Understanding Post-Intensive Care Syndrome (PICS) and COVID-19 survivorship

Although, intensive care has evolved significantly as a result of technological innovations in ICUs the effects of life-threatening illness extend beyond the hospital stay and have a great impact on patient’s life. Post-intensive care syndrome (PICS) refers to a patient’s new or worsened impairment after an ICU stay, persisting past hospital discharge. PICS is evident in one or more of the following domains: physical function, cognitive abilities and mental health[1]. At the same time, critical illness has a great psychological impact on the patient’s family. Adverse psychological reactions from family members are referred to as Post-Intensive Care Syndrome-family (PICS-F). Traditionally, individuals affected by PICS-F are mostly affected in the domain of mental health (depression, anxiety, Post-Traumatic Stress Disorder (PTSD), complicated grief).

A common assumption is that when a patient is discharged from the hospital, their life goes back to normal. This notion may be misleading and based on the experience from previous outbursts (SARS-CoV, H1N1) it is far from true. Existing knowledge available after the outbreak of SARS in 2003 indicate that a pandemic can turn into a major physical and mental health challenge. In a follow-up study of 195 adult SARS patients, 10%-18% reported Post-traumatic Stress Disorder (PTSD) one month after discharge. The severity of symptoms was attributed to higher perceived life-threat and low emotional suppor [2]. Based on relevant research findings, SARS patients exhibited higher stress levels during the outbreak with no sign of decline after 1 year and also exhibited worrisome depression and anxiety with a 64% reaching the diagnostic criteria for psychosis [3,4].  In the past, research on acute-respiratory distress syndrome (ARDS) survivors demonstrated a significant reduction in all physical and mental constructs in regard to Quality of Life (QoA) assessments following a discharge period between 6months and 2 years [5].

Long-COVID19 survivors are at a high risk for developing PICS following discharge from the hospital. A variety of factors will make the rehabilitation process for COVID19 survivors more complicated: prolonged mechanical ventilation, deep sedation, limited physical therapy due to the risk of transmission. Patients with severe respiratory failure may experience delirium which is an important risk factor for cognitive impairment. At the same time, lack of social support and interaction can contribute to low cognitive functioning due to the lack of stimulation. Long-COVID19 survivors may also experience mental health impairments related to additional stressors like: stigma, survivor guilt and fear of disease transmission to loved ones. Awareness of PICS is necessary in designing and delivering services that will improve the long-term experience of COVID19 survivors that may require prolonged rehabilitation. Although, there is no available data in regard to the prevalence of PICS in long-COVID19 survivors, the duration of critically ill patients is much higher than that of SARS and, consequently, the negative impact on patients’ QoL is expected to be a lot higher. Data on the aftermath of COVID-19 patients discharge is still limited yet there is growing concern on how to assist survivors effectively. The anticipated cohort of post-ICU patients that the pandemic will create great challenges for the patients and their caregivers. It is essential to adopt an interprofessional approach that brings together: patient, family, HCPs and caregivers. Developing chronic lung issues as a result of COVID-19 infection can significantly impair the quality of life including mental and physical health. In this case, the implementation of telecare and remote patient monitoring in the home environment may contribute in improving patient outcomes by making an impact on the rehabilitation process.

Sophia Vassiliadis

WELLICS LTD

[1] Needham DM, Davidson J, Cohen H, et al. Improving long-term outcomes after discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med. 2012;40(2):502–509. doi:10.1097/CCM.0b013e318232da75

[2]  Wu KK, Chan SK, Ma TM. Posttraumatic stress, anxiety, and depression in survivors of severe acute respiratory syndrome (SARS). J Trauma Stress. 2005;18(1):39–42.

[3] Cheng SK, Wong CW, Tsang J, Wong KC. Psychological distress and negative appraisals in survivors of severe acute respiratory syndrome (SARS). Psychol Med. 2004;34(7):1187–95

[4] Cao W, Fang L, Xiao D. What we have learnt from the SARS epidemics in mainland China? Glob Health J. 2019;3(3):55–9.

[5] Bein, Thomas et al. “Long-term outcome after the acute respiratory distress syndrome: different from general critical illness?.” Current opinion in critical care vol. 24,1 (2018): 35-40. doi:10.1097/MCC.0000000000000476