There are certain facts that everyone knows. We are in a terrible COVID-19 pandemic. Hundreds of thousands of people have fallen ill, tens of thousands have been hospitalized and large numbers are in an ICU. The ICU stays have been long and medical personnel are our heroes, saving the lives of scores of patients.  

As these patients improve and leave the ICUs and acute care hospitals, we must carefully examine the needs of these patients to get them back to their pre-COVID-19 lives. 

While we don’t know all the impacts COVID-19 may have on a patient, we do know that after an extended stay in an acute hospital or the ICU, a patient is likely to have physical and cognitive problems. These problems need to be addressed in an inpatient rehabilitation hospital, where a team of physical, occupational and speech therapists can address them. In addition, inpatient rehabilitation care delivers round-the-clock nursing care as well as frequent physician visits. These patients are complex and need to be in a rehabilitation hospital. 

The impact of a Cytokine Storm

We know from our experience that these patients’ brains and organs are exposed to what has been termed a “Cytokine Storm.” The virus not only attacks the lungs, but also causes cytokines to be released that cause a severe inflammatory response throughout the entire body. The brain, muscles, nerves and other organs are all affected. This takes place while the patient lies motionless and severely ill. 

Physical, cognitive and behavioral problems

We know from previous studies of critically ill patients that they will leave the ICU with physical, cognitive and behavioral problems. While the patient is in the ICU, everyone is feverishly working to save their life–adjusting ventilators, balancing complicated intravenous medicines and even dialysis. As a result, it is easy to miss the cognitive and behavioral changes that have taken place. Weakness is attributed to having been “sick” and in bed a long time. 

Studies of critically ill ICU patients reveal that 70-100% of these patients have significant cognitive problems at the time they are discharged from the ICU. A surprising two thirds still have problems a year later. There can be problems with their memory, attention, concentration and problem solving. In addition, behavioral problems like depression, apathy and fatigue may be prominent. As we rapidly make room for the next patient it is easy to overlook these cognitive and behavioral issues. 

Weakened and damaged muscles and nerves

In the past physicians have written off complaints of weakness as the side effects of prolonged bedrest. However, the same “cytokine storm” that affects the brain causes damage to the patient’s muscles and nerves. At least 50% of patients with a prolonged ICU stay will develop a Critical Illness Neuropathy/Myopathy. They may have difficulty lifting their arms up over their head to comb their hair or even brush their teeth. Trying to get up from a chair takes more strength than they can muster. All of this is particularly true of patients who have been on a ventilator for a prolonged period and may be difficult to wean off the ventilator. The muscles that control our breathing are attacked by this same “cytokine storm.”

Solving the problem

These are all issues that need to be addressed in a rehabilitation hospital where both the complex medical needs and rehabilitation can be addressed. Aggressive rehabilitation is the key to returning someone safely to their home and family.  The main goal in the acute care hospital is to save lives. The main goal of the rehabilitation hospital is to help the person return home to their loved ones.

What could feel better after a prolonged period of isolation than hugging your family and going to sleep in your own bed?

Citations

Angus DC, van der Poll T: Severe Sepsis and Septic Shock. NEJM 2013; 369:840-851.

Iwashyna TJ, Ely EW et al: Long Term Cognitive Impairment and Functional Disability Among Survivors of Severe Sepsis. JAMA 2010; 304:1787-1794.

Khan J, Harrison TB, Rich MM, Moss M. Early Development of Critical Illness Myopathy and Neuropathy in Patients with Severe Sepsis. Neurology 2006; 67:1421-1425.

Pandharipande PP, Girard TD et al: Long-term Cognitive Impairment after Critical Illness. NEJM 2013; 369:1306-16.

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