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Patients with COVID-19 admitted to intensive care in the first months of the pandemic had a significantly higher burden of delirium and coma than that typically seen in patients with acute respiratory failure. The choice of sedating drugs and restrictions on family visits played a role in the increase in acute brain dysfunction in these patients.
This is according to an international study published on January 8 in The Lancet Respiratory Medicine, led by researchers from the Vanderbilt University Medical Center in coordination with Spanish researchers.
The study, which is by far the largest of its kind to date, tracks the incidence of delirium and coma in 2,088 COVID-19 patients admitted before April 28, 2020, in 69 adult intensive care units in 14 countries .
Delirium in intensive care is associated with higher medical costs and an increased risk of death and long-term dementia associated with intensive care. Foundational studies at VUMC over the past two decades have sparked widespread interest in intensive care delirium research, and the resulting body of evidence has come to inform critical care guidelines endorsed by medical societies from several. country. These guidelines include well-calibrated pain management with prompt discontinuation of analgesics and sedatives, daily spontaneous awakening trials, daily spontaneous breathing trials, assessments of delirium throughout the day, mobility and exercise. early childhood, and family engagement.
Some 82% of patients in this observational study were comatose for a median of 10 days and 55% were delirious for a median of three days. The acute brain dysfunction (coma or delirium) lasted an average of 12 days.
“This is double what is seen in non-COVID ICU patients,” said Brenda Pun, DNP, RN, co-first author of the study with Rafael Badenes MD, PhD, from the University of Valencia in Spain. The authors cite a previous large-scale multi-site ICU study, also led by VUMC, where acute brain dysfunction lasted an average of five days, including four days in coma and one day in delirium.
The authors note that COVID-19 disease processes could predispose the patient to a higher burden of acute brain dysfunction. But they also note that a number of factors related to patient care, some of which are linked to the pressures on healthcare from the pandemic, also appear to have played a significant role.
The study appears to show a return to outdated intensive care practices, including deep sedation, the widespread use of benzodiazepine infusions (benzodiazepine is a nervous system depressant), immobilization and isolation of families. The authors find that when it comes to COVID-19, there has been an apparent widespread abandonment of new clinical protocols that have been shown to help prevent the acute brain dysfunction that plagues many critically ill patients.
“It’s clear in our results that many intensive care units have reverted to sedation practices that are not in line with best practice,” Pun said, “and we have yet to speculate on the causes. Many hospitals in our sample reported shortages of Intensive care providers were advised of best practice. Problems with a shortage of sedatives have been expressed, and early reports on COVID-19 suggested that the observed pulmonary dysfunction required unique management techniques, including deep sedation. boards.”
Using electronic health records, investigators were able to closely examine patient characteristics, care practices, and clinical assessment results. About 88% of the patients followed in the study were mechanically ventilated invasively at some point during hospitalization, 67% on the day of ICU admission. Patients receiving sedative benzodiazepine infusions had a 59% higher risk of developing delirium. Patients who received family visits (in person or virtual) had a 30% lower risk of delirium.
“There is no reason to believe that since the end 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 is sounding the alarm: as we move into waves two and three of COVID-19, critical care teams must first return to milder sedation levels for these patients, frequent awakenings and breathing trials, mobilization and visits in person or virtual in complete safety. “
Pandharipande is co-director, along with the other lead author of the study, Wesley Ely, MD, MPH, of the Critical Illness, Brain Dysfunction, and Survivorship Center. Pun is the director of data quality at the center. Other VUMC researchers participating 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.
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