Prolonged acute brain dysfunction in patients with COVID-19ICU

According to a large multicenter cohort study, acute brain dysfunction (coma or delirium) occurred frequently and was prolonged in patients with severe COVID-19.

Of the more than 2,000 COVID-19ICU patients in 14 countries, 82% had a median 10-day coma, Rafael Badenes, MD, PhD, and PhD at the University of Valencia, Spain. Lancet Respiratory Medicine.. For 55% with delirium, the median duration was 3 days.

Acute brain dysfunction lasted a median of 12 days, twice as much as commonly seen in other ICU patients. Benzodiazepine use and family visits have been identified as modifiable risk factors for COVID-19 delirium.

Dr. Wes Erie, MD, co-author of the Vanderbilt University Medical Center in Nashville, said long-term acute brain dysfunction is a “precursor of bad consequences.” Previous studies have shown that the duration of delirium is a predictor of mortality, length of stay, cost of care, and acquired dementia, he said.

“What we’re learning is that the ICU’s COVID is like a delirium factory,” Ely said. Today’s MedPage. “”That’s why we raise our hackle and say OK, what are we going to do about it? “

The study examined 2,088 COVID-19 patients admitted to 69 ICUs by April 28, 2020. The median age of the patients was 64 years, which was a simplified median acute physiology score. (SAPS) II At admission 40; most were male (71.7%) and white (76.5%). Patients who were dying or whose life-sustaining measures were withdrawn within 24 hours of admission to the ICU, and patients with pre-existing psychiatric disorders, neurodegenerative disorders, or brain injuries were excluded.

Invasive ventilation was initiated on the first day of admission to the ICU in two-thirds (66.9%) of patients. Overall, 87.5% received mechanical ventilation at some point during hospitalization and 63.1% were placed in the prone position for a median of 4 days.Median score Richmond Stirring-Sedation Scale It was –4 during invasive ventilation.

Most patients received continuous sedative infusions during mechanical ventilation. 64.0% of patients received benzodiazepines for a median of 7 days and 70.9% received propofol for a median of 7 days.

Sedative benzodiazepine infusion (OR 1.59), antipsychotic (OR 1.59), invasive ventilator (OR 1.48), continuous opioid infusion (OR 1.39), restricted use (OR 1.32), and pressor agent (OR 1.25) The next day’s delirium, each associated with a higher risk (all) P≤ 0.04). Family interactions, including virtual visits, reduced the risk of delirium (OR 0.73, P<0.0001).

Almost all institutions surveyed (94%) taught hospitals. Most (84%) increased ICU bed capacity during pandemics, 42% primarily reported lack of resources for critical care providers, personal protective equipment, ventilators, ICU beds, and sedatives. Did.

Prior to the COVID-19 pandemic, the reported incidence of new excitatory delirium was up to 13% in adults with serious illness and the overall prevalence was up to 20%, Watford, UK. General Hospital Valerie Page, MBBCh, said. AN Ancillary editorial..

“The optimal approach to sedation for COVID-19 remains uncertain, but evidence-based practices available outside the context of COVID-19 should form the basis of an approach to delirium management,” Page writes. I am. “The severity of COVID-19 disease is corrected by reduced viral load, reduced risk factors, and early symptoms, and more is understood about the encephalopathy caused by COVID-19, so clinicians. May be able to safely manage the majority of these patients. Use of deep sedation. “

The ICU delirium rate was lower before COVID-19, mainly due to the following protocols: ABCDEF (A2F) Ely pointed out, a bundle that frequently reassess sedation. “We have lost a lot of our position at COVID,” he said. “Since 2005, there has been no use of this type of benzodiazepine.”

The researchers observed that the study had some limitations. Routine care for patients with severe COVID-19 may have changed after the study was completed. No neuroimaging data has been collected and no information about acute kidney injury has been collected. The sedative dose, sedative goals, and rationale for drug selection were also not evaluated.