Babar Khan, MD, critical care physician at Regenstrief Institute, Indiana University, talks about long-term recovery after staying in the ICU for COVID-19.
I want to start by asking you, you’ve been on the frontlines for this. We’re seeing now patients starting to come home after extended stays in the ICU from the initial spike. But people kind of forget that once an ICU patient gets home they don’t go right back to feeling the way they were. What are some of the side effects or some of the things that COVID patients and ICU survivors are experiencing after they get out?
Dr. Khan: So, one of the main things that the general public and also the physician’s community or the health care community fails to understand is when you go to the ICU you’re suffering from acute illness. And then most of the time we as physicians and other health care personnel we think that once your acute phase of the illness is over and you get discharged from the ICU you’re back to your physical health that you were before coming to the intensive care unit. This is pretty far from the truth. Just because by virtue of being in the intensive care unit by virtue of your illness, the severity of illness in the intensive care unit, being on the breathing machine, and other medications that we use you can be afflicted with some long-term sequelae of your ICU state. Those sequelae could be more prominent if the sicker you are in the ICU and COVID-19 as a specific group when they’re in the intensive care unit they’re pretty sick. One example I usually give is when you’re in the intensive care unit you’re on a breathing machine. You’re unable to provide oxygen to the tissues. That’s a major problem for COVID-19 patients and they’re requiring a very high amount of ventilator support. Now because of this hypoxia as well as some of the other disease aspects the COVID-19 survivor once they come out of the ICU they could develop symptoms associated with cognitive impairment, which essentially means they’re unable to do the things that the brain demands or that they were doing before coming to the ICU such as high-level executive function, paying attention to things. They could also suffer from symptoms of anxiety and depression, even post-traumatic stress disorder. And because of just being in the ICU and not able to mobilize themselves for an extended period of time, they can develop symptoms of physical impairment or physical weakness which would require physical therapy. You put them all together, you have an ICU survivor of COVID-19 who has problems with memory, attention, executive function. They have problems with anxiety and depression, may develop post-traumatic stress disorder, and have physical impairments. You put this all together, this is what we call post-intensive care syndrome. And that seems to be prevalent in COVID-19 ICU survivors.
So how do we help this group of people coming out of the ICU?
Dr. Khan: Right. That’s a great question. About 9 to 10 years ago we started a program at Indiana University called the Critical Care Recovery Center, which was geared towards the long-term complications that happened in ICU survivors. It was specifically made to cater to the impairments that I just discussed with you to help them get over those impairments. And we are utilizing the same program to help the COVID-19 ICU survivors. We have a clinic where the survivor can come in. They can get a standard screening for cognitive function, physical impairment, and mood and anxiety disorders. And then based on those screening results we can start specific targeted therapies focusing on the impairment. ‘
So, you’re talking about both physical and emotional.
Dr. Khan: Right.
So, this is not just one doctor. This has to be a team approach?
Dr. Khan: Right. It’s a very interdisciplinary program. The clinic consists of an ICU physician, which is myself, we have a care coordinator with a social worker. We have a nurse care coordinator, and then we have a psychometrician that can screen patients for these cognitive problems. And then we can refer patients to physical therapy. So, once we find the impairment, the usual way it goes that the COVID-19 survivor comes to my clinic. We screen them extensively for both emotional, psychological, physical impairments as well as social vulnerabilities. And based on that we develop a personalized program that we then convey to their primary care physician. Along with the primary care physician, we start the recovery process for a COVID-19 ICU survivor.
I know you probably can’t answer this but I’m going to ask it anyway. Is there a timeframe for patients recovering after and going back to full function after they’ve had COVID?
Dr. Khan: Yeah, so as this disease is pretty new and we don’t have much of a long term follow up, it is difficult to. Say what time would be optimum for a COVID-19 ICU survivor to go back to the activities of daily living that they were doing. Based on our prior work in patients who have acute lung injury or with features similar to COVID-19 of survivors, it can be up to a year or up to two years in certain ICU survivors where they can go back to their functioning that they were doing before. So that period is critical for multiple reasons. Obviously one is that the ICU survivor needs to understand the impairment that they are facing. Two, the family needs to understand what they will be coping with once the ICU survivor comes home. Three, the health care community needs to understand what are the long term sequelae of a COVID-19 ICU stay. And if they have special services available such as an ICU survival clinic then they want to be engaged with that clinic so that the recovery of the ICU survivor is optimal.
Are there a lot of these specialized clinics across the country, Dr. Kahn, or is it fairly limited to the largest universities?
Dr. Khan: So at this point, the ICU survivor clinics are limited to large academic centers. When we started it in 2011 ours was the first one in the United States to start the ICU recovery process. Now I think they are around 16 or 17 ICU survivor clinics available. The important thing is that now there is an awareness of post-intensive care syndrome. So even if the community does not have an ICU survivor clinic, the primary care physicians are aware of this so they can screen for these disorders in their clinic. There are small batteries available that they can utilize in the primary care offices to screen for these disorders and then they can guide the ICU survivor towards specialized services such as physical therapy or emotional support through behavioral interventions or behavioral specialists.
Is there anything that you would tell patients who have been through this experience – do they need to have patience with themselves as they recover? Is there one message that you’d like to get across? I know you mentioned you’ve got to tell the patients and families hey this might be a year or two. But is there one thing that you say to them?
Dr. Khan: I mean I would tell them to be patient. The symptoms of ICU survivorship or post-intensive care syndrome symptoms improve with time. They will require an effort to improve. They need to look at it as a chronic disease process and not as an acute illness. Acute illness is a small part of ICU. The long part is the ICU survivorship. So, it needs to be looked at as a marathon, not as a sprint. And then the important thing is to work with their physicians and their care providers and other health care personnel. Have the family involved in the recovery process and just be patient.
Well then is there anything about the care model for ICU survivors that I didn’t ask you that you want people to know?
Dr. Khan: So, at this point, ICU survivorship care models are focused on specialized ICU survival clinics. Here at Indiana University, we’re piloting a program where we are taking the clinic model to the community. We have a nurse care coordinator that we have trained in our ICU survivor clinic with what we have been providing in the ICU survival clinic over the years about physical recovery, emotional support, as well as cognitive exercises. Now the care coordinator goes over to the homes of the patient, and she’s delivering those services at the homes. The reason we started developing this model for home delivery is that it’s sometimes difficult for ICU patients to come back to the clinic because of the logistics because of transport. And we think that if we can have a program which is combined with a clinic and an extended arm into the community, we can approach a higher number of ICU survivors in a shorter time. And hence we can scale the ICU survivorship effectively.
Perfect. I wanted to ask you one or two questions about delirium if you don’t mind. You’ve also studied delirium. For our viewers who may not be familiar with it can you describe what it is?
Dr. Khan: So, when you look at delirium, one thing to look at delirium is a state of acute brain failure. And the reason I want to use the term acute brain failure is when we’re in the hospital people can understand what acute heart failure is, what is acute kidney failure. But people don’t pay much attention to the brain at the time when they’re in the ICU. So, if I have to describe acute brain failure I say you will develop a state of acute confusion that develops quickly, is fluctuating and you cannot pay attention to things. So essentially in a nutshell you’re not behaving the way you behave normally. So, it’s a state of altered mental status for there. So that’s how we can classify delirium when you’re in the ICU or when you’re in the hospital.
Risk for developing this?
Dr. Khan: Older adults and adults who are on mechanical ventilation are at a higher risk for developing delirium. One thing that we have learned in the COVID-19 pandemic that COVID-19 patients have a much higher risk of delirium compared to the historical patients before. The numbers, it can affect up to 75 percent of COVID-19 patients in the intensive care unit based on our numbers.
So, what should families be watching out for? I guess most of them won’t be visiting during COVID, but under normal circumstances, if you’re visiting someone who’s been in ICU, what kinds of changes would you see?
Dr. Khan: So, these are difficult times right now because families cannot visit their loved ones. Sometimes they can come. And if they can come they can see that their loved one is not behaving the way they expected them to behave. The things that families do when they are in the ICU is that they can orient the patients. They can provide them the time. They can provide them the date. They can also talk to them even while they’re on the ventilator and they’re sedated to tell them about the things that were happening, where they come from, what is going on with the family. So, this orientation thing helps. Now there are certain specific things that we do in the ICU which are useful which is essentially we stop their sedation and we mobilize the patients even if they are on the mechanical ventilation. And those are shown to reduce the risk of delirium. Now one of the important thing is once you go home up to 30 percent of patients can have delirium even at home after getting discharged from the hospital. Now for the families to do certain common things at home is to keep, maintain a sleep cycle. They go to bed at the usual time, waking up, get plenty of exercise during the daytime. If the weather is good go outside. Get sunlight. Take your medications. Avoid medications that can cloud your judgment, cloud the brain. And also have other family members talk to the patient and again orient the patient that, hey, you are home and you are with us. And I’m this way related to you and these are the things we like to do and try to engage them. The more cognitively the patients that engage, the more physical function activities are doing, the normal sleep cycle, and then sunlight, those are the things that can reduce the intensity of delirium.
How can a family distinguish between delirium and the onset of dementia? Are some of the symptoms similar?
Dr. Khan: The main difference between delirium and dementia is delirium develops acutely and it tends to fluctuate. So the patient could be fine at one moment and very soon they can be fluctuating, they can have an altered mental status. Compared to dementia which is essentially a chronic state that patients cannot function, and they don’t have the ability to do certain tasks. It is sometimes very difficult to differentiate between delirium and dementia because sometimes they are superimposed on each other. I think that the best way would be that if it is acute and they have features and periods of lucidity, then the family can say that this is delirium and they do the thing which is essentially doing physical activity and exercise. If by a few months after discharge from the ICU if they feel that the things are not getting better and those symptoms are persistent, then it might be time to go over to a specialized memory clinic to look up a geriatrician or a memory specialist who can differentiate between delirium and dementia.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Regenstrief Institute Pr
Sign up for a free weekly e-mail on Medical Breakthroughs called First to Know by clicking here
