Patients with COVID-19 admitted to intensive care in the first months of the pandemic were subjected to a significantly higher burden of delirium and coma than is normally found in patients with acute respiratory failure. The choice of sedative medications and restrictions on family visitation played a role in increasing acute brain dysfunction for these patients.
This is in line with an international study published on January 8 in The Lancet Respiratory Medicine, led by researchers at Vanderbilt University Medical Center in coordination with researchers in Spain.
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 intensive care units for adults in 14 countries.
ICU delirium is associated with higher medical costs and a higher risk of death and long-term dementia related to the ICU. Seminal studies at VUMC over the past two decades have stimulated widespread interest in research on delirium in the ICU, and the resulting body of evidence has come to inform the intensive care guidelines endorsed by medical societies in several countries. These guidelines include well-calibrated pain control with immediate interruption of analgesics and sedatives, daily spontaneous awakening tests, daily spontaneous breathing tests, assessments of delirium throughout the day, early mobility and exercise and family involvement.
About 82% of patients in this observational study were in a coma for a median of 10 days and 55% raved for a median of three days. Acute cerebral 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 at VUMC, co-author of the study with Rafael Badenes MD, PhD, at the University of Valencia, Spain. The authors cite a large previous study in a multi-site ICU, 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 note that COVID-19 disease processes can predispose the patient to a greater burden of acute brain dysfunction. But they also note that a number of patient care factors, some of which are related to the pressures imposed on health care by the pandemic, also appear to have played a significant role.
The study appears to show a reversal to obsolete intensive care practices, including deep sedation, widespread use of benzodiazepine infusions (benzodiazepine is a nervous system depressant), immobilization and isolation from families. The authors found that, with respect to COVID-19, there was an apparent and widespread abandonment of the most recent clinical protocols that have been proven to help prevent acute brain dysfunction that haunts many critically ill patients.
“It is clear from our findings that many ICUs have returned to sedation practices that do not comply with best practice guidelines,” said Pun, “and we have been speculating about the causes. Many of the hospitals in our sample reported a shortage of ICU providers. informed about best practices There were concerns about the scarcity of sedatives, and early reports from COVID-19 suggested that the observed lung dysfunction required exclusive treatment techniques, including deep sedation. In the process, the main preventive measures against acute brain dysfunction went to Planks. “
Using electronic health records, the researchers were able to closely examine patient characteristics, care practices and clinical evaluation results. About 88% of the patients followed up in the study were mechanically ventilated in an invasive manner at some point during hospitalization, 67% on the day of admission to the ICU. Patients who received sedative benzodiazepine infusions were 59% more at risk of developing delirium. Patients who received a family visit (face-to-face or virtual) had a 30% lower risk of delirium.
“There is no reason to think that, since the end of our study, the situation of these patients has changed,” said one of the study’s senior 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, above all, to return to lighter levels of sedation for these patients. , frequent awakening and breathing tests, mobilization and safe personal or virtual visitation. “
Pandharipande is co-director, with the other senior author of the study, Wesley Ely, MD, MPH, of the Center for Critical Illness, Cerebral Dysfunction and Survival. Pun is the data quality director at the center. 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.