COVID-19 patients admitted to intensive care in the early months of the pandemic experienced a higher burden of delirium and coma than is typically found in those hospitalised with acute respiratory failure, according to the largest study of its kind to date.
The research, published in The Lancet Respiratory Medicine journal, tracked the incidence of delirium and coma in over 2,000 COVID-19 patients admitted before April 28, 2020, to 69 adult intensive care units across 14 countries. According to the scientists, led by those at Vanderbilt University Medical Center in the US, the choice of sedative medications and curbs on family visitation played a role in increasing acute brain dysfunction for these patients.
They said ICU delirium is associated with higher medical costs and greater risk of death and long-term ICU-related dementia. Nearly 82 per cent of the patients in the study were comatose for a median of 10 days, and 55 per cent were delirious for a median of three days. The scientists noted that acute brain dysfunction lasted for an average of 12 days. “This is double what is seen in non-COVID ICU patients,” said study co-author Brenda Pun from VUMC.
The scientists believe COVID-19 could predispose patients to a higher burden of acute brain dysfunction. However, they also noted that patient care factors, some of which are related to pressures posed on health care by the pandemic, also appear to have played a significant role. With respect to COVID-19, the scientists believe there has been widespread abandonment of newer clinical protocols that are proven to help ward off the acute brain dysfunction that usually affects many critically ill patients.
“It is clear in our findings that many ICUs reverted to sedation practices that are not in line with best practice guidelines and we’re left to speculate on the causes,” Pun said. “Early reports of COVID-19 suggested that the lung dysfunction seen required unique management techniques including deep sedation. In the process, key preventive measures against acute brain dysfunction went somewhat by the boards,” she added. Analysing patient characteristics from electronic health records, and care practices and findings from clinical assessments, the scientists found that about 90 per cent of patients tracked in the study were invasively mechanical ventilated at some point during hospitalisation, and 67 per cent on the day of ICU admission.
Patients receiving benzodiazepine sedative infusions were at 59 per cent higher risk of developing delirium, they added. In comparison, the patients who received family visitation were at 30 per cent lower risk of delirium, the study noted. “There’s no reason to think that, since the close of our study, the situation for these patients has changed,” said study senior author, Pratik Pandharipande.
“These prolonged periods of acute brain dysfunction are largely avoidable. ICU teams need above all to return to lighter levels of sedation for these patients, frequent awakening and breathing trials, mobilisation and safe in-person or virtual visitation,” Pandharipande added.
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