Gaps in knowledge: Unmasking post-(Acute) COVID-19 syndrome and potential long-term complications in COVID-19 survivors
2020; Medknow; Volume: 8; Issue: 2 Linguagem: Inglês
10.4103/amhs.amhs_324_20
ISSN2321-6085
Autores Tópico(s)Disaster Response and Management
ResumoWhat's true of all the evils in the world is true of plague as well. It helps men [sic] to rise above themselves. – Albert Camus, The Plague "Each individual is an expression of the collective consciousness of humanity, and the collective consciousness of humanity is an expression of the one universal consciousness." – Eckhart Tolle Man in his entirety has been governed by his own created philosophy based on the orthodoxy of scientism and the empirical knowledge from the tangible scientific methodology. Thus, the phenomenal progress of Man's Science and the Industrial Revolution has impacted on the multitude facets of humanity, where man has become the master of destiny of the human species and the collective life of humanity on our Terra Madre (Mother Earth). Perhaps as a deluge of my naive (pseudoscience) thoughts through the lens of Greek mythology of Goddess Gaia (Earth Goddess) and James Lovelock's Gaia hypothesis, I ask "Is Nature's mother God sending us a message with the COVID-19 storm?" "Is COVID-19 a symptom of Gaia's sickness?"[1] On the 50th anniversary of the Earth Day, 22nd April 2020, the Pope Francis reiterated the need to protect "our garden-home, our Mother Earth", that creation must be protected and not exploited, and that nature will not forgive our trespasses. He recounted a Spanish proverb "God always forgives, man sometimes forgives but nature never forgives" in the context of COVID-19 and made a proclamation for Environmental stewardship. It is my steadfast conviction that coronavirus 2019 (COVID-19) is perhaps one such reality of a catastrophe stemming from Man's ideology of Anthropocentrism, an absolute decry of Biospheric egalitarianism and Planetary health, and Man's dereliction of moral responsibility for an Earth-Environmental Stewardship strategy. Humankind should envision "One Nature" Post-COVID-19 Planetary health governance. This will certainly transcend our current astigmatism of 'false binaries' i.e. Humans versus Nature, and Humans versus Non-Humans. This co-existentialism and harmony of different species of living creatures, including plants and animals is notably embraced in the Indian tradition, the concept of Vasudhaiva Kutumbakam that originated initially from ancient Sanskrit text of Maha Upanishad and later in the literary works of Hitopadesha. To my soulful mind, this renewed philosophical view, would be pivotal in paving the way for Environmental justice and Biospheric egalitarianism. Such a post-anthropocentric conceptualization would be a progressive and transformative futuristic policy to prevent zoonotic spillover emerging infectious disorders, and future ecological crisis. The humanity of Humans must be re-awakened so as to avert a dystopian future and possible human and biological annihilation on Planet Earth. The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic is undoubtedly a cataclysmic health crisis, but its ripple effects have traumatized and fractured almost all the pillars of our dynamic and thriving human society. To "hit the nail on the head," I would only reiterate that the COVID-19 pandemic is indeed a grim "SOS signal for the human enterprise" on Planet Earth for a "One Health" concept (rethinking health at the Human- Animal-Environmental-Ecosystem Interface). The 'One Health' Perspective was in fact a key focus session as part of the COVID-19 Summit in November 2020 by Cornell University researchers in the United States. I would state that the future of Mankind and Earth systems needs an exit from the Anthropocene and an entry to an era of Symbiocene that resonates with the mindset of Ernest Hemingway, "TheEarthisafineplaceandworthfightingfor." It has been my steadfast philosophy that science and technology alone cannot solve the panoply of challenges imposed by COVID-19 pandemic, but pluralistic approaches, most importantly humanities and behavioral and social sciences, must help and be on the top of the COVID-19 research agenda. This notion resonates with the affirmations made by Viktor Frankl, i.e., "Whenwearenolongerabletochangeasituation,wearechallengedtochangeourselves.Everythingcanbetakenfromamanbutonething:thelastofthehumanfreedoms–tochooseone'sattitudeinanygivensetofcircumstances,tochooseone'sownway.Betweenstimulusandresponsethereisaspace.Inthatspaceisourpowertochooseourresponse.Inourresponselieourgrowthandourfreedom." The acute COVID-19 illness, human sufferings, and the catastrophic loss of lives unequivocally do represent large collective wreckage in human history. COVID-19 pandemic underscores how emerging infectious diseases are presenting an existential threat to humanity. At the time of writing, the rapidly evolving SARS-CoV-2 pandemic has spread across 217 countries that have led to a cumulative total of 52,454,684 confirmed cases with over 1,289,983 global deaths and a recovery of 36,685,543 cases. After a dip in new cases during June–August, Europe and the United Kingdom are now reporting a second wave with a far higher number of cases than during its previous peak. The United States, too, is going through resurgence. As the tragedy of acute COVID-19 infectious disease is ravaging across the globe, the world now seems to be pinning all of its hopes on the COVID-19 vaccine race. Scientists around the world are working at an unprecedented pace to develop safe and effective vaccines that could generate long-lasting protective immunity against SARS-CoV-2 and provide population immunity, thus reducing the transmission of SARS-CoV-2 infection. Not sounding too Pollyannaish, I would now like to draw attention to the two dark sides of the prevailing COVIDomics. (i) the acute illness of COVID-19 and (ii) the hidden (unexpected) long-term health complications among COVID-19 survivors. COVID-19 has spread worldwide since first being recognized in Wuhan, a city in Central China, in December 2019. Even though the number of COVID-19 cases worldwide now has approached astronomical numbers, we are still amazed how little we know about this very complex disease. The clinical spectrum varies widely. Up to 40% of people infected with SARS-CoV-2 never develop symptoms. About 80% of those who do become symptomatic have a mild illness that does not require hospitalization; about 15% are sick enough to require hospitalization; however, only 5% require care in an intensive care unit (ICU), usually for mechanical ventilation to treat respiratory insufficiency. Early in the pandemic, many people believed that COVID-19 was a short-term illness. With the acute COVID-19 infection, there was no sense of what was coming next in the first few months. There is now emerging preliminary knowledge of subacute and long-term health worrisome and grave consequences in the post–acute-COVID-19 phase, a COVID-19 survivorship syndrome. The prevalence of post–COVID-19 long-term complications is not yet fully known and may only become apparent in the months and years to come. An article in the November issue of JAMA has suggested a proposed framework and timeline of the spectrum of SARS-CoV-2 infection.[2] The timeline for the spectrum of COVID-19 illness could be categorized into (i) acute COVID-19 infection, (ii) postacute hyperinflammatory illness, and (iii) late inflammatory and virological sequelae. It is possible that the late sequelae of COVID-19 represent multiple syndromes resulting from distinct pathophysiological processes along the spectrum of disease. Such a framework would have important implications for public health surveillance, clinical research, future treatments, and health services planning. The relevance of this Editorial is to encapsulate the long-term health consequences (i.e., the third illness period of the proposed framework) that are now adding to the ever-emerging landscape of medical knowledge on COVID-19. I would reiterate that the health problem does not stop with the first (acute) COVID-19 illness. I would not hesitate to state that it seems to be a dangerous illusion that survivors could be discharged home COVID-free without further medical attention. The end of a clinical acute COVID-19 disease may seem to be the beginning of a silent wave of under-recognized long-term sequelae, a second wave of challenges, the aftermath of COVID-19 survivor syndrome, namely the post–(acute) COVID-19 syndrome. This post–COVID-19 recovery phase does seem to be a longer and harder aftermath, does indeed mark the onset of a broader challenge, certainly not the end of the crisis, and does portray a Sisyphean challenge. The war on COVID-19 pandemic is far from over akin to the adage, "It's not over until it's over." This sets alarm bells for the entire healthcare fraternity to recalibrate our healthcare environment and health teams to be able to effectively provide patient-centric, team-based multidisciplinary care and rehabilitation ensuring a good quality of life (QoL) in such post–COVID-19 survivors. The quote cited above by Albert Camus in his fictional novel "The Plague" symbolizes a way of overcoming nihilism exemplified through the fight against an epidemic. Therefore, global healthcare community will need to summon the collective Hercules ethos as a collective solidarity of the human spirit, commitment, empathy, and collective innate human resilience not only to transcend the first wave of acute COVID-19 crisis but also to recognize and effectively establish protocols for battling the emerging second wave of "post–acute-COVID-19 syndrome" and other long-term health-related sequelae. MY JOURNEY WITH COVID-19 AND POST-COVID SYNDROME Allow me to share my self-reflective narrative of my COVID-19 illness behavior. My positive nasopharyngeal RT-PCR COVID-19 journey began in September 2020 where I became unwell with a symptom complex of a persistent raging fever for 2 weeks, during which time I developed olfactory disturbances, dysgeusia, watery diarrhea, cough with mucoid sputum, chest pressure, mild dyspnea, headache, malaise, and musculoskeletal aches. These were hellish days where I was literally hit with a wave of extreme fatigue, had fever with rigors, and had lost appetite. I had lost 5 kg of my body weight during this illness period. I was virtually bed-bound for about 2 weeks with acute COVID-19. I had fairly deep restful sleep but was colored by "emotionally intense" vivid movie-like dreams, often negatively-toned dreams (fever dreams). The 21 days of self-quarantine caused anxiety symptoms and a sense of helplessness in me. I became afebrile by the end of 2 weeks and resumed my work by the end of the 3rd week. By the end of the 3rd week, my rapid antigen test was negative, and as I rejoined my work, I found myself to be vexed by lingering rollercoaster symptoms comprising malaise and exhaustion, diffuse myalgia, joint pains, physical fatigue, dry cough, smell and taste disturbances, anorexia, insomnia (COVID-somina) with nonrestorative sleep, lethargy, and subtle neurocognitive difficulties ("brain fog"), all of which caused difficulty to engage fully in day-to-day activities. I currently feel that I am living in a "COVID cycle" of symptoms that are present to this day. Intrigued and perplexed by these constellation of new symptoms after I have recovered from COVID-19, my innate curiosity, self-inquiry, and self-directed temperament of seeking answers to my new-found persistent symptom complex led me to the newly emerging diagnosis of Post–COVID-19 syndrome. I do feel that I am now beginning to see the light at the end of this spiraling "COVID tunnel" as I feel I am not alone and there seems to be evidence of post–COVID syndrome (PCS) from across the world. This undoubtedly was indeed reassuring to me and that I was not suffering from a health anxiety and/or illness anxiety disorder. I don't know what's in store for me. It's never easy and it's never over, but for sure I will get through this Post COVID-19 syndrome. DECODING POST-COVID-19 SYNDROME COVID-19 is a complex disease with a wide spectrum of clinical patterns. COVID-19 clinical spectrum does range from asymptomatic or paucisymptomatic to severe clinical presentations with life-threatening outcomes. Although predominantly a respiratory illness, emerging data suggest that multiorgan injury is common, particularly in those with moderate-to-severe infections. Most of the infections are not severe, but 81% are mild (no or mild pneumonia), 14% manifest themselves through a severe disease (with dyspnea, hypoxia, or >50% lung involvement on imaging within 24–48 h), and 5% develop a critical illness (e.g., with respiratory failure, shock, or multiorgan dysfunction). It is interesting to note that seven different forms of mild COVID-19 were published in November by a team of MedUni Vienna scientists led by immunologist Winfried F. Pickl. The research showed the seven symptom cluster groups of symptoms in mild COVID-19: (1) "flu-like symptoms" (with fever, chills, fatigue, and cough), (2) "common cold-like symptoms" (with rhinitis, sneezing, dry throat, and nasal congestion), (3) "joint and muscle pain," (4) "eye and mucosal inflammation," (5) "lung problems" (with pneumonia and shortness of breath), (6) "gastrointestinal (GI) problems" (including diarrhea, nausea, and headache), and (7) "loss of sense of smell and taste and other symptoms." PCS is a collection of symptoms that persist for 2 or more months following the initial infection with the SARS-CoV-2 virus. PCS is defined as post–acute-COVID-19 as extending beyond 3 weeks from the onset of first symptoms and chronic COVID-19 (otherwise called as "Long COVID" or post–COVID "Long Haulers" or "Long Haul COVID") as extending beyond 12 weeks.[3] In another word, "Long COVID" is a term being used to describe a multisystem disease in people who have either recovered from a relatively mild acute COVID-19 illness but are still report lasting effects of the infection or have had the usual symptoms for far longer than would be expected. Long COVID is a patient-made term, first used by Elisa Perego (a research associate at the University College London) in May 2020 to describe her own COVID-19 experience. The most noticeable finding to date about PCS or Long COVID syndrome is that one does not need to have suffered from severe COVID to get this condition. Previously healthy adults who had mild symptoms and recovered from COVID-19 without ever-needing intensive care are also reporting subacute to long-lasting, debilitating symptoms even 2–3 months later. The kaleidoscopic array of lingering, fluctuating, bedeviling, and multisystem symptom complex reported in COVID-19 survivors includes fatigue, exhaustion and anergia, dyspnea, dry cough, chest pain, musculoskeletal aches, joint pains, headaches, myalgias, protracted loss of taste or smell, loss of appetite, gastrointestinal symptoms, diarrhea, sleep disturbances, cognitive impairment-forgetfulness and memory disturbances ("brain fog"), and mental health disturbances, all of which affect the QoL and delay the return to usual health. The wide range of rollercoaster persistent symptoms among COVID-19 survivors does occur not only among the hospitalized and critically ill patients but sadly also reported in nonhospitalized asymptomatic or mild COVID-19 patients. As the magnitude of COVID-19 pandemic is ravaging at an unprecedented scale, and considering the high number of people affected by COVID-19 infection worldwide, it can be expected that there will be a significant influx of patients with lingering and significant post–(acute) COVID-19 syndrome and other subacute and long-term health consequences. Therefore, this underestimated silent wave of PCS and "unexpected" medium- to long-term multiorgan health consequences in COVID-19 survivors would need to be more fully anticipated and addressed. A COVID-19 survivor registry and a long-term healthcare map are absolutely quintessential to study the long-term health complications impacting QoL in COVID-19 survivors. POST-COVID SYNDROME - WHAT DOES THE EVIDENCE SAY? Prolonged symptom duration and disability are common in adults hospitalized with severe COVID-19. However, relatively little is known about the clinical course of COVID-19 and return to baseline health for persons with milder, outpatient illness. What do we know so far about PCS? What does the evidence say about this less known, hidden subacute to chronic "unsuspected" PCS associated with posthospitalized and nonhospitalized COVID-19 survivorship? As yet, there is little research into the number of people at risk of developing ongoing PCS and/or Long COVID. Early attention has been on the acute illness generated by the virus, but it is becoming clear that, drawing on some COVID 19 survivor experiences, the post–acute-COVID-19 infection is a long-term illness. As yet PCS and Long COVID are not a well-defined term, with a lack of empirical diagnostic tests, there is no strict diagnostic code for PCS and/or "Long COVID." Although it is too early to give a precise definition, guidance on reaching a working diagnosis and a code for clinical datasets is needed. This is imperative to envisage clinical care models and rehabilitation programs to address and mitigate the physical, social, and psychological consequences of PCS and/or "Long COVID" syndrome. A recent Medscape article in October alluded facts from a dynamic themed review of the evidence around ongoing COVID-19 symptoms (often called Long COVID) published by Dr. Elaine Maxwell of the United Kingdom's National Institute for Health Research. This review suggested that the term "Long COVID' does not represent a single illness phenomenon and maybe a "Catch-All Term" for a wide range of recurring symptoms among people who had been hospitalized because of COVID-19, as well as those who had COVID-19 in the community. In their review, the term "Long COVID" (review preferred the term phrases "ongoing COVID-19" and "living with COVID-19") is being used as a catch-all for more than one syndrome and perhaps did actually represent four different syndromes. These different clinical phenotypes are best described and categorized as (i) postintensive care syndrome (PICU) in ICU survivors, (ii) postviral PCS that resembles a postviral fatigue syndrome or akin to chronic fatigue syndrome (CFS)/myalgic encephalomyelitis, (iii) long-term multisystem illness spectrum of Long COVID, and (iv) potential long-term organ-specific complications such as long-term post-acute respiratory distress syndrome (ARDS) pulmonary sequelae, long-term cardiovascular sequelae, post–COVID-19 emerging sequelae in children, long-term liver and kidney sequelae, long-term neuropsychiatric sequelae, post-COVID neurological syndromes (PCNSs), and post–acute-COVID-19 vulnerability to neurodegenerative and neuroimmunological disorders. It is worthwhile to note that some COVID survivors may be suffering with more than one syndrome at the same time. The UK COVID Symptom Study, an epidemiological research mobile app-driven data, has shown that there are six distinct "types" of acute COVID-19, each distinguished by a cluster of symptoms. The six clusters were categorized as (1) "flu-like" with no fever, (2) "flu-like" with fever (3) GI, (4) severe level 1, fatigue, (5) severe level 2, confusion, and (6) severe level 3, abdominal and respiratory. This categorization did help to predict the symptom cluster that would require hospitalization. This study predicted that patients in the three "severe" clusters were more likely to require oxygen or ventilation in a hospital. Researchers discovered that only 1.5% of people with cluster 1, 4.4% of people with cluster 2, and 3.3% of people with cluster 3 COVID-19 symptoms required breathing support. These figures were considerably higher for the remaining clusters, with 8.6%, 9.9%, and 19.8% for clusters 4, 5, and 6, respectively. About half of the patients in cluster 6 ended up in the hospital when compared with 16% of those in cluster 1. The UK COVID-19 study data do show that one in 10 people with COVID-19 continue to be sick and suffer from lingering and debilitating symptoms for 3 weeks or more and a smaller proportion for months. Furthermore, the COVID Symptom Study also revealed that Long COVID could be predicted in their model if patients were experiencing more than five moderate symptoms of fatigue, headache, cough, dyspnea, hoarseness of voice, and myalgia during the 1st week of illness, and was more likely with increasing age (elderly), body mass index, and female sex. Another study published in the August JAMA 2020 issue, a team of researchers (Angelo Carfi etal.) from Italy reported that nearly nine in 10 patients (87%) discharged from a Rome hospital after recovering from COVID-19 were still experiencing at least one symptom, particularly fatigue and dyspnea, 60 days after onset. They found that 13% of the 143 people were completely free of any symptoms, while 32% had one or two symptoms, and 55% had three or more. Many still reported fatigue (53%), dyspnea (43%), joint pain (27%), and chest pain (22%). Two-fifths of patients reported a worsened QoL. Yet, another large published study in September 2020 from Belgium and the Netherlands involving 112 hospitalized and 2001 nonhospitalized COVID-19–positive patients has noted that even among a large number of asymptomatic or very mildly symptomatic patients, prolonged symptoms such as muscle pain, dizziness, headaches, fatigue, and anosmia continued to experience for months. This undoubtedly reinforces that previously hospitalized and nonhospitalized COVID-19 patients can still have multiple persistent symptoms 3 months after the onset of infection-related symptoms. This suggests the presence of a "post-COVID-19 syndrome" and highlights the unmet healthcare needs in a subgroup of patients with "mild" or "severe" COVID-19. The Influenza Vaccine Effectiveness in the Critically Ill Network Investigators; CDC COVID-19 Response Team Study from the United States is another study in July 2020 that did confirm the validity of a "post-COVID-19 syndrome" and documented the delayed return to usual health. Among the 292 telephonic interview respondents, 94% (274) reported experiencing one or more symptoms at the time of testing; 35% of these symptomatic respondents reported not having returned to their usual state of health by the date of the interview (median = 16 days from testing date), including 26% among those aged 18–34 years, 32% among those aged 35–49 years, and 47% among those aged =50 years. Among respondents reporting cough, fatigue, or shortness of breath at the time of testing, 43%, 35%, and 29%, respectively, continued to experience these symptoms at the time of the telephonic interview. These findings indicate that COVID-19 can result in prolonged illness even among persons with milder outpatient illness, including young adults even without underlying chronic medical conditions. Older age and the presence of multiple chronic medical conditions and possibly chronic psychiatric conditions are thought to be plausible risk factors for the delayed return to usual health. Albeit these studies described, the evidence is far from complete on the long-term effects of COVID-19 partly because it has not been possible to fully research them this early in the pandemic. It is becoming increasingly clear that, for some people, COVID-19 infection is not a discrete single entity but one that marks the start of ongoing, often debilitating symptoms life-changing experiences affecting normal functional capacities and QoL. The narrative of COVID survivorship real experiences is captured and evident from members of the Long COVID Facebook group, a discussion and support group for patients with Long COVID. The PCS and Long COVID illness are likely to become a permanent demand for health and social care services, as the COVID-confirmed cases are rising and even after the pandemic subsides. The awareness and recognition of PCS and Long COVID would need research thrust on the postinfectious pathogenesis and immune mechanisms that may contribute to these lingering long-term health sequelae. There is a need for multinational longitudinal research to explore the prevalence, risk factors, and whether it would be possible to predict a protracted course early in the acute COVID-19 disease. In conclusion, these studies do indeed endorse the presence of a "post-COVID-19 syndrome." Long-lasting and debilitating symptoms could affect people of all ages, including those with paucisymptomatic acute COVID-19 illness who did not require hospitalization. POST-INTENSIVE CARE SYNDROME: SURVIVORSHIP AFTER COVID-19 INTENSIVE CARE UNIT STAY To many of us, a common assumption around the world is that once a critical COVID-19 ICU patient is discharged from the hospital, the critical illness has been resolved and that would be the end of the matter. However, most of us are caught unaware of what happens to the COVID-19 survivors after they are discharged from critical care. Survival of critically unwell patients, in general, has improved in the last decade due to advances in critical care medicine. Millions of people worldwide have survived an admission to the ICU, and the number of survivors is growing. While the patients with critical COVID-19 have, many a times, have survived a life-threatening illness, it is prudent to take note that most survivors of severe COVID-19 would experience postintensive care syndrome (PICS) and suffer important long-term complications. This has the potential to be the next significant public health crisis when patients are discharged from the hospital.[4] Patients who survived COVID-19 may have to face another battle. This subacute to long-term crisis of patient survivorship after the severe, life-threatening crisis of critically-ill patients with COVID-19 is marred by a combination of long-lasting physical disability, neuropsychological and cognitive impairments, sleep difficulties, and/or disturbances in emotional well-being affecting the mental health, mainly in terms of anxiety, depression, and posttraumatic stress disorder (PTSD). PICS is a term that describes new or worsening cognitive, psychological, physical, and other consequences that plague ICU survivors. With the rising of COVID-19 and second wave of infection in Europe and the United States, critical COVID-19 would surpass the ICU capacity in most of these countries. On the flipside, this upsurge of acute COVID-19 would likely result in many more patients with PICS and its associated health and economic challenges. It is crucial to note that the impairments from PICS could possibly persist beyond the ICU hospitalization for as long as 5–15 years. The major risk factors for the development of PICS in acute COVID-19 survivors are ARDS, sepsis, delirium and the duration of delirium, prolonged mechanical ventilation with exposure to higher amount of sedatives and systemic corticosteroids, multiorgan failure, and metabolic aberrations [hypoglycemia, hyperglycemia, hypoxemia, hypotension]. The physical impairments in post–COVID PICS are prevalent to a figure of 80% and include muscular weakness, critical illness neuromyopathies, fatigue, dyspnea, impaired pulmonary function, sleep-disordered breathing, and decreased exercise tolerance, all of which frequently lead to a reduction in activities of daily living (ADLs) and QoL. Emotional well-being and mental health impairments have a higher prevalence of post-ICU psychological sequelae with predictive risk factors such as patients who are younger, were female, have poor recall of the ICU stay, and had a longer duration of ICU sedation. The neuropsychiatric sequelae of such an ICU stay include anxiety, depression, and PTSD and are said to occur in 8%–57% of patients with PICS. The cognitive domain is affected by vexing symptoms of forgetfulness, memory loss and difficulty with concentration, attentional span, comprehension, and critical thinking. The ICU patient's experiences of isolation and the reduction in human interactions cause a "domino effect" of reduced cognitive stimulation, reorientation, and reassurance to patients with tell-tale effects on the cognitive and emotional well-being of the COVID-19 survivors. The multidomain PICS impairments do indeed have a profound impact on patients' QoL, as well as that of their family members, known as PICS-F. It is also prudent to realize that the limited visitation policies due to the risk of transmission also increase the risk of PICS-F. Individuals with PICS-F are most commonly affected in the domain of mental health. It is sad to note that as many as 40% of patients with PICS are unable to return to their former level of function that could potentially result in job loss and financial difficulties. I would highlight that in the wake of the acute COVID-19 life-threatening ICU scenario, the current emphasis is overwhelmingly on the acute treatment of complications and in-hospital management. In another words, PICS highlights a largely neglected but important issue in the wake of the COVID-19 pandemic. PICS is indeed one of the long-term complications of post-ICU COVID-19 survivors, and it is quintessential for early mobilization and integration of multidisciplinary rehabilitation teams for the prevention of PICS-associated complications. Now, another question is what can we do about it? Therefore, it is crucial that all ICU staff and multidomain rehabilitation team be aware and skillfully trained to evaluate the extent of physical, emotional, and cognitive impairments with ongoing assessment of patients' need for physical and occupational therapy. Efforts should be directed toward preventing PICS by minimizing sedation and early mobilization during ICU. I will not be able to dwell on the nitty–gritty evidence-based management of PICS but suffice for me to reiterate that there must be an absolute need to utilize the daily ICU checklist and the ABCDEF
Referência(s)