Surviving severe COVID-19 means surviving viral sepsis. And while there is little published data on long-term outcomes of severe COVID-19, what is known is that recovering from sepsis caused by other pathogens is a long and difficult process that includes, among other things, increased odds of cognitive impairment and functional limitations—even down to inability to bathe, toilet or dress independently.
A recent Viewpoint essay published in JAMA, “Recovery From Severe COVID-19: Leveraging the Lessons of Survival From Sepsis,” calls out the lessons physicians should take from sepsis cases generally to prevent overly intensive ICU practices and promote speedier recovery for COVID-19 patients.
The AMA is closely monitoring the COVID-19 pandemic. Learn more at the AMA COVID-19 resource center. Also check out pandemic resources available from the AMA Code of Medical Ethics, JAMA Network™ and AMA Journal of Ethics, and consult the AMA’s physician guide to COVID-19.
What to expect in recovery
About 20% of patients hospitalized with COVID-19 develop severe disease, including viral sepsis and acute respiratory distress syndrome, says the essay. It was co-written by Hallie C. Prescott, MD, MSc, associate professor of pulmonary and critical care medicine at the University of Michigan, Ann Arbor, and Timothy D. Girard, MD, MSCI, associate professor of critical care medicine at the University of Pittsburgh School of Medicine.
While there are plenty of features of COVID-19 that may seem either unique or highly unusual, once patients develop sepsis from SARS-CoV-2, the condition is quite similar to sepsis caused by other pathogens, the critical care specialists noted.
Studies in related populations, including those with other coronaviruses, have documented a number of problems stemming from sepsis, including post-traumatic stress disorder, depression and anxiety, as well as pulmonary dysfunction, reduced exercise tolerance and reduced health-related quality of life.
“The prevalence and severity of post-intensive care syndrome among COVID-19 survivors may also be greater than in general sepsis cohorts because the pandemic has impeded normal care practices,” the authors noted, adding that recovery is also typified by further deterioration. Some 40% of patients discharged after hospitalization with sepsis end up rehospitalized within 90 days, most often for infections or worsening of chronic health conditions.
To illustrate the point, they cited a meta-analysis that showed just one-third of patients who survived critical illness were back at work in three months, and only a little more than half, 56%, had returned to work a year after.
Think prevention, even in crisis
Some of these outcomes can be prevented by physicians in ICUs by “prioritizing sedation minimization, daily breathing trials, early mobility and other evidence-based practices,” the authors wrote, adding, however, that such time- and coordination-intensive practices may not be in place in overwhelmed ICUs.
“As a result, patients with severe COVID-19 may receive deeper sedation, fewer breathing trials and more limited mobility than other patients with sepsis, all of which could contribute to a worse recovery,” they wrote.
In particular, the authors recommended patients with viral sepsis from COVID-19 receive “anticipatory guidance regarding potential new problems, screening for new impairments at hospital discharge and early out-patient follow-up, anticipation and mitigation of risk for common and preventable health deterioration, medication optimization and referral or instructions for a structured exercise program.”
Now's also the time for research
Patients are at increased risk of mortality for at least two years after sepsis, the authors noted, adding that the compressed timeframe of the response to COVID-19 has shed light on the need for more research on recovery.
“Even before the COVID-19 pandemic, there was a need to develop better systems by which to promote recovery and adaptation to new disability after sepsis,” they wrote. “COVID-19 now underscores the urgency of this clinical problem and represents an important opportunity to develop and test new programs that support sepsis survivors.”
