key: cord-0975200-0tdqg5cl
authors: Ramani, Chintan; Davis, Eric M.; Kim, John S.; Provencio, J Javier; Enfield, Kyle B.; Kadl, Alex
title: Post-Intensive Care Unit COVID-19 Outcomes-a Case Series
date: 2020-08-21
journal: Chest
DOI: 10.1016/j.chest.2020.08.2056
sha: 80f73949aee993f561fd4d94b9f8711ca0c7f80f
doc_id: 975200
cord_uid: 0tdqg5cl

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Critically ill patients with COVID-19 spend significant time on mechanical ventilation and have prolonged hospitalization duration 1 . Whether these patients after discharge have immediate pulmonary and neurocognitive recovery is unknown.

Patients were admitted to the University of Virginia (UVA) Medical Center intensive care unit (ICU) with COVID-19 and underwent follow-up at the UVA Post-COVID-19-ICU clinic approximately six weeks after discharge. Lung function and exercise capacity were assessed by spirometry, lung volumes, diffusion capacity (DLCo), and 6-minute walk test. Depression, cognitive function, and insomnia were assessed by the Patient-Reported Outcomes Measurement Information System (PROMIS) depression 8a-short score, the Quality of Life in Neurological Disorders (Neuro-QoL) adult cognitive function v2.0 score, the Montreal Cognitive assessment (MOCA) scores, and insomnia severity index. The study was approved by the UVA Institutional Review Board.

As of July 30, 2020, 102 patients with COVID-19 were admitted to the UVA ICU. Fifty-nine patients (57.84%) were discharged alive, 22 (21.57%) died, and 21 (20.59%) remained hospitalized. Every discharged patient is contacted to follow up in the UVA Post-ICU COVID clinic. The first patient was seen on June 2, 2020. Twenty-eight of the 29 scheduled patients attended clinic as of July 30, 2020 (Table 1) , resulting in a 96% show-rate. The remaining discharged patients are scheduled but have not been seen yet. Seven (25%) and ten (57.14%) patients self-identified as African American and non-white Hispanic, respectively. The median age was 56 years [interquartile range (IQR) 47.5-65.75]; 24 patients (85.71%) required mechanical ventilation (MV) and the median days on MV was 11 [IQR 3.25-15]. The mean SOFA, APACHE II and SAPS II scores were 6 (standard deviation (SD) 2.42), 14.3 (SD 5.86) and 32 (SD 11.91) respectively. Seventy-five percent were diagnosed with delirium in the ICU. Median ICU and hospital-length of stay (LOS) were 14 [IQR 6-21.5] and 22 days [IQR 11.5-31], respectively. Two patients were discharged on antipsychotic agents or opiates.

The median days to follow up in the clinic post hospital discharge was 39.5 days [IQR 36-41]. Prior lung function tests were not available for comparison. At follow-up, 16 patients (61.54%) had normal lung function, 4 (15.38%) had obstruction, 5 (19.23%) had restriction, 1 (3.85%) mixed obstruction and restriction; and 7 (26.92%) had reduced DLCo. The mean 6-minute walk distance (6MWD) was 315 meters (SD 85.4 m) and mean percent predicted was 65.5 [IQR 51.5-76.5]. None of the patients required supplemental oxygen.

None of the patients had clinically diagnosed depression, cognitive impairment, or insomnia prior to admission. At follow-up, seven patients had mild-to-moderate depression. Assessment of mild cognitive impairment was more frequent by MOCA (n=16 (57.14%)) but not by Neuro-QoL (n=6 (22%)). All, but one patient (96%) had no difficulties performing activities of daily life (ADL). Five out of 23 patients who completed the insomnia severity index had moderate-to-severe insomnia. Detailed patient information is found in table 1, Figure 1 shows representative examples of the Visuospatial/Executive MOCA test. 

To the best of our knowledge, this is the first case series of outpatient follow-up visits for patients who were hospitalized in the ICU with COVID-19. We found a low prevalence of obstruction and restriction, similar to previously published data in acute respiratory distress syndrome (ARDS) 1,2 . The prevalence of diffusion impairment in our cohort was lower compared to post-ARDS follow-up 3 . The mean 6MWD in our cohort is higher compared to what has been reported in prior ARDS studies 3 . Despite significant dosages for sedation and a high prevalence of delirium in the ICU, majority of our patients had no or only mild cognitive impairment at six weeks after hospital discharge. This observation, and the fact only one patient had still difficulties with ADLs, is different from previous reports of survivors of critical illness 4 , . The prevalence of depression and insomnia were comparable with previous post-ICU outcome studies 5, 6 . The majority of our post-ICU clinic patients were African-American or Hispanic which is supportive of recent studies that suggest non-white racial/ethnic groups are severely impacted by COVID-19 7 .

This was a single center case series and we do not have sufficient long-term data to assess how these outcomes change over time. The long-term impact of this disease remains unclear, but our study suggests the feasibility of an in-person outpatient clinic for post-ICU COVID-19 patients and a low burden of pulmonary and neurocognitive morbidity at immediate follow-up.

Chest-Research letter Ramani et al.

Author Contribution: C.R. and A.K. are the guarantors of the manuscript. C.R. and A.K. decided to follow up COVID 19 ICU patients in clinic. C.R was responsible for scheduling. C.R., A.K., E.D. and J.J.P. contributed to follow up questionnaires. C.R. and A.K analyzed and interpreted the data. C.R., A.K., J.K., E.M.D., J.J.P. and K.B.E contributed to manuscript. A.K was responsible for final editing. All authors approved the final draft. 

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