COVID-19 patients admitted to the intensive care unit in the early months of the pandemic had a significantly higher burden of delirium and coma than is usual in patients with acute respiratory failure. The choice of sedatives and curbs during family visits has played a role in increasing acute brain dysfunction for these patients.
This is according to an international study published on January 8 in The Lancet Respiratory Medicine, led by researchers from Vanderbilt University Medical Center in collaboration with researchers in Spain.
The study, which is by far the largest of its kind to date, follows the prevalence of delirium and coma in 2088 COVID-19 patients admitted before April 28, 2020, in 69 adult units in 14 countries.
ICU delirium is associated with higher medical costs and greater risk of death and long-term ICU-related dementia. Seminal studies at VUMC over the past two decades have sparked widespread interest in ICU delirium research, and the resulting information has led to critical care guidelines endorsed by medical associations in several countries. These guidelines include well-calibrated pain management with immediate discontinuation of painkillers and sedatives, daily spontaneous wake-up tests, daily spontaneous breathing tests, delirium assessments during the day, early mobility and exercise, and family involvement.
Approximately 82% of the patients in this observational study were median of ten days coma and 55% were median of three days misleading. Acute brain dysfunction (coma or delirium) lasted a median of 12 days.
“This is double what is seen in non-COVID ICU patients,” said Brenda Pun, DNP, RN, co-author of VUMC, about the study with Rafael Badenes MD, PhD, of the University of Valencia in Spain. The authors cite a previous major ICU study in several fields, also led by VUMC, where acute brain dysfunction lasted a median of five days, including four days of coma and one day of delirium.
The authors note that COVID-19 disease processes may tend the patient to a higher burden of acute brain dysfunction. But they also note that a number of patient care factors, some of which are related to the pressure the pandemic is exerting on healthcare, have also played an important role.
The study appears to show a return to outdated critical care practices, including deep sedation, widespread use of benzodiazepine infusions (benzodiazepine is a nervous system), immobilization, and isolation of families. According to COVID-19, there has been an apparent proliferation of newer clinical protocols proving that it can prevent acute brain dysfunction that promotes highly critically ill patients.
“It is clear in our findings that many ICUs have relapsed into sedation practices that are not in line with best practice guidelines,” Pun said, “and we can still speculate on the causes. ICU providers have informed about best practices.” “was concerned about a shortage of sedatives, and early reports from COVID-19 suggested that the lung dysfunction seen required unique management techniques, including deep sedation. In the process, the most important preventative measures against acute brain dysfunction have passed somewhat.”
Using electronic health records, investigators were able to examine patients’ characteristics, care practices, and findings of clinical assessments more closely. About 88% of the patients detected in the study were mechanically ventilated intrusively at some point during hospitalization, 67% on the day of admission to the ICU. Patients receiving benzodiazepine sedative infusions have a 59% higher risk of developing delirium. Patients who have received family visits (in person or virtually) have a lower risk of delirium.
“There is no reason to think that the situation for these patients has changed since the end of our study,” said one of the senior authors of the study, Pratik Pandharipande, MD, MSCI, professor of anesthesia.
“These prolonged periods of acute brain dysfunction are largely avoidable. Our study leaves an alarm: as we enter the second and third waves of COVID-19, ICU teams must return to milder levels of anesthesia for these patients, awake regularly and breathing tests, mobilization and safe personal or virtual visit. “
Pandharipande is co-director, along with the other senior author of the study, Wesley Ely, MD, MPH, of the critical illness, brain dysfunction and survival center. Pun is director of data quality at the center. Other VUMC investigators on 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.