COVID-19 patients admitted to intensive care in the early months of the pandemic were under a much higher burden of delirium and coma than is typically found in patients with upper respiratory failure. Selection of sedative medications and loops on family visit played a role in increasing severe brain dysfunction for these patients.
That’s according to an international study published Jan. 8 in Lancet respiratory medicine, led by researchers at Vanderbilt University Medical Center in coordination with researchers in Spain.
The study, the largest of its kind to date, monitors the incidence of delirium and coma in 2,088 COVID-19 patients admitted by April 28, 2020, to 69 adult intensive care units across 14 countries.
ICU delirium is associated with higher medical costs and an increased risk of ICU-related death and depression in the long run. VUMC’s fundamental studies over the past two decades have sparked widespread interest in ICU delirium research, and the resulting body of evidence is coming to inform emergency care guidelines with the support of medical associations. in several countries. Such guidelines include well-calibrated pain management with prompt discontinuation of analgesics and sedatives, daily spontaneous arousal tests, daily spontaneous breath tests, daytime delirium assessments, early movement and exercise, and com- family sharing.
Approximately 82% of patients in this observational study comatose for a median of 10 days, and 55% were delirious for a median of three days. Brain failure (coma or delirium) lasted for a median of 12 days.
“This is double what has been seen in non-COVID ICU patients,” said Brenda Pun, DNP, RN, co-author of the study by Rafael Badenes MD, PhD, University of Valencia, Spain. The authors cite a large, previous multivariate, VUMC-led ICU study, in which mid-brain depression lasted a five-day period, involving four days of coma and one day of delirium.
The authors note that COVID-19 disease processes may predispose a patient to a higher burden of brain damage. But they also note that a number of patient care factors appear to have played an important role, some of which are related to pressures on health care with the pandemic.
The study appears to show a shift back to old-fashioned emergency care practices, including deep sedation, widespread use of benzodiazepine ingestion (benzodiazepine is a nervous system depression), immobile movement and loneliness from families. The authors find that, where COVID-19 is of concern, there appears to be a more recent discontinued clinical protocol that has been proven to help maintain true. brain damage that stalks many patients is very severe.
“It is clear in our conclusions that many ICUs have returned to sedation practices that are not in line with best practice guidelines,” Pun said, “and we are left to consider the reasons. hospitals in our sample reported a shortage of ICU providers were kept informed of best practices.There were concerns about sedative shortages, and early reports of COVID-19 suggested the need for specific management methods including a deep dose in the lung process. In the process, the main preventive measures against severe brain dysfunction were partially by the board. “
Using electronic health records, researchers were able to closely examine patient characteristics, care practices, and conclusions from clinical evaluations. Some 88% of patients examined in the study were mechanically admitted at some point in the hospital, 67% on the day the ICU was admitted. Patients receiving benzodiazepine sedative intake had a 59% higher risk for developing delirium. Patients who received a family visit (in person or in person) were at 30% lower risk of delirium.
“There is no reason to think that, since the end of our study, the situation for these patients has changed,” said one of the study’s lead authors, Pratik Pandharipande, MD, MSCI, senior professor of Anesthesiology.
“These long periods of brain depression are largely avoided. Our study feels cautious: 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 waking up and safe breath, movement and visit tests in person or online. “
Pandharipande is co-director, with another senior author of the study, Wesley Ely, MD, MPH, of the Center for Critical Illness, Brain Dysfunction, and Survivorship. Pun is the director of data quality with the center. Other VUMC researchers examined 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 .