Management of Agitation, Delirium, and Catatonia in Intubated COVID-19 Patients: A Case Series & Rationale for Valproate Sodium Use During Extubation

Abstract

The complete spectrum of neuropsychiatric effects of SARS-CoV-2 acute respiratory distress syndrome has yet to be fully appreciated, particularly in intubated patients. Manifestations including delirium and catatonia need to be considered in intubated COVID-19 patients. Medications known to exhibit neuroprotective effects, like valproate, can assist in agitation related to sedative withdrawal during extubation. This case series reports on the management of agitation, delirium, and catatonia in COVID-19 patients during and after extubation efforts. We present three cases in which Psychiatry was consulted for agitation in intubated COVID-19 patients. These patients were managed for severe agitation during weaning from extubation as well as for subsequent psychiatric challenges, including catatonia. Patient 1: 26-year-old female with bipolar I with psychotic features who was admitted for acute hypoxic respiratory failure from COVID-19 pneumonia. After an emergency C-section at 31 weeks’ gestation, she was intubated for 9 days and started on valproate 250 mg BID for agitation. She was extubated successfully and discharged home. Patient 2: 42-year-old female with bipolar I and PTSD who was intubated following COVID-19-related acute hypoxic respiratory failure. She received valproate 250mg BID and was extubated successfully. She became catatonic when home quetiapine was resumed and recovered following quetiapine discontinuation and lorazepam. She was discharged on valproic acid and alprazolam. Patient 3: 23-year-old female with bipolar I with psychotic features who was admitted for COVID-19 acute hypoxic respiratory failure and intubated. She received valproate 250 mg BID and was extubated successfully. She became catatonic when risperidone was re-initiated, but recovered following risperidone discontinuation and addition of lorazepam, gabapentin, and duloxetine. Quetiapine was added before discharge. Valproate was effective for managing delirium and agitation during extubation, as evidenced by normalizing Richmond Agitation and Sedation Scale scores. Additionally, valproate aided in managing catatonia post-extubation. This case series reports on the management of agitation in COVID-19 patients during extubation efforts with valproate sodium, due to its ability to manage delirium and catatonia. Valproate is known to exhibit neuroprotective effects, which possibly explains successful management of agitation during the extubation process.

Catatonia after COVID-19 infection: scoping review

“…36 Many of these conditions were described in patients with COVID-19 identified in our review. [37][38][39][40] Consequently, misclassification or missed diagnoses of catatonia is a possibility, and many cases fall within the grey zones of disease classification. Grey zones in medicine represent a complex situation and a great challenge to the diagnostic classification and subsequent treatment of patients.…”