POST COVID COMPLICATIONS - DR. NISHTHA SINGH

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

3. 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.

4. 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

5. 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

6. Social Media Reports and Groups • We need to be believed, helped, treated with compassion and supported by those around us.

7. Personal Accounts In Journals

8. Long Covid Support

10. 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

11. 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. doi:10.1001/JAMA.2020.12603

12. 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%

13. Most Common Symptoms of Post Acute COVID-19

14. Systemic Complications Post COVID

15. Multisystem inflammatory syndrome in children (MIS – C) • Multisystem inflammatory syndrome in adults (MIS – A)

16. Which patients are at risk for post-acute COVID-19 ??

17. Patients requiring hospitalization, more so in those requiring ICU,NIV or MV • Patients who had a prolonged stay in the hospital or ICU • Pre–existing respiratory disease and comorbidities • Higher BMI • Older age • Black or Asians • Patients who experienced medical complications (egg. secondary bacterial pneumonia, venous thromboembolism)

18. So please note that the symptoms persisting post recovery from COVID are REAL And please do not attribute these to patient’s imagination or hypochondriac-ness??

19. 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

20. 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.

21. 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

22. Asthma Bhawan Pulmonary Clinic

23. Is Proning Use

24. Proning Cycle

25. Awake proning If Spo2 <94% 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.

26. 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

27. Management of Post Acute COVID-19 Pharmacological • Post discharge – Antcoagulant ?? • Steroid – Inhaled and oral, duration ?? • Ant-fibrotics ??

28. 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.

29. To Conclude… A screening protocol and multidisciplinary approach would help early detection of post COVID complicationand would dramatically change lives!! THANK YOU