By Steve Dechan
Managing the immediate demands of the coronavirus pandemic (COVID-19) has tested many of the world’s healthcare systems to their limits. As we move forward, the new challenges presented by this impact must be faced.
More than 111.3 million cases of COVID have occurred worldwide in the months since the initial outbreak in December 2019. However, the speed of spread appears to be slowing, the curve in many countries is beginning to flatten, and attention is starting to turn to how the international community will address the continuing needs of those most affected by the pandemic.
Recent UK data (covering February-April 2020) indicates that 17% of those admitted to hospital with COVID-19 required support in Intensive Care Units (ICU), and of those, more than 50% required mechanical ventilation. About 20% of those requiring mechanical ventilation are said to be discharged, with a further 27% receiving ongoing care. Given the number of global infections, this suggests a cohort of critically ill survivors of unprecedented size.
The treatment needs of COVID-19 survivors are not yet fully appreciated. Although initially assumed to be a respiratory disease, it is now clear that the disease affects a variety of internal systems. According to the American Centers for Disease Control and Prevention, the long-term complications of COVID-19 can include:
- Cardiovascular: inflammation of the heart muscle
- Respiratory: lung function abnormalities
- Renal: acute kidney injury
- Dermatologic: rash, hair loss
- Neurological: smell and taste problems, sleep issues, difficulty with concentration, memory problems
- Psychiatric: depression, anxiety, changes in mood
From these difficulties, it is therefore likely that COVID-19 survivors will have significant issues requiring ongoing support post-pandemic. As a result of this, there has been a recent ‘call to action’ amongst the rehabilitation community to act quickly to ensure adequate resources to provide early phase, multidisciplinary interventions to promote physical and psychological recovery from COVID-19.
These complex long-term challenges have been termed post-intensive care syndrome (PICS). This term incorporates all complications reported post-ICU that can have acute effects on an individual’s quality of life. Chronic pain is often part of this, but how this affects sufferers of PICS is poorly understood. Estimates of chronic pain prevalence post-ICU vary from 14% to 77% depending on timescale, method of measurement, and population. Pain also appears to be an important factor affecting one’s ability to return to work and quality of life up to 5 years after discharge. Those surviving critical COVID-19-related illness will likely be at particular risk of developing chronic pain, PICS and the lifestyle implications this carries.
As the occurrence of acute pain is a consistent risk factor for those with chronic pain, it is worth considering how this is managed in the ICU. Those recalling higher pain and distress during ICU admission appear to be at higher risk of developing chronic pain after discharge. Unfortunately, even in quiet periods in ICU, pain is an often-neglected symptom receiving low priority and surprisingly poor assessment and management given the highly staffed, well-skilled environment.
In response to this, guidelines to improve pain assessment and management in ICU have been developed in the USA and Europe. These guidelines are aimed at improving long-term outcomes through multidisciplinary management of symptoms, mobility, and communication. However, these processes, which often involve non-pharmacological strategies, are labour intensive and realistically may be unachievable in current pandemic conditions.
It is now clear that COVID-19 itself is associated with painful symptoms, including myalgia, arthralgia, abdominal pain, headache, and chest pain, and even those not admitted to critical care environments may have pain requiring opioids for symptom management.Flexibility and changes to the delivery of health and social care are required in this rapidly changing clinical environment. While the path of this pandemic has not given us the luxury of creating a high-quality evidence base on which to base our management decisions, it is up to us to critically evaluate how we are approaching these ongoing issues. Looking forwards, we need to work collaboratively to evaluate interventions used in post-COVID-19 patient rehabilitation, and ensure we can support those who need support in the future.