Since the beginning of the Covid19 epidemic, more than four million cases have been reported worldwide as of early May 2020. The most frequent symptoms and signs are fever, dry cough, asthenia, anosmia and dyspnea. Thirty percent of people with COVID19 require hospital admission and 4% are considered critically ill, defined as requiring mechanical ventilation or other criteria for ICU care.

The advances developed in recent years in the field of Intensive Care Medicine have significantly increased the survival of critically ill patients.

Up to 50% of critically ill patients will present with what is known as post-intensive care syndrome (PICS), which presents with weakness in the extremities, cognitive alterations and/or mood disorders that were not present before admission or that have been exacerbated.

This syndrome has a significant impact on the quality of life of people, since it has been seen that one year after admission to the ICU, 30% of people cannot return to their usual work and 25% will require assistance for basic activities such as dressing or toileting.

In the article entitled “Covid-19 and Post Intensive Care Syndrome: A Call For Action“,

published in April of this year in the Journal of Rehabilitation Medicine, physicians from Rehabilitation Services of hospitals in Switzerland and Holland, warn of the need to prepare ourselves to be able to attend to the increase in the number of patients with this syndrome secondary to Covid-19 and to prevent the Rehabilitation Units from collapsing as has happened with the ICUs.

Factors such as advanced age or certain previous diseases such as cognitive impairment, neuromuscular diseases or psychiatric pathology increase the risk of suffering from this syndrome.

It has also been related to aspects derived from the stay in the ICU such as the need for mechanical ventilation and its duration, acute respiratory distress syndrome, sepsis, the use of certain drugs (sedatives, corticosteroids, muscle blockers) or prolonged immobilization.

The most frequent symptoms of post – uci syndrome are classified into 3 groups:

1. Motor symptomsdepending on the severity can range from a slight clumsiness to walk with falls to paralysis of all 4 limbs. It is due to peripheral nerve and/or muscle involvement, known as polyneuropathy-myopathy of the critically ill patient. Sometimes this weakness can extend to the facial and pharyngeal musculature causing difficulty in swallowing (dysphagia).

• Cognitive symptoms which include problems with attention, concentration, memory lapses or executive dysfunction. These symptoms can significantly limit the person’s autonomy (e.g. they may forget to take medication or have difficulty performing daily tasks). In many cases, as the motor symptoms are more striking, the diagnosis and treatment of these cognitive symptoms are not given adequate attention.

• Mood disorders such as anxiety, depression or even post-traumatic stress syndrome. They may include irritability, restlessness, fatigue, sadness, insomnia and/or loss of appetite.

The diagnosis of post-ICU syndrome is fundamentally clinical, based on the patient’s medical history, neurological examination and the performance of a neuropsychological study with standardized tests that evaluate the cognitive and emotional state. Occasionally, the study is completed with an electromyogram to assess the polyneuropathy-myopathy of the critically ill patient.

This syndrome can affect patients who have been admitted to intensive care for covid19.

The treatment is based on preventive measures and early initiation of rehabilitation. Among the preventive measures it is important to reduce as much as possible the use of some drugs (e.g. corticosteroids, sedatives) and to monitor the nutritional status of the person to avoid malnutrition. Several studies show that physical rehabilitation not only facilitates motor recovery, but also reduces cognitive problems, mood alterations and significantly improves the degree of functional recovery achieved by people with post-ICU syndrome.

This treatment begins with mobilizations during the ICU stay and is often continued after hospital discharge. It is a multidisciplinary treatment, with the coordinated participation of intensivists, neurologists, psychiatrists and rehabilitation teams. Each patient will require individualized treatment depending on the presenting symptoms.

The physiotherapist and occupational therapist will treat motor symptoms, the speech therapist will treat swallowing or speech problems, and the neuropsychologist will treat cognitive symptoms.

Our Neurorehabilitation Unit has extensive experience in the treatment of this pathology and works in coordination with the ICU team of the Ruber Internacional Hospital.

Bibliography

1. Technical scientific information. Coronavirus disease, COVID-19. Center for Coordination of Health Alerts and Emergencies. Ministry of Health. Updated April 17, 2020

• Griffiths J, Hatch RA, Bishop J, et al. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 21-month follow-up study. Crit Care 2013; 17: R100.

• Marra A, Pandharipande PP, Girard TD, et al. Co-Occurrence of Post-Intensive Care Syndrome Problems Among 406 Survivors of Critical Illness. Crit Care Med. 2018;46(9):1393.

• Stam HJ, Stucki G, Bickenbach J.Covid-19 and Post Intensive Care Syndrome: A Call for Action. J Rehabil Med. 2020 Apr 15;52(4).

• Rawal G, Yadav S, Kumar R. Post -intensive care syndrome: an overview. J Transl Int Med 2017; 5: 90-92.

• Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 2009; 373: 1874-1882.

• Hopkins RO, Suchyta MR, Farrer TJ, et al. Improving post-intensive care unit neuropsychiatric outcomes: understanding cognitive effects of physical activity. Am J Respir Crit Care Med. 2012 Dec;186(12):1220-8. Epub 2012 Oct 11.

Author: Dr. Elena Riva Amarante . May 2020.