Monday, March 14, 2022

"Long COVID" symptoms in COVID-19 ICU survivors

 - Jennifer Middleton, MD, MPH

Our understanding of Post-Acute Sequelae of SARS-CoV-2 (PASC), also known as "post-COVID conditions," and/or "long COVID," continues to grow as we pass the 2-year mark of the onset of the COVID pandemic in the United States (US). In the spring of 2021, Dr. Lin reviewed data suggesting that approximately 10% of persons who are infected with COVID experience symptoms for greater than 4 weeks; since then, estimates of PASC have ranged as high as 50% in COVID survivors. A new study sought to identify the prevalence of PASC in persons with COVID-19 infection who required care in the intensive care unit (ICU) and found even higher rates of persistent symptoms, but it's unclear what degree of those symptoms were specifically due to COVID-19.

The symptoms associated with PASC are numerous and include physical, mental, and cognitive concerns, including "cough, breathlessness, fatigue, fever, sore throat, nonspecific chest pains (lung burn), cognitive blunting (brain fog), anxiety, depression, skin rashes, and diarrhea." This study of ICU COVID-19 survivors followed the outcomes of 246 persons in the Netherlands who had been admitted at least one year prior. The researchers sent surveys to these survivors that included several validated symptom scores for physical, mood, and cognitive symptoms following hospitalization. They found that:

At 1 year after ICU treatment for COVID-19, physical symptoms were reported by 182 of 245 patients (74.3% [95% CI, 68.3% to 79.6%]), mental symptoms were reported by 64 of 244 patients (26.2% [95% CI, 20.8% to 32.2%]), and cognitive symptoms were reported by 39 of 241 patients (16.2% [95% CI, 11.8% to 21.5%]).

The study authors appropriately note that these outcomes are quite similar to those published in patients without COVID-19 surviving ICU care. It's difficult to disentangle, at this point, how much of this symptom burden is directly attributable to COVID-19 infection versus just the expected sequelae of illness serious enough to require ICU care - not to mention that the stress of ICU care itself can cause post-traumatic stress disorder (PTSD) (with a prevalence of approximately 10%). It certainly seems plausible, though, that patients with severe COVID-19 infection would also have at least a similar, if not higher, risk of PASC as those patients with COVID-19 who didn't need ICU care. 

Regardless of the exact numbers and/or the degree of contribution of COVID-19 itself, primary care clinicians are likely to provide much of the care to COVID-19 survivors with persistent symptoms. These high prevalence rates should encourage us to ask proactively about PASC/"long COVID" symptoms in our COVID-19 survivors and to validate our patients' frustration and suffering. Though we still have much to learn about PASC, informal guidelines are emerging regarding best treatment practices; this AFP editorial on "Long COVID: A Primer for Clinicians" contains a helpful overview, and look soon for review article on long COVID in an upcoming issue of AFP. The US Centers for Disease Control and Prevention (CDC) also has interim guidance on Post-COVID conditions on its website, and this AFP article on "Post-ICU Care in the Outpatient Setting" provides excellent guidance as well for caring for ICU survivors in general.