Post-ICU Syndrome in a Cohort of COVID-19 Survivors in New York City

Connecting the Dots: Unveiling the Overlapping Realities of Long Coronavirus Disease and Post-Intensive Care Syndrome

Critical care areas saw an unprecedented number of patients throughout the coronavirus disease 2019 (COVID-19) pandemic. Unfortunately, many of these patients continue to experience lingering symptoms long after their discharge from the intensive care unit, related to post-intensive care syndrome and/or post-acute sequelae of COVID-19. Nurses should be aware of these often invisible illnesses and attentive to the fact that this patient population requires ongoing support via multidisciplinary, coordinated care.

Easing Suffering for ICU Patients and Their Families: Evidence and Opportunities for Primary and Specialty Palliative Care in the ICU

Intensive care unit (ICU) admissions are often accompanied by many physical and existential pressure points that can be extraordinarily wearing on patients and their families and surrogate decision makers (SDMs). Multidisciplinary palliative support, including physicians, advanced practice nurses, nutritionists, chaplains and other team members, may alleviate many of these sources of potential suffering. However, the palliative needs of ICU patients undoubtedly exceed the bandwidth of current consultative specialty palliative medicine teams. Informed by standard-of-care palliative medicine domains, we review common ICU symptoms (pain, dyspnea and thirst) and their prevalence, sources and their treatment. We then identify palliative needs and impacts in the domains of communication, SDM support and transitions of care for patients and their families through their journey in the ICU, from discharge and recovery at home to chronic critical illness, post-ICU disability or death. Finally, we examine the evidence for strategies to incorporate specialty palliative medicine and palliative principles into ICU care for the improvement of patient- and family-centered care. While randomized controlled studies have failed to demonstrate measurable improvement in pre-determined outcomes for patient- and family-relevant outcomes, embracing the principles of palliative medicine and assuring their delivery in the ICU is likely to translate to overall improvement in humanistic, person-centered care that supports patients and their SDMs during and following critical illness.

Mortalidad, Secuelas Clínicas y Calidad de Vida Luego del Alta de Unidades de Cuidados Intensivos en Pacientes con COVID-19: Estudio Multicéntrico Descriptivo en Argentina

OBJECTIVE

Patients with COVID-19 who require hospitalization in an intensive care unit, in addition to being at risk of presenting premature death, have higher rates of complications. This study aimed to describe mortality, rehospitalizations, quality of life, and symptoms related to postintensive care syndrome (PICS) and prolonged COVID-19 in patients with COVID-19 discharged from the intensive care unit in hospitals in Argentina.

METHODS

A cross-sectional study was conducted in 4 centers in the Autonomous City and province of Buenos Aires as of December 2022. The variables of interest were mortality after discharge, rehospitalization, health-related quality of life, post-COVID-19-related symptoms, cognitive status, and PICS. Data collection was by telephone interview between 6 and 18 months after discharge.

RESULTS

A total of 124 patients/families were contacted. Mortality was 7.3% (95% CI: 3.87-13.22) at 14.46 months of follow-up after discharge. Patients reported a reduction of the EQ-5D-3L visual analog scale of 13.8 points, reaching a mean of 78.05 (95% CI: 73.7-82.4) at the time of the interview. Notably, 54.4% of patients (95% CI: 41.5-66.6) reported cognitive impairment and 66.7% (95% CI: 53.7-77.5) developed PICS, whereas 37.5% (95% CI: 26-50.9) had no symptoms of prolonged COVID-19.

CONCLUSION

The results showed a significant impact on the outcomes studied, consistent with international evidence.

One-Year Recovery Among Survivors of Prolonged Severe COVID-19: A National Multicenter Cohort

OBJECTIVES

Understanding the long-term effects of severe COVID-19 illness on survivors is essential for effective pandemic recovery planning. Therefore, we investigated impairments among hospitalized adults discharged to long-term acute care hospitals (LTACHs) for prolonged severe COVID-19 illness who survived 1 year.

DESIGN

The Recovery After Transfer to an LTACH for COVID-19 (RAFT COVID) study was a national, multicenter, prospective longitudinal cohort study.

SETTING AND PATIENTS

We included hospitalized English-speaking adults transferred to one of nine LTACHs in the United States between March 2020 and February 2021 and completed a survey.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Validated instruments for impairments and free response questions about recovering. Among 282 potentially eligible participants who provided permission to be contacted, 156 (55.3%) participated (median age, 65; 38.5% female; 61.3% in good prior health; median length of stay of 57 d; 77% mechanically ventilated for a median of 26 d; 42% had a tracheostomy). Approximately two-thirds (64%) had a persistent impairment, including physical (57%), respiratory (49%; 19% on supplemental oxygen), psychiatric (24%), and cognitive impairments (15%). Nearly half (47%) had two or more impairment types. Participants also experienced persistent debility from hospital-acquired complications, including mononeuropathies and pressure ulcers. Participants described protracted recovery, attributing improvements to exercise/rehabilitation, support, and time. While considered life-altering with 78.7% not returning to their usual health, participants expressed gratitude for recovering; 99% returned home and 60% of previously employed individuals returned to work.

CONCLUSIONS

Nearly two-thirds of survivors of among the most prolonged severe COVID-19 illness had persistent impairments at 1 year that resembled post-intensive care syndrome after critical illness plus debility from hospital-acquired complications.

The incidence of neurological complications in mechanically ventilated COVID-19 ICU patients: An observational single-center cohort study in three COVID-19 periods

BACKGROUND

Neurological complications in COVID-19 patients admitted to an intensive care unit (ICU) have been previously reported. As the pandemic progressed, therapeutic strategies were tailored to new insights. This study describes the incidence, outcome, and types of reported neurological complications in invasively mechanically ventilated (IMV) COVID-19 patients in relation to three periods during the pandemic.

METHODS

IMV COVID-19 ICU patients from the Dutch Maastricht Intensive Care COVID (MaastrICCht) cohort were included in a single-center study (March 2020 - October 2021). Demographic, clinical, and follow-up data were collected. Electronic medical records were screened for neurological complications during hospitalization. Three distinct periods (P1, P2, P3) were defined, corresponding to periods with high hospitalization rates. ICU survivors with and without reported neurological complications were compared in an exploratory analysis.

RESULTS

IMV COVID-19 ICU patients (n=324; median age 64 [IQR 57-72] years; 238 males (73.5%)) were stratified into P1 (n=94), P2 (n=138), and P3 (n=92). ICU mortality did not significantly change over time (P1=38.3%; P2=41.3%; P3=37.0%; p=.787). The incidence of reported neurological complications during ICU admission gradually decreased over the periods (P1=29.8%; P2=24.6%; P3=18.5%; p=.028). Encephalopathy/delirium (48/324 (14.8%)) and ICU-acquired weakness (32/324 (9.9%)) were most frequently reported and associated with ICU treatment intensity. ICU survivors with neurological complications (n=53) were older (p=.025), predominantly male (p=.037), and had a longer duration of IMV (p<.001) and ICU stay (p<.001), compared to survivors without neurological complications (n=132). A multivariable analysis revealed that only age was independently associated with the occurrence of neurological complications (ORadj=1.0541; 95% CI=1.0171-1.0925; p=.004). Health-related quality-of-life at follow-up was not significantly different between survivors with and without neurological complications (n = 82, p=.054).

CONCLUSIONS

A high but decreasing incidence of neurological complications was reported during three consecutive COVID-19 periods in IMV COVID-19 patients. Neurological complications were related to the intensity of ICU support and treatment, and associated with prolonged ICU stay, but did not lead to significantly worse reported health-related quality-of-life at follow-up.

Evaluating Mental Health Outcomes in COVID-19 ICU Survivors: A Scoping Review of Measurement Tools

Objective: The objective of this scoping review was to map the range of measurement tools used to study the prevalence of common mental health conditions in COVID-19 ICU survivors. Introduction: Increased rates of admission to and survivorship from intensive care units (ICUs) have been observed in recent years, particularly during the global pandemic. ICU patients are at a higher risk of developing depressive, anxiety, and PTSD symptoms. Due to the high burden of disease, an accurate understanding of long-term mental health challenges for this population is key. Unfortunately, there is significant variability in reported prevalence rates. Heterogeneity in measurement tools potentially contribute to this. Inclusion criteria: Studies were eligible if they (a) reported mental health outcomes of adult patients diagnosed with COVID-19 and admitted to an ICU, (b) used standardised mental health outcome measures, and (3) were peer-reviewed. Methods: Searches were conducted in PubMed, PsycInfo, and Scopus. The initial search retrieved 1234 publications. After de-duplication and title and abstract screening, 72 full-text articles were examined for eligibility and 44 articles were excluded, leaving 28 eligible studies. Reference lists of the eligible studies were screened, and four other studies were added. 32 studies were ultimately included in this review. Results: Significant heterogeneity of measurement tools and clinical thresholds were observed. Only 6.25% of the studies compared changes in mental health outcomes to baseline measurements. Between five and nine unique measurement tools were used to study depression, anxiety, and PTSD, respectively. Studies were also observed to use up to 19 different thresholds to establish the prevalence of PTSD. Conclusions: The heterogeneity of measurement tools and thresholds continues to confound prevalence rate estimations of mental health complications post-ICU admission. Future research will benefit from consistency in the use of recommended outcome measures and the use of psychometrically comparable cut-off points between key measures.

Post-intensive care syndrome and health-related quality of life in long-term survivors of cardiac arrest: a prospective cohort study

Patients discharged from intensive care are at risk for post-intensive care syndrome (PICS), which consists of physical, psychological, and/or neurological impairments. This study aimed to analyze PICS at 24 months follow-up, to identify potential risk factors for PICS, and to assess health-related quality of life in a long-term cohort of adult cardiac arrest survivors. This prospective cohort study included adult cardiac arrest survivors admitted to the intensive care unit of a Swiss tertiary academic medical center. The primary endpoint was the prevalence of PICS at 24 months follow-up, defined as impairments in physical (measured through the European Quality of Life 5-Dimensions-3-Levels instrument [EQ-5D-3L]), neurological (defined as Cerebral Performance Category Score > 2 or Modified Rankin Score > 3), and psychological (based on the Hospital Anxiety and Depression Scale and the Impact of Event Scale-Revised) domains. Among 107 cardiac arrest survivors that completed the 2-year follow-up, 46 patients (43.0%) had symptoms of PICS, with 41 patients (38.7%) experiencing symptoms in the physical domain, 16 patients (15.4%) in the psychological domain, and 3 patients (2.8%) in the neurological domain. Key predictors for PICS in multivariate analyses were female sex (adjusted odds ratio [aOR] 3.17, 95% CI 1.08 to 9.3), duration of no-flow interval during cardiac arrest (minutes) (aOR 1.17, 95% CI 1.02 to 1.33), post-discharge job-loss (aOR 31.25, 95% CI 3.63 to 268.83), need for ongoing psychological support (aOR 3.64, 95% CI 1.29 to 10.29) or psychopharmacologic treatment (aOR 9.49, 95% CI 1.9 to 47.3), and EQ-visual analogue scale (points) (aOR 0.88, 95% CI 0.84 to 0.93). More than one-third of cardiac arrest survivors experience symptoms of PICS 2 years after resuscitation, with the highest impairment observed in the physical and psychological domains. However, long-term survivors of cardiac arrest report intact health-related quality of life when compared to the general population. Future research should focus on appropriate prevention, screening, and treatment strategies for PICS in cardiac arrest patients.

Beyond survival: understanding post-intensive care syndrome

Post-intensive care syndrome (PICS) refers to persistent or new onset physical, mental, and neurocognitive complications that can occur following a stay in the intensive care unit. PICS encompasses muscle weakness; neuropathy; cognitive deficits including memory, executive, and attention impairments; post-traumatic stress disorder; and other mood disorders. PICS can last long after hospital admission and can cause significant physical, emotional, and financial stress for patients and their families. Several modifiable risk factors, such as duration of sepsis, delirium, and mechanical ventilation, are associated with PICS. However, due to limited awareness about PICS, these factors are often overlooked. The objective of this paper is to highlight the pathophysiology, clinical features, diagnostic methods, and available preventive and treatment options for PICS.

Social Networks as a Key Health Determinant in Acute Illness Recovery: A Lesson from the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic highlighted the importance of considering social determinants of health in health outcomes. Within this spectrum of determinants, social networks garnered attention as the pandemic highlighted the negative effects of social isolation in the context of social distancing measures. Postpandemic, examining the role social networks play in COVID-19 recovery can help guide patient care and shape future health policies. This study aimed to investigate the relationship between social networks and self-rated health change, as well as physical function, in patients recovering from COVID-19 pneumonia.

METHODS

This was a retrospective cohort study utilizing clinical data from 2 New York City hospitals and a 9-month follow-up survey of COVID-19 pneumonia survivors. We evaluated a composite Social Network Score from the 6-item Lubben Social Network Scale and its association with 2 outcomes: 1) self-rated health change and 2) physical function.

RESULTS

A total of 208 patients were included in this study. A 1-point increase in the Social Network Score was associated with greater odds of both same or improved self-rated health change (odds ratio [OR] 1.07, 95% CI 1.02-1.12, P = .01), as well as unimpaired physical function (OR 1.08, 95% CI 1.03-1.14, P < .01).

CONCLUSION

This study emphasized the importance of social networks as a social determinant of health among patients recovering from COVID-19 hospitalization. Targeted interventions to enhance social networks may benefit not only COVID-19 patients but also individuals recovering from other acute illnesses.

Long-Term Risk of Reduced Cognitive Performance and Associated Factors in Discharged Older Adults with COVID-19: A Longitudinal Prospective Study

BACKGROUND

Increasing numbers of reports have suggested a deterioration in cognitive performance after recovery from coronavirus disease 2019 (COVID-19), however insufficient information is available regarding long-term brain health and risk factors related to reduced cognitive performance in advanced age. We investigated the prevalence of reduced cognitive performance and its associated factors among older adults after COVID-19.

METHODS

This prospective observational study enrolled older individuals (aged ≥65 years) hospitalized for COVID-19. Discharged patients were contacted after an average of 15 months and a brief battery was administered during telephone interviews to assess their mental status.

RESULTS

Among the 174 patients, 77 (44.3%) showed reduced cognitive performance at follow-up. Multivariate analysis revealed that female sex, education level, and increased Deyo/Charlson Comorbidity Index score, which is an objective indicator of chronic disease burden, were independent risk factors for long-term cognitive performance. Depression and anxiety symptoms, assessed using the Patient Health Questionnaire-2 and Generalized Anxiety Disorder 2-item questionnaire at the end of the study, were not associated with reduced cognitive performance.

CONCLUSION

Our findings provide key insights into discharged older adults with COVID-19 at risk of long-term cognitive impairment, and help to ascertain the factors associated with this problem.

The global prevalence of depression, anxiety, and sleep disorder among patients coping with Post COVID-19 syndrome (long COVID): a systematic review and meta-analysis

BACKGROUND

Post COVID-19 syndrome, also known as "Long COVID," is a complex and multifaceted condition that affects individuals who have recovered from SARS-CoV-2 infection. This systematic review and meta-analysis aim to comprehensively assess the global prevalence of depression, anxiety, and sleep disorder in individuals coping with Post COVID-19 syndrome.

METHODS

A rigorous search of electronic databases was conducted to identify original studies until 24 January 2023. The inclusion criteria comprised studies employing previously validated assessment tools for depression, anxiety, and sleep disorders, reporting prevalence rates, and encompassing patients of all age groups and geographical regions for subgroup analysis Random effects model was utilized for the meta-analysis. Meta-regression analysis was done.

RESULTS

The pooled prevalence of depression and anxiety among patients coping with Post COVID-19 syndrome was estimated to be 23% (95% CI: 20%-26%; I2 = 99.9%) based on data from 143 studies with 7,782,124 participants and 132 studies with 9,320,687 participants, respectively. The pooled prevalence of sleep disorder among these patients, derived from 27 studies with 15,362 participants, was estimated to be 45% (95% CI: 37%-53%; I2 = 98.7%). Subgroup analyses based on geographical regions and assessment scales revealed significant variations in prevalence rates. Meta-regression analysis showed significant correlations between the prevalence and total sample size of studies, the age of participants, and the percentage of male participants. Publication bias was assessed using Doi plot visualization and the Peters test, revealing a potential source of publication bias for depression (p = 0.0085) and sleep disorder (p = 0.02). However, no evidence of publication bias was found for anxiety (p = 0.11).

CONCLUSION

This systematic review and meta-analysis demonstrate a considerable burden of mental health issues, including depression, anxiety, and sleep disorders, among individuals recovering from COVID-19. The findings emphasize the need for comprehensive mental health support and tailored interventions for patients experiencing persistent symptoms after COVID-19 recovery.

Cognitive impairment in post-acute COVID-19 syndrome: a scoping review

Emerging studies indicate the persistence of symptoms beyond the acute phase of COVID-19. Cognitive impairment has been observed in certain individuals for months following infection. Currently, there is limited knowledge about the specific cognitive domains that undergo alterations during the post-acute COVID-19 syndrome and the potential impact of disease severity on cognition. The aim of this review is to examine studies that have reported cognitive impairment in post-acute COVID-19, categorizing them into subacute and chronic phases. The methodology proposed by JBI was followed in this study. The included studies were published between December 2019 and December 2022. The search was conducted in PubMed, PubMed PMC, BVS - BIREME, Embase, SCOPUS, Cochrane, Web of Science, Proquest, PsycInfo, and EBSCOHost. Data extraction included specific details about the population, concepts, context, and key findings or recommendations relevant to the review objectives. A total of 7,540 records were identified and examined, and 47 articles were included. The cognitive domains most frequently reported as altered 4 to 12 weeks after acute COVID-19 were language, episodic memory, and executive function, and after 12 weeks, the domains most affected were attention, episodic memory, and executive function. The results of this scoping review highlight that adults with post-acute COVID-19 syndrome may have impairment in specific cognitive domains.

Quality of life, exercise capacity, cognition, and mental health of Chilean patients after COVID-19: an experience of a multidisciplinary rehabilitation program at a physical and rehabilitation medicine unit

Background

Post-COVID disabilities, encompassing physical, cognitive, and psychological aspects, constitute the primary health sequelae for survivors. While the rehabilitation needs post COVID-19 are now well understood, each country possesses unique characteristics in terms of populations, healthcare systems, social dynamics, and economic profiles, necessitating context-specific recommendations. This study aims to address two main objectives: (1) analyze the impact of an 8-week multidisciplinary rehabilitation program on the quality of life, functional capacity, cognition, and mental health adaptations in adults recovering from COVID-19 in northern Chile, and (2) propose a personalized model for predicting program dropouts and responses.

Methods

A total of 44 subjects were enrolled, forming two groups during the study: a treatment group (n = 32) and a dropout group (n = 12). The treatment group participated in the 8-week multidisciplinary rehabilitation program.

Results

The results indicate that (1) After 8 weeks, the quality of life of the patients in the treatment group exhibited significant improvements reflected in all aspects of the Short Form-36 Health Survey (SF36, p < 0.005) and the total score (p < 0.001), with a concurrent decrease in dysfunctionality (p < 0.001). (2) Significant improvements were also observed in various physical performance tests, including the: 6-minute walk test, 1-min sit-to-stand, dynamometry, Tinetti balance, and Berg score (p < 0.001). Moreover, physical therapy led to a reduction in neuropathic symptoms and pain, psychological therapy reduced anxiety and depression, and language therapy enhanced memory and speech (all p < 0.05). (3) Demographic and clinical history characteristics did not predict responses to rehabilitation. (4) A regression model for predicting changes in SF-36 total score, based on physical function, physical role, general health, and mental health, was established based on the data from study (p < 0.01, adjusted R2 = 0.893). (5) Classification models for predicting dropouts achieved 68% accuracy, with key predictors of treatment adherence including diabetes, hypertension, and dyslipidemia, Tinetti balance, physical role, and vitality of SF36, and performance on the 6-minute walk test and 1-minute sit-to-stand.

Conclusions

This study demonstrates significant enhancements in quality of life, improved functional performance, and reductions in mental and cognitive burdens within an 8-week rehabilitation program. Additionally, it is possible to identify patients at risk of dropping out using cost-effective, outpatient, and clinically applicable tests.

The Relationship Between COVID-19 and the Development of Depression: Implications on Mental Health

Initially, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), the virus responsible for coronavirus disease-2019 (COVID-19), was predominantly considered to primarily affect the respiratory system. However, later studies revealed that it also affects brain function through its ability to bind to the angiotensin-converting enzyme type 2 (ACE2) receptors expressed on neural cells. Our study involved a comprehensive review of literature aiming to investigate the relationship between COVID-19 and the development of depression. Our analysis shows a connection between these 2 conditions, as a consequence of the inflammatory response in the nervous system to the COVID-19 virus and the psychophysiological effects of the pandemic. In COVID-19 patients, depression can arise either due to the direct viral infection of the brain or as a result of an indirect immune response triggering neuroinflammation after a cytokine storm. The resulting depression can be treated with non-pharmacological therapies such as psychotherapy, antidepressant medications, or a combination of these treatments depending on the severity of the symptoms.

Long-term outcomes of COVID-19 intensive care unit survivors and their family members: a one year follow-up prospective study

Purpose

To describe the long-term physical, functional and mental status of COVID-19 intensive care unit (ICU) patients and their family members 1 year after ICU discharge.

Methods

We performed a prospective observational cohort study among patients admitted to the ICU for COVID-19-associated respiratory failure and their family members. Patients attended a one-year follow-up consultation with family members. Physical, functional and respiratory outcomes were collected. In addition, participants completed the Hospital Anxiety and Depression Scale and the Revised Impact of Event Scale. Qualitative components were collected during a 2-h face-to-face interview.

Results

Fifty-four patients and 42 family members were included. Thirty-four (63%) patients reported chronic fatigue and 37 (68.5%) dyspnea. Computed tomography scans were abnormal in 34 patients (72.3%). Anxiety symptoms were present in 23 (48%) patients and 26 (66%) family members, depression in 11 (23%) and 13 (33%), and post-traumatic stress disorder in 12 (25%) and 23 (55%), respectively. Visit limitation was reported as the most painful experience for family members. Numerous patients recalled nightmares that contributed to the anxiety. Long-term reconstruction was difficult for both patients and family members.

Conclusion

The vast majority of patients and their relatives reported long-term consequences on various physical and mental components, leading to a profound impact on their well-being.

Researching COVID to Enhance Recovery (RECOVER) adult study protocol: Rationale, objectives, and design

IMPORTANCE

SARS-CoV-2 infection can result in ongoing, relapsing, or new symptoms or other health effects after the acute phase of infection; termed post-acute sequelae of SARS-CoV-2 infection (PASC), or long COVID. The characteristics, prevalence, trajectory and mechanisms of PASC are ill-defined. The objectives of the Researching COVID to Enhance Recovery (RECOVER) Multi-site Observational Study of PASC in Adults (RECOVER-Adult) are to: (1) characterize PASC prevalence; (2) characterize the symptoms, organ dysfunction, natural history, and distinct phenotypes of PASC; (3) identify demographic, social and clinical risk factors for PASC onset and recovery; and (4) define the biological mechanisms underlying PASC pathogenesis.

METHODS

RECOVER-Adult is a combined prospective/retrospective cohort currently planned to enroll 14,880 adults aged ≥18 years. Eligible participants either must meet WHO criteria for suspected, probable, or confirmed infection; or must have evidence of no prior infection. Recruitment occurs at 86 sites in 33 U.S. states, Washington, DC and Puerto Rico, via facility- and community-based outreach. Participants complete quarterly questionnaires about symptoms, social determinants, vaccination status, and interim SARS-CoV-2 infections. In addition, participants contribute biospecimens and undergo physical and laboratory examinations at approximately 0, 90 and 180 days from infection or negative test date, and yearly thereafter. Some participants undergo additional testing based on specific criteria or random sampling. Patient representatives provide input on all study processes. The primary study outcome is onset of PASC, measured by signs and symptoms. A paradigm for identifying PASC cases will be defined and updated using supervised and unsupervised learning approaches with cross-validation. Logistic regression and proportional hazards regression will be conducted to investigate associations between risk factors, onset, and resolution of PASC symptoms.

DISCUSSION

RECOVER-Adult is the first national, prospective, longitudinal cohort of PASC among US adults. Results of this study are intended to inform public health, spur clinical trials, and expand treatment options.

REGISTRATION

NCT05172024.

The long wave of COVID-19: a case report using Imagery Rehearsal Therapy for COVID-19-related nightmares after admission to intensive care unit

Introduction

The COVID-19 pandemic caused several psychological consequences for the general population. In particular, long-term and persistent psychopathological detriments were observed in those who were infected by acute forms of the virus and need specialistic care in the Intensive Care Unit (ICU). Imagery rehearsal therapy (IRT) has shown promising results in managing nightmares of patients with different traumas, but it has never been used with patients admitted to ICUs for severe COVID-19 despite this experience being considered traumatic in the literature.

Methods

The purpose of this case study is to describe the application of a four-session IRT for the treatment of COVID-related nightmares in a female patient after admission to the ICU. A 42-year-old Caucasian woman who recovered from a pulmonary rehabilitation program reported shortness of breath, dyspnea, and everyday life difficulties triggered by the long-COVID syndrome. She showed COVID-related nightmares and signs of post-traumatic symptoms (i.e., hyperarousal, nightmares, and avoidance of triggers associated with the traumatic situation). Psychological changes in the aftermath of a trauma, presence, and intensity of daytime sleepiness, dream activity, sleep disturbances, aspects of sleep and dreams, and symptoms of common mental health status are assessed as outcomes at the baseline (during the admission to pneumology rehabilitation) at 1-month (T1) and 3-month follow-up (T2). Follow-up data were collected through an online survey.

Results

By using IRT principles and techniques, the patient reported a decrease in the intensity and frequency of bad nightmares, an increase in the quality of sleep, and post-traumatic growth, developing a positive post-discharge.

Conclusion

Imagery rehearsal therapy may be effective for COVID-19-related nightmares and in increasing the quality of sleep among patients admitted to the ICU for the treatment of COVID-19. Furthermore, IRT could be useful for its brevity in hospital settings.

Neurorecovery after Critical COVID-19 Illness

With the hundreds of millions of people worldwide who have been, and continue to be, affected by pandemic coronavirus disease (COVID-19) and its chronic sequelae, strategies to improve recovery and rehabilitation from COVID-19 are critical global public health priorities. Neurologic complications have been associated with acute COVID-19 infection, usually in the setting of critical COVID-19 illness. Neurologic complications are also a core feature of the symptom constellation of long COVID and portend poor outcomes. In this article, we review neurologic complications and their mechanisms in critical COVID-19 illness and long COVID. We focus on parallels with neurologic disease associated with non-COVID critical systemic illness. We conclude with a discussion of how recent findings can guide both neurologists working in post-acute neurologic rehabilitation facilities and policy makers who influence neurologic resource allocation.

A Survey to Assess Primary Care Physician Awareness of Complications Following Critical Illness

Background: Survivors of critical illness are at risk for post-intensive care syndrome (PICS, comprised of physical dysfunction, cognitive impairment, and neuropsychiatric disorders including anxiety, depression, and post-traumatic stress). Their family members and caregivers are at risk for PICS-F (PICS-family, comprised of anxiety, depression, post-traumatic stress). PICS and PICS-F are increasingly recognized in critical care; however, the awareness among primary providers of the domains and the terms of PICS/PICS-F is unknown. Objectives: To determine current practice patterns and knowledge among primary care physicians in regards to patients recovering from critical illness; to determine barriers to care of post-critically ill patients. Methods: A paper and electronic survey were developed and randomly distributed to a subset of North Carolina primary care physicians. Survey questions consisted of the following domains: demographics, current practice, barriers to providing care, knowledge of common issues/complications following critical illness, and interest in changing care for survivors of critical illness. Results: One hundred and ninety-six surveys were delivered and 77 completed surveys (39% response rate) were analyzed. Respondents confirmed significant barriers to care of post-critically ill patients including lack of awareness of PICS/PICS-F terminology, insufficient time to spend with patients, and inadequate education of patients/families about recovery after critical illness. Fifty-seven percent of respondents thought a specialized transitional post-ICU clinic would be helpful. Sixty-two percent reported feeling comfortable caring for patients after a critical illness and 75% felt they were aware of common problems encountered after critical illness. However, 84% also thought more education about PICS/PICS-F would be helpful as would a list of common problems seen after critical illness (91%). Conclusions: Significant gaps and barriers to providing optimal post-ICU care by PCPs exist. Providers identified time constraints and educational gaps as domains needing attention. Dedicated post-ICU clinics might provide a bridge to transition care post-critical illness back to primary care providers.

Persistent effects of COVID-19 in patients hospitalized during the first wave of the pandemic: The impact of persistent fatigue on quality of life in a cross-sectional study

COVID-19 can affect physical and mental health long after acute infection. In this descriptive study, 48 individuals hospitalized for COVID-19 between April and May 2020 were interviewed regarding their experience with COVID-19 after hospitalization. The mean age of participants was 51.1 (±11.91) years (range 25-65 years) and 26 (54.2%) were men. Individuals had a mean of 1.2 (±0.94) comorbidities associated with more severe COVID-19, with hypertension (37.5%) being most common. Nineteen (39.6%) individuals required treatment in the intensive care unit. Participants were interviewed a median time of 553 days (IQR, 405.5-589.0) after discharge from the hospital. Thirty-seven (77.1%) individuals had 5 or more persistent symptoms at time of interview with only 3 (6.3%) experiencing none. The most reported persistent symptoms were fatigue (79.2%), difficulty breathing (68.8%), and muscle weakness (60.4%). Poor quality of life was experienced by 39 (81.3%) participants and 8 (16.7%) had a posttraumatic stress disorder (PTSD) score within the clinical range for diagnosis. For multivariable analyses, persistent fatigue was significantly predicted by number of symptoms during acute COVID-19 (t = 4.4, p < 0.001). Number of symptoms during acute COVID-19 was also significantly associated with persistent dyspnea (t = 3.4, p = 0.002). Higher scores on the Chalder fatigue scale after COVID-19 was significantly associated with poor quality of life (t = 2.6, p = 0.01) and PTSD symptomatology (t = 2.9, p = 0.008). More research is needed to highlight the wide range of resources those suffering from Long COVID require long after discharge.

Multidisciplinary approach of the sequelae one month after hospital discharge in patients with severe bilateral COVID-19 pneumonia, are there differences depending on the respiratory therapy used during admission to intensive care?

OBJECTIVE

To describe the sequelae one month after hospital discharge in patients who required admission to Intensive Care for severe COVID 19 pneumonia and to analyze the differences between those who received therapy exclusively with high-flow oxygen therapy compared to those who required invasive mechanical ventilation.

DESIGN

Cohort, prospective and observational study.

SETTING

Post-intensive care multidisciplinary program.

PATIENTS OR PARTICIPANTS

Patients who survived admission to the intensive care unit (ICU) for severe COVID 19 pneumonia from April 2020 to October 2021.

INTERVENTIONS

Inclusion in the post-ICU multidisciplinary program.

MAIN VARIABLES OF INTEREST

Motor, sensory, psychological/psychiatric, respiratory and nutritional sequelae after hospital admission.

RESULTS

104 patients were included. 48 patients received high-flow nasal oxygen therapy (ONAF) and 56 invasive mechanical ventilation (IMV). The main sequelae found were distal neuropathy (33.9% IMV vs 10.4% ONAF); brachial plexopathy (10.7% IMV vs 0% ONAF); decrease in grip strength: right hand 20.67kg (±8.27) in VMI vs 31.8kg (±11.59) in ONAF and left hand 19.39kg (±8.45) in VMI vs 30.26kg (±12.74) in ONAF; and limited muscle balance in the lower limbs (28.6% VMI vs 8.6% ONAF). The differences observed between both groups did not reach statistical significance in the multivariable study.

CONCLUSIONS

The results obtained after the multivariate study suggest that there are no differences in the perceived physical sequelae one month after hospital discharge depending on the respiratory therapy used, whether it was high-flow nasal oxygen therapy or prolonged mechanical ventilation, although more studies are needed to be able to draw conclusions.

["Multidisciplinary Approach of the sequelae one month after hospital discharge in patients with severe bilateral COVID-19 pneumonia, are there differences depending on the respiratory therapy used during admission to Intensive Care?"]

OBJECTIVE

To describe the sequelae one month after hospital discharge in patients who required admission to Intensive Care for severe COVID 19 pneumonia and to analyze the differences between those who received therapy exclusively with high-flow oxygen therapy compared to those who required invasive mechanical ventilation.

DESIGN

Cohort, prospective and observational study.

SETTING

Post-intensive care multidisciplinary programPatients or participants: Patients who survived admission to the intensive care unit (ICU) for severe COVID 19 pneumonia from April 2020 to October 2021Interventions: Inclusion in the post-ICU multidisciplinary programMain variables of interest: Motor, sensory, psychological/psychiatric, respiratory and nutritional sequelae after hospital admissionResults. 104 patients were included. 48 patients received high-flow nasal oxygen therapy (ONAF) and 56 invasive mechanical ventilation (IMV). The main sequelae found were distal neuropathy (33.9% IMV vs 10.4% ONAF); brachial plexopathy (10.7% IMV vs 0% ONAF); decrease in grip strength: right hand 20.67kg (+/- 8.27) in VMI vs 31.8kg (+/- 11.59) in ONAF and left hand 19.39kg (+/- 8.45) in VMI vs 30.26kg (+/- 12.74) in ONAF; and limited muscle balance in the lower limbs (28.6% VMI vs 8.6% ONAF). The differences observed between both groups did not reach statistical significance in the multivariable study.

CONCLUSIONS

The results obtained after the multivariate study suggest that there are no differences in the perceived physical sequelae one month after hospital discharge depending on the respiratory therapy used, whether it was high-flow nasal oxygen therapy or prolonged mechanical ventilation, although more studies are needed to be able to draw conclusions.

Evolution in Care Delivery within Critical Illness Recovery Programs during the COVID-19 Pandemic: A Qualitative Study

Rationale: There are limited data on the impact of the coronavirus disease (COVID-19) pandemic on intensive care unit (ICU) recovery clinic care delivery practices. Objectives: We sought to better understand the patient-level factors affecting ICU recovery clinic care and changing clinical thinking during the COVID-19 pandemic. We also sought to understand how the COVID-19 pandemic sparked innovation within ICU recovery clinics. Methods: A multicenter qualitative study was conducted with ICU recovery clinic interprofessional clinicians involved with the Critical and Acute Illness Recovery Organization (CAIRO) between February and March 2021. Data were collected using semistructured interviews and were analyzed using thematic analysis. Key themes were organized in a working analytical framework. Results: Twenty-nine participants from 15 international sites participated in the study. Participants identified three patient-level key themes that influenced care delivery in ICU recovery programs: 1) social isolation, 2) decreased emotional reserve in patients and families, and 3) substantial social care needs. Changes in ICU recovery clinic care delivery occurred at both the clinician level (e.g., growing awareness of healthcare disparities and inequities, recognition of financial effects of illness, refinement of communication skills, increased focus on reconstructing the illness narrative) and the practice level (e.g., expansion of care delivery modes, efforts to integrate social care) in response to each of the patient-level themes. Identified gaps in ICU recovery clinic care delivery during the COVID-19 pandemic included a need for multidisciplinary team members, access to care issues (e.g., digital poverty, health insurance coverage, language barriers), and altered family engagement. Conclusions: This study demonstrates that addressing patient-level factors such as efforts to integrate social care, address financial needs, refine provider communication skills (e.g., empathic listening), and enhance focus on reconstructing the illness narrative became important priorities during the ICU recovery clinic visit during the COVID-19 pandemic. We also identified several ongoing gaps in ICU recovery clinic care delivery that highlight the need for interventions focused on the integration of social and clinic services for critical care survivors.

A primer on Post-COVID-19 conditions and implications for clinical pharmacists

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and is largely viewed as an acute illness involving multiple organ systems. In the wake of the acute illness, many survivors fully recover and return to baseline, while others suffer from a wide range of lingering symptoms collectively known as "post-COVID conditions". The recognition of these conditions as a clinical entity represents the first step in developing a targeted plan for recovery and symptom mitigation. While interventions to directly minimize or reduce new, recurrent, or persistent symptoms are currently unknown, pharmacists can play a key role in optimizing management of these patients.

A multicomponent family support intervention in intensive care units: study protocol for a multicenter cluster-randomized trial (FICUS Trial)

BACKGROUND

Family members of critically ill patients face considerable uncertainty and distress during their close others' intensive care unit (ICU) stay. About 20-60% of family members experience adverse mental health outcomes post-ICU, such as symptoms of anxiety, depression, and posttraumatic stress. Guidelines recommend structured family inclusion, communication, and support, but the existing evidence base around protocolized family support interventions is modest and requires substantiation.

METHODS

To test the clinical effectiveness and explore the implementation of a multicomponent, nurse-led family support intervention in ICUs, we will undertake a parallel, cluster-randomized, controlled, multicenter superiority hybrid-type 1 trial. It will include eight clusters (ICUs) per study arm, with a projected total sample size of 896 family members of adult, critically ill patients treated in the German-speaking part of Switzerland. The trial targets family members of critically ill patients with an expected ICU stay of 48 h or longer. Families in the intervention arm will receive a family support intervention in addition to usual care. The intervention consists of specialist nurse support that is mapped to the patient pathway with follow-up care and includes psycho-educational and relationship-focused family interventions, and structured, interprofessional communication, and shared decision-making with families. Families in the control arm will receive usual care. The primary study endpoint is quality of family care, operationalized as family members' satisfaction with ICU care at discharge. Secondary endpoints include quality of communication and nurse support, family management of critical illness (functioning, resilience), and family members' mental health (well-being, psychological distress) measured at admission, discharge, and after 3, 6, and 12 months. Data of all participants, regardless of protocol adherence, will be analyzed using linear mixed-effects models, with the individual participant as the unit of inference.

DISCUSSION

This trial will examine the effectiveness of the family support intervention and generate knowledge of its implementability. Both types of evidence are necessary to determine whether the intervention works as intended in clinical practice and could be scaled up to other ICUs. The study findings will make a significant contribution to the current body of knowledge on effective ICU care that promotes family participation and well-being.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05280691 . Prospectively registered on 20 February 2022.