Understanding the COVID-19 patient: Acute care to long ...€¦ · •Neuromuscular blockers...
Transcript of Understanding the COVID-19 patient: Acute care to long ...€¦ · •Neuromuscular blockers...
Michelle Kho, PT, PhDMcMaster UniversitySchool of Rehabilitation ScienceCanada Research Chair in Critical Care Rehabilitation and Knowledge Translation
6 April 2021
Understanding the COVID-19 patient:Acute care to long term recovery
Objectives:1. To provide home and community care PTs and PTAs with a
clinical presentation of COVID-19 patients who are:• Critically ill in ICU• Hospitalized in acute care, and• Those who are managed directly within the community without
requiring hospitalization
2. Describe “persistent/residual symptoms” in those recovering from COVID-19
3. Offer ideas about home and community rehab needs for those with persistent/residual symptoms
Session Objectives
Land Acknowledgement
McMaster University recognizes and acknowledges that it is located on the traditional territories of the Mississauga and Haudenosaunee nations, and within the lands protected by the “Dish with One Spoon” wampum agreement.
Needham et al., Crit Care Med 2012 Vol. 40, No. 2
Post-Intensive Care Syndrome (PICS)
Rousseau et al. Crit Care (2021) 25:108.
ICU-Acquired Weakness
ICU conditions• Sepsis• Multi-Organ failure• Acute respiratory distress syndrome• Systemic inflammation
Metabolic• Hypoglycemia
Critical illness polyneuropathy / Critical illness myopathyCritical illness neuromyopathy
Baseline factors• ↑Age• Female Sex• Frailty• Comorbidity
ICU interventions• Mechanical ventilation• Sedation• Neuromuscular blockers• Corticosteroids
Muscle atrophy
Delirium
Immobility/ bed rest
• Severe muscle atrophy• Preferential myosin loss• Sarcomere disorganization• Hypoexcitability
5 tips for patient-centred rehabilitation with COVID-19 survivors1. Remember the basics2. Consider patient-important outcomes3. Consider shoulder involvement4. Start with low-intensity activity5. Consider the whole person and family
1. REMEMBER THE BASICS
MACE – Major Acute Cardiac Event(heart failure, MI, stroke or arrhythmia)
BMJ 2021;372:n693.
Rehabilitation Implications:Diabetes: glycemic control, risk of future neuropathy, retinopathyMACE: carefully monitor heart rate, blood pressure
2. CONSIDER PATIENT-IMPORTANT OUTCOMES
Emerging evidence in COVID-19
RCTs
Cohort studies
Case control
Case series
Pre-prints, Case Reports, Biological rationale
News reports, press releases
↓ Bias
↑ Bias
Study design Core Outcomes
Tong et al., Critical Care Medicine, 2020. DOI: 10.1097/CCM.0000000000004585Adapted from CMAJ. 1981. 24: 985-990.
Synthesis
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Measuring shortness of breath:Modified Borg Scale for Dyspnea
International Journal of COPD 2012:7 345–355.
3. CONSIDER SHOULDER INVOLVEMENT
Prone positioning in COVID-19
Prone positioning accompanied by:• Invasive ventilation• Deep sedation• Neuromuscular blockers
Risks include:• Brachial plexus injuries• Pressure ulcers• Joint contractures
Clinical tips:• Patient history of ICU or hospital stay• Conduct shoulder assessment
https://www.cbc.ca/radio/day6/icus-in-crisis-beyond-the-chauvin-trial-unionizing-amazon-china-s-digital-currency-depresh-mode-and-more-1.5973360/situation-in-ontario-icus-like-a-never-ending-fire-amid-covid-19-3rd-wave-says-nurse-1.5973374
Sakelliariou et al., ISRN Orthopedics. Volume 2014, Article ID 726103
Early research: Ulnar nerve injury most common in patients proned in ICUNerve roots: C8, T1Muscles: Flexor carpi ulnaris; intrinsic muscles of handTest: Wrist/ finger flexion; finger abductionFurther MSK PT input may be needed
Miller C et al., Brachial Plexus Neuropathies During the COVID-19 Pandemic: A Retrospective Case Series of 15 Patients in Critical Care. Phys Ther 2021; 101.
4. START WITH LOW-INTENSITY ACTIVITY
Salman et al., BMJ 2021;372:m4721
Continuum of physical activity
https://sites.google.com/site/compendiumofphysicalactivities/
< 1.5 METS
1.0 1.5
Vigorous >6
9.8 10.08.0 23.0
Moderate 3-6
3.5 5.02.0
Light <3
2.5
> 1.5 METS
PT761 McMaster University | M Kho PT PhD
Get the guidelines here: https://csepguidelines.ca/adults-18-64/
Ross et al., Applied Physiology, Nutrition, and Metabolism. 45(10 (Suppl. 2)): S57-S102. https://doi.org/10.1139/apnm-2020-0467
Physical activity contributes to mental health and wellness
Learn more at csepguidelines.ca
5. CONSIDER ADDITIONAL FACTORS
• Heterogeneous disease states
• Varied health trajectories
Extreme illness
Advanced life support in distinct hospital location
New or worsened medical complexity and multimorbidity
Herridge. Am J Respir Crit Care Med. 2017. 196(11). 1380–1384.1 Herridge et al., Am J Respir Crit Care Med 2016;194(7) 831–844.2 Pandharipande et al., N Engl J Med 2013;369:1306-16.3 Cameron et al., N Engl J Med 2016;374:1831-41.
40% unable to walk @ 7 days post-ICU1
1 year: 20% severe PTSD; 20% severe depression1
3 months: 66% global cognition scores worse than TBI2
3 months: 49% depressive symptoms3
• Heterogeneous disease states
• Varied health trajectories
Extreme illness
Advanced life support in distinct hospital location
New or worsened medical complexity and multimorbidity
Herridge. Am J Respir Crit Care Med. 2017. 196(11). 1380–1384.1 Herridge et al., Am J Respir Crit Care Med 2016;194(7) 831–844.2 Pandharipande et al., N Engl J Med 2013;369:1306-16.3 Cameron et al., N Engl J Med 2016;374:1831-41.
40% unable to walk @ 7 days post-ICU1
1 year: 20% severe PTSD; 20% severe depression1
3 months: 66% global cognition scores worse than TBI2
3 months: 49% depressive symptoms3
5 tips for patient-centred rehabilitation with COVID-19 survivors1. Remember the basics2. Consider patient-important outcomes3. Consider shoulder involvement4. Start with low-intensity activity5. Consider the whole person and family
Thank you!Michelle Kho, PT [email protected] @khome