Delirium in COVID-19: can we make the unknowns knowns?

Wilcox, M. Elizabeth; Shankar-Hari, Manu; McAuley, Daniel F.

doi:10.1007/s00134-021-06467-2

Cited by 9 publications

(14 citation statements)

References 18 publications

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“…The prevalence of delirium noted in our cohort is consistent with that reported in the literature for COVID‐19 patients 5,6 . The use of various classes of sedatives seen in our study, for example, BZD and OP use (60.4% and 81.1%, respectively), was significantly higher than other contemporary non‐COVID cohorts 12 .…”

Section: Discussionsupporting

confidence: 90%

“…Early in the pandemic, estimates of delirium incidence among hospitalized COVID‐19 patients varied widely from 20% to 70%, with a recent large international cohort reporting prevalence of 55% 3–5 . Although the pathophysiology of delirium remains complex and poorly understood, several factors, including neurotropism of SARS CoV2, immune‐mediated microvascular damage, and microbleeds, have been identified as putative factors 3,6 . Given the unique, infectious nature of the disease, environmental and iatrogenic factors such as the use of deep sedation, prolonged immobilization, fewer sedation holidays, and social isolation are likely contributory as well 6 .…”

Section: Introductionmentioning

confidence: 99%

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Sedative polypharmacy mediates the effect of mechanical ventilation on delirium in critically ill COVID‐19 patients: A retrospective cohort study

Bose

Kelly

Shahn

et al. 2022

Acta Anaesthesiol Scand

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Background: Polypharmacy of sedatives (PP) is a potentially modifiable, iatrogenic risk factor for ICU delirium. The extent to which sedative PP influenced development of high rates of delirium among critically ill COVID-19 patients is unknown. We tested the hypothesis that PP, defined as the use of four or more classes of intravenous agents, is a mediator in the causal pathway of mechanical ventilation and delirium.Methods: Retrospective cohort study of adults admitted with a primary diagnosis of RT-PCR+ for SARS-CoV2 to ICUs of a tertiary-level academic medical center between February 2020 and April 2021. Mediation analysis was conducted with bootstrap estimation to assess whether an association between mechanical ventilation and delirium was mediated by PP. Analyses were adjusted for potential confounders related to mechanical ventilation, mediator, and outcome, including age, gender, vasopressor use, median RASS scores, SOFA score within 24 h of admission, and maximum CRP levels.Results: A total of 212 patients were included in the analysis. Of total patients, 72.6%(154/212) of patients had delirium (CAM-ICU+) during ICU stay. 54.7%(116/ 212) patients received PP. Mechanical ventilation ) and PP ) were identified as risk factors for development of ICU delirium after adjusting for prespecified confounders. PP acts as a mediator in the causal pathway between mechanical ventilation and delirium. 39% (95% CI: 17%-94%) of the effect of mechanical ventilation on delirium was mediated through PP. Conclusion:PP mediates approximately 39% of the effect of mechanical ventilation on delirium, which is clinically and statistically significant. Studies should assess whether mitigating PP could lead to reduction in ICU delirium.Implication Statement: PP of sedatives (defined as use of four or more intravenous agents) mediates approximately 39% of the effect of mechanical ventilation on development of ICU delirium. Avoidance of sedative PP may represent a viable strategy for reduction of ICU delirium.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Sedative polypharmacy mediates the effect of mechanical ventilation on delirium in critically ill COVID‐19 patients: A retrospective cohort study

Bose

Kelly

Shahn

et al. 2022

Acta Anaesthesiol Scand

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“…At first glance, these findings might seem counterintuitive since SARS-CoV-2 has neurotropic characteristics and might invade the central nervous system via the angiotensin converting enzyme 2 receptors expressed in the olfactory bulb, thereby causing neuroinflammation and ultimately delirium [ 29 ]. It is important, however, to consider that several other medical conditions like acute respiratory distress syndrome [ 27 ], cardiac arrest [ 30 ], and acute kidney injury [ 31 ] might also complicate the ICU course of COVID-19 patients.…”

Section: Discussionmentioning

confidence: 99%

Delirium in Critically Ill Patients with and without COVID-19—A Retrospective Analysis

Jäckel

Aicher

Biever

et al. 2021

JCM

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Background: Delirium complicating the course of Intensive care unit (ICU) therapy is a known driver of morbidity and mortality. It has been speculated that infection with the neurotrophic SARS-CoV-2 might promote delirium. Methods: Retrospective registry analysis including all patients treated at least 48 h on a medical intensive care unit. The primary endpoint was development of delirium as diagnosed by Nursing Delirium screening scale ≥2. Results were confirmed by propensity score matching. Results: 542 patients were included. The primary endpoint was reached in 352/542 (64.9%) patients, without significant differences between COVID-19 patients and non-COVID-19 patients (51.4% and 65.9%, respectively, p = 0.07) and correlated with prolonged ICU stay in both groups. In a subgroup of patients with ICU stay >10 days delirium was significantly lower in COVID-19 patients (p ≤ 0.01). After adjustment for confounders, COVID-19 correlated independently with less ICU delirium (p ≤ 0.01). In the propensity score matched cohort, patients with COVID-19 had significantly lower delirium incidence compared to the matched control patients (p ≤ 0.01). Conclusion: Delirium is frequent in critically ill patients with and without COVID-19 treated at an intensive care unit. Data suggests that COVID-19 itself is not a driver of delirium per se.

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“…For instance, dealing with asynchronies and treating them, even in ICUs, is a subject of debate [27] as depicted by a study showing that senior physicians tend to adapt patients by modifying ventilator parameters while nurses and residents tend to increase analgesia and sedation [28]. Management out of ICU settings could also lead to a poor adherence to standard clinical ICU practice such as cutting in family visitation, deeper levels of sedation and less mobilization favoring delirium [29,30]. We strongly suspect delirium and P-SILI to be substantially responsible for the genesis of a previously reported very severe cohort of our ICU's rst COVID-19 patients [4].…”

Section: Discussionmentioning

confidence: 99%

Ventilatory ratio and pre-ICU management delay as early predictors of mortality in invasively ventilated COVID-19-related ARDS patients. A retrospective observational cohort study.

Toumi

Meddeb

Bedhiafi

et al. 2022

Preprint

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Purpose: Coronavirus disease 2019 (COVID-19) caused by the novel SARS-CoV-2 has been a burden on healthcare systems with numerous hospital and intensive care unit (ICU) admissions, the most severe of which requiring invasive mechanical ventilation (IMV).The aim of this study is to analyze characteristics of COVID-19-related ARDS patients requiring IMV in order to determine early clinical and physiological predictors of mortality.Methods: This is a retrospective observational cohort study carried out in the medical ICU of Farhat Hached University hospital in Sousse, Tunisia, between March 3rd 2020 and December 31st 2021. All consecutive patients with confirmed SARS-CoV-2 infection admitted to the ICU and requiring IMV were included. Demographic, clinical, physiological and ventilator data were collected. Univariate and multivariate cox regression models and Kaplan–Meier overall survival curves were used to identify risk factors of mortality.Results: 732 patients were admitted to the ICU, 465(63.5%) had a confirmed COVID-19 infection, 247(53.1%) required IMV. Median [IQR] age was 67[59-74] years; and pre-ICU management delay, 4[3-7] days. 149(60.3%) were on standard oxygenation; High-Flow Nasal Oxygen, 20(8.1%); Non-Invasive Positive Pressure Ventilation, 56(22.7%) and already on IMV, 15(6.1%). SAPS II, 31[27-37]; P/F ratio, 96[76.3-139.8]. At day1 of IMV, tidal volume, 6.5[6-7] ml; PEEP, plateau and driving pressures, respectively, 10[8-10], 27[24-28] and 16[14-19] cmH2O; P/F ratio, 126.3[90.3-170.8]; ventilatory ratio, 2.36±0.89 and mechanical power, 36.0[29.3-45.2] J/min. Median length of stay, 12[7-17] days and median IMV duration, 8[5-12] days. Mortality rate, 84.6%. Early independent factors predicting mortality were age, pre-ICU management delay and ventilatory ratio at day1 of IMV.Conclusion: In invasively ventilated COVID-19-related ARDS patients, older age, longer pre-ICU management delay and higher ventilatory ratio at day1 of invasive mechanical ventilation, were independent risk factors of mortality.

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Delirium in COVID-19: can we make the unknowns knowns?

Cited by 9 publications

References 18 publications

Sedative polypharmacy mediates the effect of mechanical ventilation on delirium in critically ill COVID‐19 patients: A retrospective cohort study

Sedative polypharmacy mediates the effect of mechanical ventilation on delirium in critically ill COVID‐19 patients: A retrospective cohort study

Delirium in Critically Ill Patients with and without COVID-19—A Retrospective Analysis

Ventilatory ratio and pre-ICU management delay as early predictors of mortality in invasively ventilated COVID-19-related ARDS patients. A retrospective observational cohort study.

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