Study: Higher Burden of Acute Brain Dysfunction for COVID-19 ICU Patients

Choice of sedative medications and limitations on family visitation possibly played a role in increasing acute brain dysfunction for patients with acute respiratory failure, according to a study published in The Lancet Respiratory Medicine.

The study tracks the incidence of delirium and coma in 2088 patients with coronavirus disease 2019 (COVID-19) admitted before April 28, 2020, to 69 adult intensive care units (ICU) across 14 countries.

ICU delirium is associated with higher medical costs and greater risk of death and long-term ICU-related dementia, according to the study authors. Past studies have created an interest in ICU delirium research, and the resulting body of evidence has come to inform critical care guidelines endorsed by medical societies in several countries, according to the authors of the current study.

These guidelines include well-calibrated pain management with prompt discontinuation of analgesics and sedatives, daily spontaneous awakening trials, daily spontaneous breathing trials, delirium assessments throughout the day, early mobility and exercise, and family engagement.

Approximately 82% of patients in this observational study were comatose for a median of 10 days and 55% were delirious for a median of 3 days. Further, acute brain dysfunction, also known as coma or delirium, lasted for a median of 12 days.

“This is double what is seen in non-COVID ICU patients,” said study co-author Brenda Pun, DNP, RN, in a press release.

The study authors note that COVID-19 disease processes could predispose patients to a higher burden of acute brain dysfunction. However, the authors also noted that a number of 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.

A reversion to outmoded critical care practices, including deep sedation, widespread use of benzodiazepine infusions, immobilization, and isolation from families were shown in the study. With COVID-19, there was an apparent widespread abandonment of newer clinical protocols that are proven to help ward off the acute brain dysfunction that stalks many critically ill patients, according to the study authors.

“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 in a press release. “Many of the hospitals in our sample reported shortages of ICU providers informed about best practices. There were concerns about sedative shortages, and 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.”

The research team was able to closely examine patient characteristics, care practices, and findings from clinical assessments using electronic health records.

Approximately 88% of patients tracked in the study were invasively mechanically ventilated at some point during hospitalization compared with 67% on the day of ICU admission. Additionally, patients receiving benzodiazepine sedative infusions had a 59% higher risk of developing delirium. Patients who received family visitation, in-person or virtual, had a 30% lower risk of delirium.

“There’s no reason to think that, since the close of our study, the situation for these patients has changed,” said study author Pratik Pandharipande, MD, MSCI, in a press release. “These prolonged periods of acute brain dysfunction are largely avoidable. 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 trials, mobilization and safe in-person or virtual visitation.”

REFERENCE

Large study finds higher burden of acute brain dysfunction for COVID-19 ICU patients. Vanderbilt University. https://news.vumc.org/2021/01/08/large-study-finds-higher-burden-of-acute-brain-dysfunction-for-covid-19-icu-patients/. Published January 8, 2021. Accessed January 11, 2021.