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Today, a patient was discharged after an extended stay in the hospital. As we do for many patients who have survived COVID-19, we celebrated the patient's discharge. Staff who had cared for the patient lined the halls — smiling, clapping and some even had tears in their eyes. There were balloons, and a celebratory song was played over the loudspeaker as the nurse wheeled the patient to their spouse, who was eager and ready to take their loved one home at last. As a hospital chaplain, I know the value of having a case like this patient, to the family, certainly, but also to the medical community. When illness feels overwhelming, having someone who was so sick recover so beautifully changes the mood of all those who worked with them. For many staff in our hospital, this patient was our miracle — that ray of hope that reminded us even the sickest person can get better.

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When a COVID-19 survivor leaves the hospital, recovering physically may not be the only feat they’re faced with overcoming. For many patients who have undergone intensive care, studies have shown that there is also a likelihood for cognitive and psychological complications, which can linger for months, or even years.

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In the early days of caring for critically ill patients with acute respiratory distress syndrome, sepsis or multiple organ failure, we were grateful when they survived their illness. We used any interventions we could think of to increase the likelihood of survival. We didn’t really think about what came after patients’ intensive care unit (ICU) experience; we were just happy they survived. However, we came to find out that despite our best efforts, these patients had a high risk of developing delirium and post-discharge sequelae.

Brief description of media:

The COVID-19 pandemic has led to vastly increased admissions into intensive care units (ICU). Around one in four ICU patients develop PTSD symptoms after the admission. Other disorders, including depression and various anxiety disorders are also common.This guide aims to provide information for therapists working with patients who have developed PTSD after an ICU admission, or a similar medical environment.

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Background

In this case report, we describe the trajectory of recovery of a young, healthy patient diagnosed with coronavirus disease 2019 who developed acute respiratory distress syndrome. The purpose of this case report is to highlight the potential role of intensive care unit recovery or follow-up clinics for patients surviving acute hospitalization for coronavirus disease 2019.
Case presentation

Our patient was a 27-year-old Caucasian woman with a past medical history of asthma transferred from a community hospital to our medical intensive care unit for acute hypoxic respiratory failure due to bilateral pneumonia requiring mechanical ventilation (ratio of arterial oxygen partial pressure to fraction of inspired oxygen, 180). On day 2 of her intensive care unit admission, reverse transcription–polymerase chain reaction confirmed coronavirus disease 2019. Her clinical status gradually improved, and she was extubated on intensive care unit day 5. She had a negative test result for coronavirus disease 2019 twice with repeated reverse transcription–polymerase chain reaction before being discharged to home after 10 days in the intensive care unit. Two weeks after intensive care unit discharge, the patient returned to our outpatient intensive care unit recovery clinic. At follow-up, the patient endorsed significant fatigue and exhaustion with difficulty walking, minor issues with sleep disruption, and periods of memory loss. She scored 10/12 on the short performance physical battery, indicating good physical function. She did not have signs of anxiety, depression, or post-traumatic stress disorder through self-report questionnaires. Clinically, she was considered at low risk of developing post–intensive care syndrome, but she required follow-up services to assist in navigating the healthcare system, addressing remaining symptoms, and promoting return to her pre–coronavirus disease 2019 societal role.
Conclusion

We present this case report to suggest that patients surviving coronavirus disease 2019 with subsequent development of acute respiratory distress syndrome will require more intense intensive care unit recovery follow-up. Patients with a higher degree of acute illness who also have pre-existing comorbidities and those of older age who survive mechanical ventilation for coronavirus disease 2019 will require substantial post–intensive care unit care to mitigate and treat post–intensive care syndrome, promote reintegration into the community, and improve quality of life.

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Tens of thousands of Covid-19 survivors should be screened for post-traumatic stress disorder because of their experiences in fighting for their lives, mental health experts have urged.

Leading psychiatrists and psychologists want NHS bosses to ensure that all those who were admitted to hospital when they became seriously ill with the disease are assessed and checked regularly.

Survivors showing signs of PTSD would undergo treatment to prevent nightmares and flashbacks that could blight the rest of their lives.

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You didn’t die. You battled COVID-19 in intensive care for more than a week. You were on a ventilator but pulled through. Now you are disabled.

This will happen to a significant number of people who discharge home after fighting COVID-19. It is typical of the course that post-intensive care syndrome (PICS) takes by creating or worsening physical impairment as well as causing cognitive and psychological impairment among patients who have been critically ill.

Neuromuscular weakness is the most common form of physical impairment that individuals acquired during a stay in the ICU, with more than 25% having poor mobility, recurrent falls, or quadri or tetra paresis.

Physical symptoms often resolve within 12 months after discharge from an acute care setting. However, research shows that ICU-acquired weakness can last as long as 24 months.

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The number of Americans hospitalized with the virus is increasing again, reaching 41,000 late last week, many with a circle of loved ones holding vigil in their minds, even if they can’t sit at the bedside. A decade ago, critical care clinicians coined the term post-intensive care syndrome, or PICS. It describes the muscle weakness, cognitive changes, anxiety and other physical and mental symptoms that some ICU patients cope with after leaving the hospital. Those complications are fallout from the medications, immobility and other possible components of being critically ill. Now they worry that some family members of critically ill COVID patients may develop a related syndrome, PICS-Family.

Studies show that about one-fourth of family members, and sometimes more, experience at least one symptom of PICS-Family, including anxiety, depression, post-traumatic stress disorder or “complicated grief” — grief that is persistent and disabling — when their loved one has been hospitalized, according to a 2012 review article published in the journal Critical Care Medicine. Dr. Daniela Lamas, a critical care physician at Boston’s Brigham and Women’s Hospital, believes relatives and friends of coronavirus patients may be particularly vulnerable.

Hospital rules designed to prevent the spread of the virus have robbed them of the opportunity to sit with their loved ones, watching clinicians provide medical care and gradually processing what’s happening between physician updates, Lamas said. In pre-pandemic times, a nurse “would explain what they had heard [from the doctor] and help them come to terms with unacceptable realities,” she said.

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Many are struggling to overcome a range of troubling residual symptoms of the coronavirus, and some problems may persist for months, years or even the rest of their lives. Patients who are returning home after being hospitalised for severe respiratory failure from the virus are confronting physical, neurological, cognitive and emotional issues.

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Early this year, when the world was first coming to grips with the spread of COVID-19 and the challenges it would present, Dr. Brad Butcher, a critical care medicine specialist at UPMC Mercy, was focused on what was coming next.
“We heard that patients who required time in the intensive care unit, and particularly time on a mechanical ventilator, were staying on the ventilator for a very long time,” he said. “This is concerning because the longer people stay in bed, the more physical weakness can develop, and the longer they’re on ventilation, the more drugs they need to sedate them.”
Additional medication increases the risk of patients developing delirium, which raises the likelihood of long-term cognitive complications from the critical illness. These conditions would only be intensified by the limited interactions with care providers and loved ones permitted by COVID-19 safety protocols.
“We were very concerned that these patients would be at increased risk for anxiety, depression and post-traumatic stress disorder,” Butcher said.
In other words, COVID-19 had the potential to create a perfect storm in the realm where Butcher and his colleague Tammy Eaton, C.R.N.P., specialize: Post-Intensive Care Syndrome (PICS). PICS is a set of conditions that have been around as long as critical care medicine, but it received a name only a decade ago. Addressing PICS is the mission of the UPMC Critical Illness Recovery Center (CIRC), which Butcher and Eaton founded at UPMC Mercy.

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Of all his years, 2020 was exceptionally challenging for Vietnam veteran Matthew Thomas. After the 75-year-old Aurora resident tested positive for Covid-19 in mid-May, doctors had to intubate him for 33 days so he didn’t go into respiratory failure. While Thomas survived, his 33-year-old son, diagnosed with Covid-19 shortly before his father was hospitalized, passed away.

Thomas also faced widespread effects from Covid-19, stemming from the time spent intubated and in intensive care. “The byproduct of the disease is that my muscles went to sleep,” says Thomas, who says his muscles became so weak that he could not use his arms and legs.

“I couldn’t do anything. I couldn’t even stand up,” he says.

Brief description of media:

In the early days of caring for critically ill patients with acute respiratory distress syndrome, sepsis or multiple organ failure, we were grateful when they survived their illness. We used any interventions we could think of to increase the likelihood of survival. We didn’t really think about what came after patients’ intensive care unit (ICU) experience; we were just happy they survived. However, we came to find out that despite our best efforts, these patients had a high risk of developing delirium and post-discharge sequelae.