Intensive care during COVID like a 'delirium factory', study finds

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An international study of COVID-19 treatments has found patients admitted to intensive care early in the pandemic were treated by ‘outmoded’ sedation practices, leading to a doubling in their rates of delirium and coma.

“Delirium and coma were really epidemic within this pandemic and prolonged more than what we see in our non-COVID patients,” said Brenda Pun, from Vanderbilt University Medical Centre (VUMC), co-first author of the study.

“Let’s not go backward to this deep and prolonged sedation, but let’s go forward and learn from this,” she said.

The (VUMC) study found 82 per cent of patients were comatose for a median of 10 days, and 55 per cent were delirious for a median of three days. Acute brain dysfunction (coma or delirium) lasted for a median of 12 days.

“This is double what is seen in non-COVID ICU patients,” said Dr Pun.

Compatriot Dr Wes Ely described COVID in the ICU as being “like a delirium factory”.

“It’s a reason to have our hackles up and say okay, what are we going to do about it?”

ICU delirium is associated with higher medical costs and greater risk of death and long-term ICU-related dementia, reports VUMC.

“The study appears to show a reversion to outmoded critical care practices, including deep sedation, widespread use of benzodiazepine infusions (benzodiazepine is a nervous system depressant), immobilisation, and isolation from families.

“The authors find that, where COVID-19 is concerned, there has been 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.”

AJMC.com correspondent Laura Joszt says critically ill patients had rates of delirium and coma when they were in the ICU of between 60 per cent and 80 per cent until 2015, but those rates had since reduced to under 50 per cent due to changes in care.

“It is clear in our findings that many ICUs reverted to sedation practices that are not in line with best practice guidelines,” Dr Pun said, “and we’re left to speculate on the causes. 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.”

Investigators found 88 per cent of patients tracked in the study were invasively mechanical ventilated at some point during hospitalisation, 67 per cent on the day of ICU admission. Patients receiving benzodiazepine sedative infusions were at 59 per cent higher risk of developing delirium. Patients who received family visitation (in-person or virtual) were at 30 per cent 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 one of the study’s senior authors, Pratik Pandharipande, a professor of anaesthesiology.

“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, mobilisation and safe in-person or virtual visitation.”

Delirium is defined by Pharmacy Times as “a syndrome that is characterised by the acute onset of cerebral dysfunction with a change or fluctuation in baseline mental status, as well as inattention and either disorganised thinking or an altered level of consciousness”.

“In general, delirium occurs frequently in patients experiencing life-threatening illnesses that require intensive medical support. Upon the occurrence of delirium in a patient, there is also an increased likelihood of a poorer prognosis for the patient outcome, especially among the elderly.”

Psychology Today reports that delirium can be frightening and even dangerous.

“Patients, in fear and confusion, can try to escape, pull out IVs, catheters, and breathing tubes, and even attack family or staff. However, delirium is temporary. With time, treating underlying causes, trying to disrupt sleep as little as possible, and having familiar items (like family photos) at the bedside, then symptoms tend to improve.”

Those who experience delirium in the ICU are at risk of post-intensive care syndrome (PICS), a “cognitive, psychiatric, and/or physical disability that affects survivors of critical illness”, which persists after a patient leaves the ICU.

COVID-19 patients experiencing PICS have reported persistent symptoms including fatigue, joint pain, chest pain, shortness of breath, and worsening quality of life.

“According to research on the subject, 44.1 per cent of post-COVID-19 patients experienced worsened quality of life 60 days after the onset of symptoms,” reports Pharmacy Times.

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Written by Will Brodie

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