Severe Covid survivors have more post-traumatic stress and difficulty returning to work

One year after hospital discharge, survivors of the severe form of Covid-19, who required mechanical ventilation, have twice the prevalence of post-traumatic stress symptoms, more difficulties returning to work and other disabilities than those who had severe forms. less severe disease.

The results are from a study published last week in a scientific journal of intensive care medicine, carried out between March 2020 and March 2022 in 84 hospitals linked to the Covid-19 Coalition, an alliance for conducting research that involves several leading institutions. such as Albert Einstein, Sírio-Libanês, Oswaldo Cruz, Beneficência Portuguesa (in São Paulo) and Moinhos de Vento (in Porto Alegre).

Patients were compared according to the severity of the disease: from those hospitalized who did not need oxygen to those who needed intubation (mechanical ventilation).

Among the 1,508 enrolled in the study, 36 died before completing one year of follow-up. The all-cause mortality rate among those who were intubated was 7.9%. That of people who had the less severe form of Covid was 1.2%.

The study showed that 1 in 4 intubated people needed to be rehospitalized over the subsequent 12 months (24% versus 19.6%). The rate of cardiovascular events, such as infarction, was also more than twice that of those who did not need mechanical ventilation (5.6% against 2.3%).

“The results serve as a warning not only for patients who have had severe Covid and their families, but also for health managers. [O uso de ventilação mecânica] can be an easily recognized marker for identifying patients at higher risk and to help outline rehabilitation goals”, says intensive care physician Regis Goulart Rosa, researcher at Hospital Moinhos de Vento and lead author of the study.

According to the survey, a high percentage of patients reported new disabilities, such as difficulty moving around, one year after hospitalization (40.4% against 23.5%). They also have a lower rate of return to work (88.1% against 97.5%) and studies (88.9% against 96.9%).

“More personalized follow-up and care for these patients can also mean a good cost-effectiveness ratio for health systems. If the person rehospitalizes less, manages to return more quickly to society, to their work, to their studies, everyone benefits from that .”

The study also reveals that patients who underwent intubation suffer a great impact on mental health. The prevalence of post-traumatic stress disorder among them was twice that of the group with less severity (14% against 7%). One in four had symptoms of anxiety (24.7% versus 17.5%).

The average age of study participants was 53 years; 60.8% were men. Hypertension (45%), obesity (30%) and diabetes (24%) are among the most prevalent comorbidities. The mean duration of mechanical ventilation during hospitalization was ten days.

Other studies have already pointed out that patients with Covid-19 who needed mechanical ventilation are more likely to have elevated inflammatory markers, more extensive lung involvement, multiple organ dysfunction and higher hospital mortality. “Mechanical ventilation is a very effective treatment, it saves lives, but it is not without adverse effects”, says Regis Rosa.

Scientific literature shows that factors such as deep sedation, medications (neuromuscular blocking agents and corticosteroids), immobilization and pneumonia are associated with worse long-term outcomes, with ICU-acquired weakness, post-traumatic stress, post-discharge mortality and quality of life reduced.

The study authors further point out that the overcrowding of ICUs caused by the Covid-19 pandemic may also have been associated with lower adherence to interventions aimed at preventing long-term disability among mechanically ventilated patients. These include minimizing sedation and the use of neuromuscular blocking agents, pain control, early mobilization, and family presence.

Brazil has already registered, since the beginning of the pandemic, more than 36 million cases of Covid and about 695 thousand deaths. “We have thousands of people suffering from some degree of Covid involvement. And we already know from other studies that it is not just the severe cases that are affected [pela Covid longa]. We need more research to understand this new condition, the risk factors, in addition to recognizing and offering rehabilitation to these patients”, says Regis Rosa.

In the opinion of intensive care physician Suzana Lobo, who was at the head of Amib (Associação de Medicina Intensiva Brasileira) during the critical period of the pandemic, the long-term impact of the most serious cases of Covid was already an announced tragedy.

“On countless occasions, we, from scientific societies and scientists, have warned of the risks of long-term complications and the impact on quality of life. We have known this very well for decades because of the bacterial sepsis that we live with daily in our ICUs. And Covid-19 is nothing more than a viral sepsis”, he explains.

Lobo recalls that in a meeting in April 2021 with former Minister of Health Marcelo Queiroga, Amib warned about the need to prepare and invest in rehabilitation for the next five years, in which there would be thousands of sequels from Covid-19.

The survey also warns of the need for tracking post-discharge patients, as many die as a result of complications from the disease, but appear in surveys as recovered. Another important measure is to prepare professionals to act early in rehabilitation.

The relationship between the severity of Covid-19 and the higher occurrence of cardiovascular events is another finding that worries researchers. “This association is not new and exists in other conditions, such as severe sepsis, which cause organ dysfunction. There is a greater risk of involvement of the [músculo] myocardium, arrhythmias. There is great concern about the increased incidence of these events in the years following the pandemic,” says Rosa.

The study has some limitations, such as the fact that Covid-19 may have different effects on long-term outcomes in different contexts, for example, patients with early access to post-discharge rehabilitation services.

Variables that could, in theory, modify the association between the acute severity of Covid-19 and long-term outcomes, such as vaccination, infection with different Sars-CoV-2 variants and specific treatments, were also not evaluated.