POST COVID COMPLICATIONS - DR. NISHTHA SINGH

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POST COVID COMPLICATIONS

• The Unknown Journey Ahead
• There have been variable long term outcomes of
  the patients who have recovered from COVID-19

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POST-ACUTE COVID-19,

• Similar to post-Acute viral syndromes described
  in survivors of other virulent coronavirus
  epidemics, there are increasing reports of
  persistent and prolonged effects after acute
  COVID-19.
• The term Post-Acute COVID-19 is used in this
  scenario, which is a syndrome characterized by
• persistent symptoms and/or delayed or long-term
  complications in COVID patients beyond 4 weeks
  from the onset of symptoms.

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Terminologies

• Based on recent literature, Post-Acute COVID-19
  is further divided into two categories
• a. Subacute or Ongoing symptomatic or Long
  COVID-19
• Which includes symptoms and abnormalities present
  from 4-12 weeks beyond acute COVID-19
• b. Chronic or Post-COVID-19 syndrome
• Which includes symptoms and abnormalities
  persisting or present beyond 12 weeks of the
  onset of acute COVID-19 and not attributable to
  alternative diagnoses

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What is most interesting and fascinating is that

• Patient advocacy groups, many members of which
  identify themselves as long haulers, have helped
  contribute to the recognition of post-acute
  COVID-19

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Social Media Reports and Groups

• We need to be believed, helped, treated with
  compassion and supported by those around us.

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Personal Accounts In Journals
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• Long Covid Support

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Pathophysiology of Post-Acute COVID-19

• Potential mechanisms include
• a. Virus-specific Pathophysiologic changes
• Which are direct viral toxicity causing
  endothelial damage and microvascular injury
• b. Immunologic Aberrations and inflammatory
  damage In response to the acute infection, the
  hypercoagulable state and
• C .Expected sequelae of post-critical illness
  which involves
• 1.Microvascular ischemia and injury,
• 2.Effects of immobility
• 3.Metabolic alterations during critical
  illness

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Post-Acute COVID-19 Italian Study

• 143 patients were assessed a
• mean of 60 days after the first
• symptoms- Long COVID
• Only 18 were completely free of
• any covid 19 related symptoms,
• 32 had 1or 2 symptoms and
• 55 had 3 or more symptoms
• Fatigue 53.1
• Dyspnea -43.4
• Joint pain- 27.3
• Chest pain- 21.7
• 44.1 had worsened QOL
  

None had fever or any symptoms of acute illness
July 9 2020. doi10.1001/JAMA.2020.12603
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Post-Acute COVID-19 Chinese-Wuhan Study on
Chronic COVID

• 1733 Patients were evaluated at 6 months from
  symptom onset
• 76 patients reported at least one symptom.
• Fatigue /muscular weakness -63
• Sleep difficulties 26
• Anxiety /depression -23

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Most Common Symptoms of Post Acute COVID-19
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Systemic Complications Post COVID
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Multisystem inflammatory syndrome in children
(MIS C)

• Multisystem inflammatory syndrome in adults
• (MIS A)

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Which patients are at risk for post-acute
COVID-19 ??
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• Patients requiring hospitalization, more so in
  those requiring ICU,NIV or MV
• Patients who had a prolonged stay in the hospital
  or ICU
• Preexisting respiratory disease and
  comorbidities
• Higher BMI
• Older age
• Black or Asians
• Patients who experienced medical complications
  (egg. secondary bacterial pneumonia, venous
  thromboembolism)

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So please note that the symptoms persisting post
recovery from COVID are REAL

• And please do not attribute these to patients
  imagination or hypochondriac-ness??

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• 60-80 individual may have some post covid
  sequelae
• Mild fatigue, bodyache
• Severe-
• Pulmonary fibrosis leading to requirement of
  oxygen post-covid sometimes even need for lung
  transplant,
• Significant cardiac abnormalities- heart attacks
  6 times increases
• Strokes leading to significant impairment in
  quality of life
• Mental health issues

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Post-Covid Assessment

• Cough, breathlessness, chest pain, fatigue
• Oxygen requirements
• Rehabilitation need and onward referral where
  required.
• Anxiety, depression,insomnia
• Psychosocial assessment and onward referral where
  required.
• Assess for existing or new venous thromboembolic
  disease
• Consideration of specific post-intensive care
  unit complications such as sarcopaenia, cognitive
  impairment and post-traumatic stress disorder.

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Rehabilitation Post Covid

• Impairments most likely to encounter are
• -Physical deconditioning and muscle
• weakness, fatigue
• -Impaired lung function
• -Brain fog and other cognitive impairments
• -Mental health disorders and psychosocial
• support needs
• Multidisciplinary team approach is necessary

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Asthma Bhawan Pulmonary Clinic
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Is Proning Use
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Proning Cycle
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Awake proning

• If Spo2 lt94 on Fio2 40
• By either venturi facemask or high flow nasal
  cannula
• 1. 30 to 120 mins prone
• 2. 30 to 120 mins left lateral
• 3. 30 to 120 mins right lateral
• 4. 30 to 120 mins upright
• Contraindicated
• In altered mental status and hemodynamic
  instability, pregnancy , vomiting Before proning
  increase fio2 to 100 percent for five minutes.

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Management of Post Acute COVID-19

• Non-pharmacological
• Rehabilitation a. Pulmonary,
• b. Cardiac,
• c. Neurological,
• d. Musculoskeletal,
• e. Psychological
• Oxygen therapy
• Yoga,meditation
• Nutritional support

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Management of Post Acute COVID-19

• Pharmacological
• Post discharge Antcoagulant ??
• Steroid Inhaled and oral, duration ??
• Ant-fibrotics ??

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Take Home Messages

• The multi-organ sequelae of COVID-19 beyond the
  acute phase of infection are real and
  increasingly being appreciated
• Currently healthcare professionals caring for
  survivors of acute COVID-19 have the key role of
  recognizing, carefully documenting, investigating
  and managing ongoing or new symptoms, as well as
  following up organ-specific complications that
  developed during acute illness.
• Moreover, it is clear that care for patients with
  COVID-19 does not conclude at the time of
  hospital discharge, and interdisciplinary
  cooperation is needed for comprehensive care of
  these patients in the outpatient setting.

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To Conclude

• A screening protocol and
• multidisciplinary approach would
• help early detection of post COVID
• complication and would
• dramatically change lives!!
• THANK YOU