COVID-19 patients admitted to intensive care during the first months of the pandemic suffered a significantly higher burden of delirium and coma than is normally found in patients with acute respiratory failure. The choice of sedative medications and curbs on the family visit played a role in increasing the acute brain dysfunction of these patients.
According to an international study published on January 8 a Respiratory Medicine Lancet, led by researchers at the Medical Center of the University of Vanderbilt in coordination with researchers in Spain.
The study, which is so far the largest of its kind, tracks the incidence of delirium and coma in 2,088 COVID-19 patients admitted before April 28, 2020 to 69 adult intensive care units from 14 countries.
ICU delirium is associated with higher medical costs and an increased risk of long-term ICU-related death and dementia. Seminar studies conducted at VUMC over the past two decades have aroused widespread interest in the investigation of ICU delirium, and the resulting body of evidence has supported critical care guidelines approved by medical societies in several countries. These guidelines include well-calibrated pain management with rapid discontinuation of painkillers and sedatives, daily spontaneous awakening trials, daily spontaneous breathing trials, all-day delirium assessments, early mobility and exercise, and family commitment.
About 82% of patients in this observational study were in a coma for an average of 10 days and 55% were delirious for an average of three days. Acute brain dysfunction (coma or delirium) lasted an average of 12 days.
“This is twice what is seen in patients with non-COVID ICU,” said Brenda Pun, DNP, RN of VUMC, co-author of the study with Dr. Rafael Badenes, PhD from the University of Valencia in Spain. The authors cite a previous ICU study of several sites, also led by VUMC, where acute brain dysfunction lasted an average of five days, including four days of coma and one day of delirium.
The authors point out that COVID-19 disease processes could predispose the patient to an increased burden of acute brain dysfunction. But they also note that several patient care factors, some of which are related to the pressures the pandemic puts on health care, also appear to play an important role.
The study appears to show a reversal to outdated critical care practices, including deep sedation, widespread use of benzodiazepine infusions (benzodiazepine is a nervous system depressant), immobilization, and isolation of families. The authors find that, with respect to COVID-19, there has been an apparent widespread abandonment of more recent clinical protocols that have been shown to help prevent the acute brain dysfunction that many critical patients grant.
“It is clear in our findings that many ICUs have returned to sedation practices that do not conform to good practice guidelines,” Pun said, “and we are left to speculate on the causes. Many of the hospitals in our sample ICU providers reported best practices.There were concerns about sedative shortages and early COVID-19 reports suggested that seen lung dysfunction needed unique management techniques, including sedation. In the process, key preventive measures against acute brain dysfunction went a little overboard. “
Using electronic medical records, researchers were able to closely examine patient characteristics, care practices, and the results of clinical evaluations. About 88% of patients tracked in the study were mechanically invasive ventilated at some point in hospitalization, 67% on the day of admission to the ICU. Patients receiving sedative benzodiazepine infusions were 59% more likely to develop delirium. Patients who received family visits (face-to-face or virtual) had a 30% lower risk of delirium.
“There is no reason to think that, since the closure of our study, the situation of these patients has changed,” said one of the study’s lead authors, Pratik Pandharipande, MD, MSCI, professor of anesthesiology.
“These prolonged periods of acute brain dysfunction are largely preventable. Our study sounds an alarm: as we enter the second and third waves of COVID-19, ICU teams need to return to higher levels of sedation. light for these patients, breathing tests, mobilization and safe in-person or virtual visits “.
Pandharipande is co-director, along with the study’s other lead author, Wesley Ely, MD, MPH, of critical illness, brain dysfunction, and survival center. Pun is the center’s data quality director. Other VUMC researchers in the study include Onur Orun, MS, Wencong Chen, PhD, Rameela Raman, PhD, Beata-Gabriela Simpson, MPH, Stephanie Wilson-Linville, BSN, Nathan Brummel, MD, and Timothy Girard, MD.