Hello everyone, my name is Michelle Biel. I am a pulmonologist and intensivist at Cleveland Clinic and the director of the post ICU recovery clinic at Cleveland Clinic in the Respiratory Institute. I joined Cleveland Clinic in July 2018 and in 2019 I founded the post ICU recovery clinic. I have long-standing interest in the fields of ARDS, ICU survivorship, patient-centered outcomes and humanizing the ICU. It is my pleasure to be here today presenting this to all of you. The topic that I'm speaking is on post-intensive care syndrome. How can we better help these patients on their road to recovery? And I will specifically talk about PICS and COVID-19. The objectives of my talk today are to describe the burden of critical illness in ICU survivors and survivors of COVID-19, discuss how COVID-19 has impacted post-intensive care syndrome and discuss the role of PICS clinics in the care of COVID-19 patients. PICS definition was created by a group of stakeholders at the 2010 Society of Critical Care Emergency Conference and stands for New or Worsening Physical, Cognitive and or Mental Health Impairments that Occur After Critical Illness. The majority of ICU survivors suffer from one or more components of PICS and unfortunately lung impairment is common, is under-recognized, costly and extends beyond survivors to families and loved ones. Each domain of PICS impacts the other domains and they may last for months to years. And it profoundly affects patients and families' lives. This figure illustrates the burden of critical illness that starts in the ICU and can prolong months to years after hospitalization. There are several risk factors for PICS and time-wise they can be divided before, during and after critical illness, as is exemplified in this figure. For example, during critical illness, delirium and sedation play a big role as well as the severity of illness. We'll quickly change gears now and we'll talk about SARS-CoV-2 causing coronavirus disease or COVID-19. It has emerged in December 2019 and in March 2020 COVID-19 was declared a pandemic by the WHO. It has created a devastating impact worldwide with more than 400 million persons infected, more than 5.9 million persons have died and more than 367 million persons have recovered. This data is as of February 2022. The illness severity of COVID-19 can range from mild to critical. 14% of patients have severe disease and about 5% will develop critical COVID-19 with respiratory failure several times leading to ARDS, shock and multi-organ system dysfunction. The case fatality rate among patients with critical disease is exceedingly high, especially on those patients on mechanical ventilation. And many COVID-19 survivors go to develop long-term impairments after acute disease. Post-acute sequel of SARS-CoV-2 infection or PASC is defined as the persistence of one or more symptoms for longer than 20 days after SARS-CoV-2 infection, after other etiologies have been excluded. It is not surprising that so many terms have been generated like long COVID, long haulers, post-COVID syndrome, post-acute COVID syndrome and others. It is common. It has been described in between 10 and 65% of survivors in different studies. It happens irrespective of severity of acute phase and the underlying mechanism have been proposed but pathophysiology is unknown. The projected impact of PASC has had a significant global burden and should be tackled as a public health emergency. This figure demonstrates the timeline of post-COVID-19. The common symptoms observed in post-COVID-19 beyond four weeks from the onset symptoms are summarized here with fatigue being one of the most common symptoms as well as exertion intolerance, dyspnea and cough. Anxiety, depression and brain fog have been particularly common as well. This figure illustrates the potential long-term manifestations of COVID-19 based on documented long-term effects of the SARS-CoV-1 infection and MERS coronavirus infection as well as COVID-19 manifestations documented to date. There is multi-organ system involvement and includes post-intensive care syndrome. COVID-19 survivors are at high risk for developing peaks for a number of reasons and I would call that COVID-19 related peaks. Although the management of peaks has been advanced, the outbreak of COVID-19 pose an additional challenge to peaks. Many tools utilizing the ICU to prevent peaks like the ABCDF bundle have been sacrificed during the pandemic. The main emphasis is placed on organizational issues like lack of ventilators, shortage of PPE, resource allocation and prioritization of limited mechanical ventilation options. Some of the factors contributing to peaks are prolonged mechanical ventilation with exposure to a great amount of sedatives, limited physical therapy during and after hospitalization due to the risk of disease transmission, scarcity of family support due to restricted visitation and constraints on social support after hospitalization due to the stigma of the disease. This figure here illustrates nicely the COVID-19 pandemic related factors that could exacerbate the physical, cognitive and our mental health impairments. As you can see the limited rehabilitation services, lifestyle changes like joblessness, fear of infecting others are being reinfected and the social isolation can affect all of the physical impairments as all of the impairments like the physical, the mental health and the cognitive impairments and each of those domains can also be exacerbated by other risk factors. For example, physical impairments can be exacerbated by proning and prolonged mechanical ventilation, cognitive impairments by prolonged delirium and prolonged ICU stay with visitor restrictions and mental health impairment can risk factors for worsening impairment can be prolonged ICU stay with also visitor restrictions. The pathophysiology of PASC has yet to be fully determined but it's likely a combination of direct and indirect mechanisms of injury and the immune response. This figure I think very well illustrates what has been proposed. From the virus infection, causing lung injury, causing a systemic response, injury and dysfunction of different organs and then leading to PICS. I will further explore COVID-19 and the risk for delirium. Delirium before the pandemic was already known to affect up to 80% of critically ill patients. Although the delirium data in COVID-19 era is limited so far, there are several risk factors that have been identified to accelerate the risk of delirium like the direct effect of the virus on the CNS and the inflammatory response in the central nervous system, prolonged mechanical ventilation, use of sedatives, immobilization. Delirium is also exacerbated by the lack of human contact. Healthcare workers while wearing PPE that can mask their facial expressions and it makes difficult for the patients to hear and makes the healthcare workers appear to patients as completely strangers. This can also increase the risk of delirium. Many patients are aware from the news coverage of how severe the disorder can be. This is further exacerbated by having no direct support from the family that may lead to feeling of abandonment and fear of dying alone. This figure from Kotfis and colleagues exemplifies very well the crucial interventions that we have learned over the years that prevent delirium and that the pandemic has caused awful interruption of these interventions. So as you can see here in blue are the interventions that we have learned and have been trying to do to prevent delirium and in red are everything that the pandemic has caused and in a way that interrupted the prevention of delirium like the restricted visitation, limitations on non-pharmacologic interventions for pain, for sedation, prolonged immobility, uncertainty about the pandemic causing anxiety, depression and increased risk of peaks and peaks family, disruptions to religious and spiritual services, increased healthcare professional workload, as well as neurocognitive dysfunction, especially with inability to express emotional and spiritual needs. It has been well-described that the pandemic has caused a lot of disruption it has been well demonstrated in the post-intensive care syndrome literature that delirium is an independent risk factor for peaks specifically for long-term cognitive impairment in patients after severe illness. Delirium also independently increased the risk for prolonged mechanical ventilation, longer ICU and hospital stay and functional dependence and is associated with a higher mortality up to two years after discharge. This brings us to the COVID-19 ICU survivor. What is it that the COVID-19 ICU survivor experienced post-critical illness? It is definitely a substantial overlap between PASC and peaks. Both causes physical, psychological and cognitive impairments. And the COVID-19 pandemic has complicated recovery across these key domains of mental, psychological and physical impairments, which are intimately connected and commonly seen in ICU survivors. Now, going back to our figure showing the burden of critical illness in ICU survivors, this is what that figure would look like for a COVID-19 ICU survivor. Pretty much the peaks exacerbated during all of these stages of peaks. I would like to show now several studies that exemplify peaks in COVID-19 survivors. This is a multi-center cohort study by Poon and colleagues that show that the prevalence of delirium was very high at 54% in critically ill patients with COVID-19. Acute pain dysfunction was also highly prevalent and prolonged in critically ill patients with COVID-19. As you can see, the median duration of coma or delirium was about 12 days. Here is the same study showing the performance of the ABCDF bundle during the study days. SAT and SBT were done in only 19% of the time, mobility 16% of the time of the study, and family engagement, as expected, was very low, especially due to COVID-19 restrictions. The ABCDF bundle plays a significant role in the prevention and mitigation of FICS and knowing that it was sacrificed during COVID-19 pandemic has definitely increased the risk of FICS. This is another study showing outcomes in patients and families three and six months post-discharge. I just want to stop here for a while and let you observe this figure. Social function like return to work affected both patients and families, and psychological aspects like anxiety, depression, and fear of reinfection also affected patients and families months after hospitalization. There are several other studies coming and showing FICS after critical COVID-19 from Belgium, from the U.S. Also studies from New York with data showing how FICS has had a high incidence in post-COVID-19 clinic and post-ICU recovery clinics. In the critical care literature, several post-ICU interventions have been studied and proposed to mitigate FICS. One of those are the post-ICU recovery programs. Several others as exemplified here like early rehabilitation, early psychological intervention, cognitive rehab, peer support groups between others. So we'll talk a little bit more now about FICS clinics and post-COVID-19 clinics. Both clinics share many things in common, again, exemplifying the significant overlap. Several centers have created multidisciplinary programs for the post-COVID-19 population. Recognition of this syndrome is key, both for post-COVID syndrome as well as for post-intensive care syndrome. A comprehensive and multidisciplinary approach are vital. Coordination of care and support for patients as well as the teams are extremely important. The clinics usually offer care pathways to other specialties and subspecialties as needed. And there is a unique opportunity for research. Many of us critical care clinicians have been working in post-ICU clinics way before the pandemic hit. This is well known to us. We can and should follow what we have learned regarding FICS clinics and apply to post-COVID clinics. This is a study by Parker and colleagues described their multidisciplinary model of care that they created to address the post-ICU sequela of COVID-19. So the elements of the initial screening evaluation, as you can see there for survivors of COVID-19, are very similar to what we do in our FICS clinics for ICU survivors. And the symptoms or impairments that generate for the workup, as you can see in the right side of the figure, are also very similar to what we have been doing in our FICS clinics. This work done by Brown and colleagues illustrates very nicely the patient needs reviewed at post-ICU recovery clinic visits and interventions that are usually done, which again can be well applied to post-COVID-19 clinics. I'll hold here for a while so you can observe this figure that talks about all of the different aspects that are worked for patients in the post-ICU clinics, pharmacy, subspecialty medical care, rehabilitation, cognitive impairment, mental health problems, and so forth. I would like to summarize here, saying that critical units of the COVID-19 can lead to several impairments, including PICS, which are very similar to ICU survivors. Post-intensive care syndrome, or PICS, has been exacerbated by COVID-19 by many reasons. Despite the limited data, already many studies are evidencing the high incidence of PICS in COVID-19 ICU survivors. And the approach that has been utilized by ICU survivors for the past 15 plus years regarding prevention and mitigation of PICS can and should be applied to post-COVID-19 ICU survivors, aiming at improving long-term survivorship of this growing population. To me, what is fundamental in the care to improve the lives of ICU survivors and then applying to COVID-19 ICU survivors is empathic listening, multi-professional teamwork, learn with experiences and utilize that to grow, raise awareness about ICU survivorship, ongoing research, and always placing patients as the center of what and why we do. I would like to thank you very much for this opportunity to talk to you today about post-intensive care syndrome and COVID-19 and ICU survivorship.

post-intensive care syndrome

PICS

COVID-19 patients

lung impairment

post-acute sequel of SARS-CoV-2 infection

PASC