Post Covid-19 Complications: A New Dimension of Awareness for Healthcare Workers

Mamta Choudhary¹*, Dr. L. Gopichandran²

¹Tutor, College of Nursing, AIIMS, New Delhi.

²Associate Professor, College of Nursing, AIIMS, New Delhi.

*Corresponding Author Email: mamta24.c@gmail.com

ABSTRACT:

Novel Coronavirus (COVID-19), a highly infectious disease, is currently affecting whole of globe with no region untouched. This Public health emergency is one of the leading causes of mortality in many of the regions of the world. Although many patients are recovering from this illness, the concern regarding Post COVID-19 complications still prevails. Various follow up studies have reported Lung fibrosis, ARDS, cardiovascular diseases, neurological and neuropsychiatric complications, multiorgan damage, and gastrointestinal complications among recovered COVID-19 patients. Thus, this evidence-based review was done focussing on published articles from the Medline, CINAHL, Social Sciences Citation Index, Psych INFO, a hand search through selected published journals and from references lists. This article provides information regarding complications experienced by recovered COVID-19 patients after being discharged from hospital, affecting their quality of life.

KEYWORDS: COVID-19, Post COVID-19 needs, Persistent symptoms, Prevention of complications, Post discharge health status.

INTRODUCTION:

Novel Coronavirus (COVID-19), a highly infectious disease, is currently affecting whole of globe with no region untouched. This Public health emergency is one of the leading causes of mortality in many of the regions of the world. On 8^th April 2021, WHO reported 13,24,85,386 confirmed cases of COVID-19, including 28,75,672 deaths globally.¹ India being third worst-hit country by the pandemic after the United States and brazil reported 12,928,574 total cases of COVID-19 by the morning of 8^th April 2021.¹ Although recovery rate of nearly 91% is reported in India on 6^th April 2021, the concern regarding Post COVID-19 complications still prevails.²

The disease cause illness ranging from mild symptoms of common cold to a very severe acute respiratory syndrome. The most common symptoms of the disease include fever, cough, sore throat, shortness of breath and headaches.³ CDC in their updated list in April added chills, repeated shaking with chills, muscle pain, headache, sore throat and loss of taste or smell as the new symptoms of COVID 19.⁴ In more severe cases it can cause Pneumonia or respiratory distress. As per a modelling study published in the Lancet Global Health one in five people with underlying Non-Communicable Diseases (NCDs) are at increased risk of severe COVID-19 infection.^5,6 As burden of NCDs in developing countries is increasing at faster rate⁷, so do the risk of COVID infection. Although Many patients have recovered from COVID-19, still the likelihood to suffer from Post CoVID-19 complications persists. Various follow up studies have reported Lung fibrosis, ARDS, cardiovascular diseases, neurological and neuropsychiatric disorders, multiorgan damage, and gastrointestinal complications among recovered COVID-19 patients.^8,9,10 These complications add to the pre- existing medical, psychological and economic burden on patients and their family, especially in developing countries with limited resources.¹¹

As WHO announced year 2020 as ‘International year of nurses and midwives’, and also general public, during midst of the pandemic, shared their gratitude towards healthcare workers in different ways, it becomes responsibility of nurses and all other healthcare workers to help recovered COVID-19 patients. Thus, this evidence-based review was carried out to gain an insight of Post COVID-19 complications.

MATERIAL AND METHODS:

This evidence-based review focused on published articles from the Medline, CINAHL, Social Sciences Citation Index, Psych INFO, a hand search through selected published journals, and from references lists. However, Journals that lacked the authentication of legitimate scholarly journals such as peer review, editing, editorial boards, editorial offices, and other editorial standards were excluded from the review.¹² Authors included case reports, prospective studies, retrospective studies, clinical guidelines, systemic reviews and meta-analysis focusing on complications of COVID-19. The literature search included the study published in English language only.

RESULTS:

Various researcher has observed and proposed that even after initial recovery, COVID-19 might be infectious in many of the patients. This can result in persistent complications following COVID 19 recovery and increases the risk of population morbidity. As per a follow up study on persistent symptoms after COVID 19 infection, only 12.6% of subjects were found to be completely free from COVID-19 related symptoms, however 32% subjects reported to 1 or 2 symptoms, and majority 55% reported to suffer from 3 or more symptoms even after recovery. ⁶ The various after effects of COVID-19 on health includes:

1. Persistent symptoms:

Patient recovered and discharged from hospital reports persistent symptoms such as fatigue, dyspnoea, joint pain, low grade fever, chest pain, cough, anosmia, rhinitis, red eye for up to 60 days post recovery impacting their quality of life. Post-intensive care syndrome and post-viral fatigue syndrome are serious concern following COVID-19.^8,10

2. Respiratory complications:

Patients experience persistent respiratory symptoms months after their initial illness. Post- COVID fibrosis, an irreversible lung damage, also known as Post ARDS fibrosis is serious complication manifested by recovered COVID-19 patients. NHS guidelines on aftercare needs of patients recovered from COVID-19 also emphasized on potential respiratory complications such as chronic cough, fibrotic lung disease, bronchiectasis and pulmonary vascular disease.^6,8,10 Respiratory distress in common cause of readmission after recovery from COVID-19. Many of the patients without pre-COVID oxygen requirements reported need of oxygen at home after even 30-40 days of hospital discharge.^13,14

3. Cardiovascular Complications:

Emerging evidence suggests significant primary and secondary cardiovascular impact of COVID-19 in recovered patients. Primary impact is presented as Arrythmias, myocardial damage, myocardial infarction, and myocarditis whereas secondary impact results in biomarker elevation and heart failure. Various studies suggest COVID-19 infection initiate myocardial injury, which further leads to cardiac arrythmias and myocardial infarction.^15,16,17,18 In addition, current investigational drug therapies, such as hydroxychloroquine is also known to adversely affect QTc duration, further enhancing risk of arrythmias.¹⁵ The incidence of Cardiovascular diseases is reported three times higher in Patients admitted in ICU as compared to non ICU patients with COVID-19.¹⁰ Increase cardiac workload secondary to ARDS and lung injury; and severe inflammatory response due to viral infection are also contributing to cardiac complications.^15,16

4. Neurological and Neuropsychiatric Complications:

Growing body of evidences regarding Post-COVID complications highlights numerous neurological and neuropsychiatric complications among these patients. Virus induced neuropsychiatric sequelae is supposed to be linked with immune response to the virus, psychological stress associated with the fear of illness, or neuro-invasive power of COVID-19.¹⁹ Webb S. et al diagnosed a 57-year-old man who presented with a progressive flaccid symmetrical motor and sensory to the hospital, to be suffering from Guillain-Barré syndrome secondary to COVID-19.²⁰ A recent Liverpool-led study of COVID-19 patients reported various neurologic complications such as ischemic stroke, intracerebral haemorrhage, CNS vasculitis, unspecified encephalopathy and encephalitis. Neuropsychiatric disorders such a new onset psychosis and affective disorder has also been reported in recovered patients.²¹

5. Gastrointestinal complications:

Several studies have proposed gastrointestinal route as a potential route of entry of COVID-19 virus, along with respiratory tract. Thus, patients with COVID-19 infection are presenting to hospital with anorexia, diarrhoea, nausea and vomiting. In critical cases, Liver injuries are also more evident.^22,23 Many of patients reported continuation of gastrointestinal upsets – like loose motions and vomiting even after recovery from COVID-19.⁹ Common GI complications linked with COVID 19 includes hepatobiliary complications, hypomotility, bowel ischemia, which can impose long run impact on health and quality of life.²⁴

6. Post Intensive care syndrome:

Post Intensive care syndrome (PICS) is the next presumed health crisis that COVID -19 survivors may face who were admitted and treated in ICU settings and received mechanical ventilator support. This aftershock of pandemic is seen as crisis after a crisis. Evidence from

patients having acute respiratory distress injuries with similar clinical profiles of COVID-19 have shown higher readmission rate and long-term cognitive decline, and the same can be expected in case of COVID-19. Neurocognitive deficits including anxiety and depression are consistent deficits affective quality of life after 1-2 years of discharge from ICU. Deteriorations in psychological health, cognitive deficits such as delirium, acute brain dysfunction, persistent muscle weakness resulting in poor mobility, frequent falls, even quadriparesis; decreased exercise capacity, and enhanced medical care expenses are major concerns related to PICS, that needs attention in Post COVID era.^25,26

Prevention of Complications:

World Health Organisation has suggested few interventions to be implemented in clinical settings (Table 1) to prevent complications associated with critical illness.²⁷

Table 1: Prevention of Complications (by WHO)

Anticipated Outcome	Interventions
Reduce days of invasive mechanical ventilation	· Use weaning protocols that include daily assessment for readiness to breathe spontaneously · Minimize continuous or intermittent sedation, targeting specific titration end points (light sedation unless contraindicated) or with daily interruption of continuous sedative infusions
Reduce incidence of ventilator associated pneumonia	· Oral intubation is preferable to nasal intubation in adolescents and adults · Keep patient in semi-recumbent position (head of bed elevation 30-45º) · Use a closed suctioning system; periodically drain and discard condensate in tubing · Use a new ventilator circuit for each patient; once patient is ventilated, change circuit if it is soiled or damaged but not routinely · Change heat moisture exchanger when it mal-functions, when soiled, or every 5–7 days
Reduce incidence of venous thromboembolism	· Use pharmacological prophylaxis (low molecular-weight heparin [preferred if available] or heparin 5000 units subcutaneously twice daily) in adolescents and adults without contraindications. For those with contraindications, use mechanical prophylaxis (intermittent pneumatic compression devices)
Reduce incidence of catheter related blood stream infection	· Use a checklist with completion verified by a real-time observer as reminder of each step needed for sterile insertion and as a daily reminder to remove catheter if no longer needed
Reduce incidence of pressure Ulcers	· Turn patient every two hours
Reduce Incidence of stress ulcers and gastrointestinal bleeding	· Give early enteral nutrition (within 24-48 hours of admission) · Administer histamine-2 receptor blockers or proton-pump inhibitors in patients with risk factors for GI bleeding. Risk factors for gastrointestinal bleeding include mechanical ventilation ≥48 hours, coagulopathy, renal replacement therapy, liver disease, multiple co-morbidities, and higher organ failure score
Reduce incidence of ICU-related weakness	· Actively mobilize the patient early in the course of illness when safe to do so

CONCLUSION:

Emerging evidence indicates that patient suffering from COVID-19 may develop numerous ‘Post COVID complications; nearly affecting each and every organ of body. The complications can affect those with mild as well as moderate-to-severe disease. More longitudinal studies are needed to assess the prevalence and impact of these complications.

CONFLICT OF INTEREST:

None.

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Received on 08.04.2021 Modified on 26.06.2021

Asian J. Nursing Education and Research. 2021; 11(4):455-458.

DOI: 10.52711/2349-2996.2021.00110