Delivery of Acute Rehabilitation to a Postcoronary Artery Bypass Graft COVID-19 Patient in a Pandemic Environment

Abstract

During the first wave of the coronavirus disease (COVID-19) pandemic, a 57-year-old COVID-19 male patient was diagnosed with non-ST-elevation myocardial infarction and required urgent coronary artery bypass graft. In-patient cardiac rehabilitation following cardiac surgery was inevitable to limit or prevent various postoperative complications. A routine rehabilitation program was not feasible because of the strict COVID-19 isolation procedures, the high risk of cross infections, and the lack of various resources. Moreover, the detrimental effects of COVID-19 infection on multiple body systems reduced his exercise tolerance, limiting his engagement in physical activity. This case report highlights the various challenges encountered during the rehabilitation of these patients and strategies adopted to overcome them, illustrating the feasibility of a modified rehabilitation program to ensure early functional recovery.

INTRODUCTION

Coronavirus disease (COVID-19) is a pandemic caused by the novel SARS-CoV-2 virus.[1] Even though the virus affects most body systems, it has a predilection for the respiratory system.[2] COVID-19 patients manifested various degrees of respiratory infection and fatigue, thereby reducing their cardiorespiratory function and exercise tolerance.[2,3,4]

Coronary artery bypass graft (CABG) is one of the most frequently performed surgical procedures to treat multiple coronary artery blocks.[5,6] The procedure might have to be undertaken on an urgent basis during the pandemic for COVID-19-positive patients.[7] The complexity of the procedure, the use of cardio-pulmonary bypass, anesthesia, surgical incision of the chest, and various medications may impact cardio-respiratory function, thus reducing the functional independence of the patient.[8,9,10,11] Studies have shown that an in-patient cardiac rehabilitation program immediately following cardiac surgery effectively limits or prevents these adverse consequences.[8,12]

Even though cardiac rehabilitation has been proven safe and feasible after CABG, the high risk of cross-infection and unavailability of various resources adversely impact the effective rendering of in-patient cardiac rehabilitation in COVID-19 settings.[13,14,15]

This case report is unique in that it describes the experiences of acute rehabilitation of a patient with COVID-19 who underwent CABG, challenges encountered, and various strategies adopted to overcome them.

This case was approved by Hamad Medical Corporation Medical Research Council (MRC) protocol ID MRC-04-21-659.

CASE PRESENTATION

A 57-year-old male patient in home quarantine due to COVID-19 (cycle threshold [CT] value = 30.3) was admitted to the COVID care hospital with complaints of severe central chest pain radiating to the back, fever, and cough of 1-day duration. He was diagnosed with non-ST-elevation myocardial infarction. The patient has a past medical history of type 2 diabetes mellitus, hypertension, and dyslipidemia.

His electrocardiography (ECG) showed sinus rhythm with T-wave inversion in the lead III without significant ST change, arrhythmia, and normal QTc. The high sensitivity troponin level was significantly increased to 840 ng/ml. The echocardiographic evaluation showed reduced left ventricular systolic function with an ejection fraction of 43% and grade 1 diastolic dysfunction. The CT value sharply dropped to 18.93 after 2 days which correlates with a high viral load. The chest X-ray on the 3^rd day of admission showed faint airspace patchy opacities in the lower zones bilaterally. During his stay in the COVID care hospital, he had multiple episodes of severe chest pain and was transferred to our tertiary cardiac care hospital after 1 week of admission to the COVID facility. At the time of his admission to the cardiac care hospital, his CT level was 30. His coronary angiogram showed triple vessel coronary artery disease with 80% left main artery occlusion.

He underwent urgent CABG with 3 grafts. After the surgery, he was transferred to cardiothoracic intensive care unit with institutional COVID-19 isolation protocols. He was extubated on the first post-operative day (POD). The mobility and activity program was initiated within 3 h of extubation according to the institutional postcardiac surgery exercise protocol.

During the initial evaluation on the first POD by the physiotherapist, the patient was on 4-l oxygen per minute via nasal cannula. He had pericardial and pleural drains, a central venous catheter, an arterial line, and a foley catheter. Mobility and activity programs were initiated with continuous monitoring of the patient's vitals. An exercise program for the extremities in bed and slow progressive mobilization to sitting in the chair was performed. Incentive spirometer exercises, deep breathing exercises, and forced expiratory techniques with sternal precautions were incorporated to improve oxygenation and facilitate expectoration. Moderate assistance was required for the mobilization activities. The patient was educated regarding the type, frequency, and intensity of exercise and sternotomy precautions.

The exercises were terminated for a short period if the saturation dropped below 90%, the rate of perceived exertion scale (RPE Scale)[16,17] was more than or equal to 14 (Borg's scale 6–20 scale), and if the patient requested to stop exercises due to fatigue. Exertional desaturation and fatigue were the main challenges in rehabilitating the patient. Despite being on 4 l of oxygen support, the patient desaturated <88% during the activities. The patient was able to tolerate <1 min of exercise continuously in the first POD.

Routine mobility and activity program were not feasible because of poor exercise tolerance, fatigue, desaturation, and isolation precautions. Thus, an individually tailored mobility and activity program with short exercise sessions incorporating multiple rest breaks was developed.

The patient was transferred to the COVID-19 isolation ward on the second POD. He required 4-l oxygen per minute via nasal cannula support to maintain his saturation of >90%. Along with the respiratory exercises, sit-to-stand exercises and an ambulation program were added. The patient was still not able to tolerate more than 1 min of continuous exercise as he would desaturate <90% and his RPE (Borg's scale 6-20 scale) would go above 14. He was able to achieve only 10 meters of continuous ambulation and 5 repetitions of a sit-to-stand exercise with minimal assistance. The patient was advised to perform respiratory exercises and active limb range of motion exercises in sitting 5 times a day. To reduce repeated staff exposure but to still maintain a line of communication, a missed call system was introduced. Here the patient would give a missed call to the physiotherapist's mobile number and the physiotherapist would call back to clarify any doubts he had regarding the mobility and activity program.

The patient still needed 4 l of oxygen per minute to maintain his saturation even on the third POD. All the exercise programs prescribed on the second POD were continued. The patient was allowed to ambulate only within his room due to COVID-19 isolation protocols. Seated cycling was added to overcome this constraint and he was able to tolerate this for up to 2 min. He achieved 30 meters of continuous ambulation with contact guard assistance. He was now able to tolerate 6 min of exercise continuously. His exercise progression was hindered by desaturation <90% (88%) and RPE of 14 (Borg's scale 6–20 scale). He was instructed to continue the respiratory and seated exercise program 3 times a day and seated cycling 2 times a day with an RPE of 12-13 (Borg's scale 6-20 scale).

On the fourth POD, he was able to maintain his saturation of >90% (96%–99%) on room air. He was able to attain 10 repetitions of sit-to-stand exercises, 50 meters of ambulation with modified independence, and 5 min and 30 s of seated cycling exercise with an RPE of 12 (Borg's scale 6-20 scale). He was now able to perform 12 min of exercises continuously. All the education was reviewed and he was advised to do seated cycling and ambulation with a maximum RPE of 13 (Borg's scale 6-20 scale) for 3 times a day.

The patient was transferred back to the COVID care facility on the fifth POD. At the time of discharge, the patient was able to perform all his activities of daily living and exercises with modified independence. He had achieved an ambulation distance of 50 meters and was able to perform seated cycling for 15 min with an RPE of 12 (Borg's scale 6-20 scale). All home exercise programs, and precautions were reviewed and an exercise log was given to monitor his exercise program.

To monitor the patient's progress ICU mobility scale (IMS), fatigue severity scale (FSS), functional independence measure (FIM), and 1-min sit-to-stand test (1MSTST) were used as outcome measures. The patient achieved an IMS score of 6 on the first POD upon transfer to the post-surgical ward. The FSS score was 6.33 on the first POD, which peaked at 7 on the third POD and gradually decreased to 4.22 and 2.5 on the fourth and fifth POD, respectively. The percentage of FIM score which was 46% on the first POD increased to 73% on the fourth POD and it reached 82% upon discharge. The patient could not complete 1MSTST on the fourth POD due to leg pain and RPE of 14 (Borg's scale 6-20 scale) and on the fifth POD he could complete 1MSTST with 17 repetitions with RPE of 12 (Borg's scale 6-20 scale).

DISCUSSION

Several studies have shown that early rehabilitation of cardiac surgery patients may reduce hospital length of stay, improve functional capacity, early functional independence, health-related quality of life, and early return to work.[10,14,20,21,22] This case report intends to bring to the fore, the challenges encountered and strategies adopted thereof involved in the early rehabilitation of a COVID-19 patient after CABG. To our knowledge, this is the first case reporting a successful rehabilitation of a COVID-19 patient after CABG.

The rehabilitation of COVID-19 patients after CABG encountered various challenges in terms of availability of human resources, equipment, altered environment, along with the physical and psychological impact of COVID-19 symptoms.[13,14,15] Early mobilization and respiratory exercises were considered safe and feasible components of rehabilitation to ensure early recovery.[8,18,19,21] However, these exercises were considered aerosol-generating procedures making the rehabilitation more challenging.[22,23,24,25] As the patient required close contact during rehabilitation, there is a high chance of cross-infection with rehabilitation providers.[23] Besides, implementing the routine rehabilitation exercise program is not feasible because of the COVID-19 isolation protocols.

COVID-19 predominantly affects the respiratory system, reducing lung capacity and causing shortness of breath.[2,26] In this case study, the patient's chest X-ray, high level of perceived exertion with minimal activity, and desaturation during exercise despite supplemental oxygen support indicate involvement of the respiratory system. Moreover, one of the most common symptoms reported in COVID-19 patients is fatigue.[27,28] In this case, the patient experienced a fatigue level of 6.33 on the FSS[29,30] on the first POD, which increased to 7 on the third POD and reduced to 2.33 on the fifth POD, indicating a higher fatigue level in the initial PODs.

Another major challenge was restricted space due to the COVID-19 isolation protocol. Early ambulation is the backbone of any rehabilitation program to enhance the functional capacity and patients' confidence to perform their daily activities.[10,31,32,33] In this case, to contain the infection, the patient was advised to ambulate only inside his room. Preoperative physiotherapy is critical to facilitate the patient participation in the rehabilitation program after the surgery.[33,34,35] This patient did not receive any preoperative education due to the urgent nature of the procedure. Apart from this, the patient was in isolation for more than 1 month, which may have negatively affected his motivation and participation. The impact of COVID-19 on different body systems, the necessity for reducing staff exposure, and the restrictions imposed due to COVID-19 isolation made it challenging to implement the routine rehabilitation exercises program, particularly in terms of frequency, intensity, and type of exercises.

These challenges were overcome by adopting a new set of rehabilitation strategies. The exercise program was modified by including sit-to-stand exercise, seated cycling, and ambulation inside the room. To reduce the exposure of health care staff, a greater emphasis on a multidisciplinary collaboratory approach was adopted.[36] Whenever a team member entered the patient's room, they would reinforce and make the patient do the exercise. The patient was also constantly motivated to do exercise through telephonic conversations. The patient was empowered to monitor his exercise program using a logbook to record and write down the doubts that he encountered while performing the exercises.

These strategies minimized the staff exposure without compromising the quality of rehabilitation services received by the patient. Even though the rehabilitation professional was at high risk of COVID-19 cross-infection, none of the healthcare professionals involved in the rehabilitation of this patient got infected. The use of appropriate PPEs and adhering to the COVID-19 infection control practices safeguarded the staff from cross-infection.

The outcome measure routinely used for assessing functional capacity in CABG patients is 6MWT.[37,38] However, due to space constraints, a 1-minute sit-to-stand test was used.[39,40,41] The Fatigue severity scale[29,30] was used to assess the fatigue level.

Despite these challenges, this patient achieved an IMS score of 6 and an FIM score of 46% on the first POD and got discharged on the fifth POD with an 82% of FIM score, and 1MSTST of 17 repetitions. This showed that the innovative strategies adopted were able to deliver an equal and effective rehabilitation program in line with those received by non-COVID-19 CABG cases.

CONCLUSION

This case study highlights the challenges in implementing a routine rehabilitation program in a CABG patient infected with COVID-19. A modified rehabilitation program is feasible to facilitate early functional recovery in these patients. A multidisciplinary team approach and strict infection control practices is essential to ensure the safety of patients and staff.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.