COVID-19 patients admitted to intensive care during the first months of the pandemic suffered significantly higher levels of delirium and coma than is typically found in patients with acute respiratory failure. The choice of sedative medications and curbing family visits played a role in increasing acute brain disorders in these patients.
That’s according to an international study published Jan. 8 in The Lancet Respiratory Medicine, led by researchers at Vanderbilt University Medical Center in collaboration 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 to 69 adult intensive care units in 14 countries before April 28, 2020.
Delirium in the ICU is associated with higher medical costs and a greater risk of death and long-term IC dementia. Groundbreaking studies at the VUMC over the past two decades have sparked a wide interest in delirium research in the ICU, and the resulting body of evidence has come to inform the critical care guidelines endorsed by medical associations in various countries. These guidelines include well-calibrated pain management with immediate discontinuation of analgesics and sedatives, daily spontaneous awakening tests, daily spontaneous breathing tests, daytime delirium assessments, early mobility and exercise, and family involvement.
Approximately 82% of patients in this observational study were comatose 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 double what is seen in non-COVID ICU patients,” said Brenda Pun, DNP, RN of VUMC, co-lead author of the study with Rafael Badenes MD, PhD, of the University of Valencia in Spain. The authors cite a previous large, multi-site ICU study, also led by VUMC, where acute brain disorders lasted an average of five days, including four days of coma and one day of delirium.
The authors note that the disease processes of COVID-19 can predispose the patient to an increased burden of acute brain disorders. But they also note that a number of patient care factors, some of which are related to the pressures exerted on healthcare by the pandemic, also appear to have played an important role.
The study appears to show a return to outdated intensive care practices including deep sedation, widespread use of benzodiazepine infusions (benzodiazepine is a nervous system depressant), immobilization and isolation from families. The authors note that, as far as COVID-19 is concerned, there has been seemingly widespread abandonment of newer clinical protocols that have been proven to help prevent the acute brain dysfunction that haunts many critically ill patients.
“It is clear from our findings that many ICUs have reverted to sedation practices that are not in line with best practice guidelines,” said Pun, “and we have yet to speculate on the causes. Many of the hospitals in our sample reported a shortage. ICU caregivers were aware of best practices. There were concerns about sedative shortages, and early reports of COVID-19 suggested that the observed lung dysfunction required unique management techniques, including deep sedation boards. “
Using electronic health records, researchers were able to accurately examine patient characteristics, care practices, and findings from clinical reviews. Approximately 88% of the patients followed in the study received invasive mechanical ventilation at some point during hospitalization, 67% on the day of admission to the ICU. Patients who received benzodiazepine sedative infusions had a 59% higher risk of developing delirium. Patients who received family visits (in person or virtually) had a 30% lower risk of delirium.
“There is no reason to believe that the situation for these patients has changed since the conclusion of our study,” said one of the study’s senior authors, Pratik Pandharipande, MD, MSCI, professor of anesthesiology.
“These protracted episodes of acute brain dysfunction are largely avoidable. Our study raises an alarm: As we enter the second and third waves of COVID-19, IC teams should especially return to lighter sedation levels for these patients, wake up often and test breathing. , mobilization and secure 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 Survivorship Center. Pun is director of data quality with 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.