Up to 31 million of coronavirus disease 2019 (COVID-19) cases have been confirmed to date. Twenty percent of COVID-19 patients are reported to need critical care, essentially because of acute respiratory distress syndrome (ARDS). ARDS is a major risk factor of post-intensive care syndrome, which refers to a patient with new or worsening impairment in any physical, cognitive or mental domain after critical illness or intensive care. There is a lack of awareness regarding post-intensive care syndrome and very few data on recovery after a severe COVID-19 episode are available. The aim of this preliminary report was to evaluate the Health-Related Quality of Life (HRQoL) in survivors of severe COVID-19 at 3-month.
This observational, retrospective, and monocentric study was based on prospectively collected data from usual care (Institutional review board of the French Society of Anaesthesiology and Critical Care: IRB 00010254-2019-203 of the 28th of December 2019, about prognosis evaluation of patients admitted to surgical intensive care unit [ICU]). All participants provided written informed consent. We evaluated HRQoL in survivors of severe COVID-19 who were admitted to surgical ICU at Saint-Louis Hospital (AP-HP, Paris, France) between the 16th of March and the 18th of May 2020. HRQoL was evaluated during a dedicated ICU follow-up service by using the 36-Item Short Form Health Survey (SF-36) [1] and the 3-level version of the EQ-5D score (EQ-5D-3 L) [2]. The SF-36 is an internationally recognised instrument that has been used to assess the QoL for patients with other respiratory infections, including those caused by avian influenza A (H7N9) virus [3], and Middle East respiratory syndrome (MERS) virus [4]. Categorical data were expressed as numbers and percentages and continuous data were reported as means ± SD and median with interquartile when appropriate.
Fifty-four COVID-19 patients (age 62 [57–68], 39 males [71%], SAPS2 37 [27–49]) were admitted in surgical ICU. The duration of mechanical ventilation (MV) was 12.0 [5.5–15.8] days and the duration of ICU stay was 12.0 [9.0–21.0] days. Thirteen (24%) patients had documented pulmonary embolism, 28 (51%) had acute kidney injury, and 15 (27%) had surgical tracheostomy for complicated mechanical ventilation weaning. Sixteen (29%) patients died in ICU. Among the thirty-eight survivors, half (n = 19) have been seen at 3-month. All survivors had impaired score in all domains of the SF-36 three months after a severe COVID-19 episode (Table 1 ). Lower SF-36 scores were seen for role-physical (50.0 [00.0−87.5]) and general health (35.0 [35.0−40.0]). The EQ-5D-3 L at 3-month was 7.0 [6.0–9.0], with 17 (89%) patients describing pain or discomfort, 9 (47%) worsened mobility, 8 (42%) worsened usual activities, 8 (42%) worsened anxiety/depression, and 2 (10%) worsened self-care.
Table 1.
Health-related Quality-of-Life among severe COVID-19 survivors compared to H7N9 and MERS survivors.
| COVID-19 (n = 19) |
H7N9 [3] (n = 37*) |
MERS [4] (n = 78**) |
|
|---|---|---|---|
| Time to interview | 3 months | 3 months | 1 year |
| SF-36 components | (median [IQR]) | (mean ± SD) | (mean ± SD) |
| PF | 70.0 [55.0−82.5] | 76.0 ± 20.3 | 72.5 ± 26.1 |
| RP | 50.0 [00.0−87.5] | 45.9 ± 40.4 | 64.9 ± 39.1 |
| RE | 100 [66.7−100] | 56.5 ± 41.3 | 75.1 ± 36.4 |
| VT | 60.0 [50.0−65.0] | 73.2 ± 15.8 | 66.0 ± 26.5 |
| MH | 68.0 [56.0−78.0] | 70.1 ± 16.0 | 79.6 ± 22.3 |
| SF | 62.5 [50.0−75.0] | 77.8 ± 23.4 | 84.4 ± 24.4 |
| BP | 67.5 [55.0−77.5] | 78.8 ± 17.6 | 79.0 ± 29.9 |
| GH | 35.0 [35.0−40.0] | 60.3 ± 12.3 | 73.0 ± 22.7 |
Abbreviations: SF-36, 36-Item Short Form Health Survey; COVID-19, coronavirus disease 2019; H7N9, avian influenza A (H7N9) virus; MERS, Middle East respiratory syndrome; PF, physical functioning; RP, physical role; RE, emotional role; VT, vitality; MH, mental health; SF, social functioning; BP, body pain; GH, general health.
At 1-month of follow-up, 20/47 (42.5%) patients had ARDS history.
36/78 (46.1%) patients were admitted in intensive care unit.
In this preliminary study, all severe COVID-19 survivors had an impaired quality of life at 3 months of follow-up. In addition, up to 80% of these survivors described pain or discomfort in their daily life, and almost half of the patients complained about mental health disturbances and worsened mobility due to muscular weakness and articular pain. Our findings are similar to those reported in studies of follow-up of survivors of ARDS due to other viral infections with high morbi-mortality (Table 1). In a study assessing the recovery in survivors of severe disease due to H7N9, the quality of life at approximately 1.5 years was lower than a sample of the general population [3]. Similarly, patients who survived the ARDS from influenza A(H1N1) pdm09 virus infection had lower SF-36 scores at 1-year follow-up compared with the general population [5]. However, the scale of the COVID-19 pandemic is much larger and constitute a burden that is well beyond the current critical care capacity, especially in developing countries. Deprived conditions due to ICU bed shortage may further increase the risk of post-intensive care syndrome, a condition that may persist for years after ICU discharge. Interestingly, patients at risk of developing post-intensive care syndrome have often comorbidities (e.g., diabetes, hypertension) and prolonged mechanical ventilation that is similar to the clinical profile of severe COVID-19 patients. Severe ARDS requires prolonged supportive care, deep sedation and neuromuscular blockade, and iterative prone positioning, all favouring the occurrence of post-intensive care syndrome. In addition, physical and psychological sequelae may be more frequent in COVID-19 patients because of restriction of visitation, and constraints on social as well as rehabilitation supports due to the risk of transmission. Recovery may also be impacted because of the lack of specialised interdisciplinary follow-up and the fragmentation and the variability of aftercare programs. There is often a mismatch between the support needed and that actually provided, and COVID-19 patients represent a vulnerable population to increased risk of subsequent hospitalisation resulting in increased healthcare-related costs. Our study is subject to several limitations. First, the small study population may not be representative of all COVID-19 patients admitted in ICU. Second, half of survivors have not been seen during the follow-up service, representing a selection bias, healthy survivors being more likely to join a follow-up consultation. Patients lost to follow-up and low social security coverage may explain this. Nevertheless, socially deprived patients may likely be even more at risk of post-intensive care syndrome and impaired HRQoL. Third, we had limited medical information on potential predictors that may alter the reported HRQoL scores. Specifically, we did not have information regarding the dose and the duration of sedatives and neuromuscular blocking agents that have been shown to affect long-term outcomes. Fourth, we were not able to evaluate the impact on patient relatives (familial post-intensive care syndrome) and caregivers. Finally, HRQoL should be classically explored at 6-month.
In conclusion, this preliminary report provided early insights regarding the quality of life after a severe COVID-19 episode. Because of the scale of this pandemic, disability related to COVID-19 may represent the next public health crisis and both healthcare professionals and decision-makers should focus on this unrecognised and underdiagnosed burden.
Sources of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest
The authors declare that they have no competing interest.
Acknowledgments
The authors would like to thank Dr. Samia Boughezala, M.D., and Ms. Nathalie Deligeon from the pre-anaesthesia evaluation department of Saint-Louis Hospital (AP-HP, Paris, France).
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