakness and atrophy of the shoulder muscles as a result of admission to an ICU and immobilization has a major effect on the stability of the shoulder, which eventually could even result in displacement of the humeral head and/or shoulder dysfunction 33, 46 . Furthermore prolonged use of neuromuscular blocking agents appears to have a negative influence on shoulder stability and muscle weakness 33 . According to Hosey and Needham (2020) , there is a risk of developing brachial plexus injury due to repeatedly movements between supine and prone positions 47 shown that the vastus intermedius muscle shows the greatest change in muscle quality having a strong relationship with muscle strength. To a lesser extent the same applied for the rectus femoris 49 . Early rehabilitation started during ICU admission, will lower the incidence of ICU-AW and improve short-term physical function in patients with critical illness 50 . Due to quarantine measures and prone position, multidisciplinary early rehabilitation interventions on the ICU were often not possible or significantly limited, which may have led to an increased incidence of muscle weakness. The present study found a median weight loss of 10kg at the moment of intake for inpatient rehabilitation. Although good nutritional care is fundamental during post-ICU rehabilitation, previous studies suggest that nutritional deficits after ICU discharge are greater than during ICU-stay 51 . Various factors, such as ICU-AW and anxiety/depression, could play a role in a decreased oral intake and malnutrition 52 . Furthermore COVID-19 patients often display symptoms likely to affect oral intake, including loss of taste and smell 53 . Follow-up by a speech therapist and dietician is important in order to monitor dysphagia, asses the need to adjust feeding consistency and monitor nutritional intakes. Anxiety symptoms were found in 39.2% of all patients. Anxiety and depressive symptoms in the post-acute phase after ICU discharge were previously found to be correlated with greater impairment in cognitive functioning 12 months after ICU admission 54 Some limitations of the current study need to be considered. First, this study included patients referred to inpatient rehabilitation for a brief period from April until May 13, 2020. It was noted that the complexity of the cases increased over time. The overall higher complexity of cases is probably associated with a longer ICU stay of patients that were referred for inpatient rehabilitation later on during the timeframe of this research. Since we stopped inclusion after May 13, the values presented might therefore underestimate the actual total population of all post-ICU COVID-19 patients referred to inpatient rehabilitation care. However, due to the urgent situation around COVID-19, it seems important to share information in this early stage. Further studies can update this information. Second, this study was situated in one rehabilitation centre. 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