Section 2: COVID-19: Potential factors contributing to ICU delirium (from DOI: 10.1186/s13054-020-02882-x)
From publication: "COVID-19: ICU delirium management during SARS-CoV-2 pandemic" published as Crit Care; 2020 04 28 ; 24 (1) 176. DOI: https://doi.org/10.1186/s13054-020-02882-x
Section 2: COVID-19: Potential factors contributing to ICU delirium
The use of sedating medications in critically ill patients, especially sedative-hypnotics and anticholinergic agents is associated with the development of delirium. Despite advances in care bundles, such as the ABCDEF bundle, to reduce the incidence of delirium and improve the care of critically ill patients, recent reports from regions of the world hardest hit by COVID-19 suggest that a flexible approach to management algorithms may be required, due to either a strained workforce or scarcity of resources. Highlighting the importance of COVID-19-related morbidities it must be underlined that agitation associated with hyperactive delirium could theoretically be a source of intra-hospital disease spread in uncooperative patients in over-crowded settings with respiratory distress prior to intubation or awaiting admission to the ICU.
Another potential factor contributing to the occurrence of ICU delirium during the SARS-CoV-2 outbreak is social isolation created by "social distancing" strategies and quarantines, which may prove especially difficult in older adults, who have no or limited support from caregivers. In the age of COVID-19, in an attempt to "flatten the curve" and slow the spread of the virus, many hospitals have instituted no-visitation or very limited visitation policy, which may propagate a sense of isolation, ultimately contributing to disorientation and lack of awareness in the patient. What is needed now, is not only high-quality ICU care, concentrated on providing adequate respiratory support to critically ill patients, but an identification of the source and degree of mental and spiritual suffering of patients as well as their families to provide the most ethical and person-centered care during this humanitarian crisis. Many patients, coming from different religious backgrounds, will need the support of religious services that are likely to be unavailable for an extended period of time. Implementation of policies that prevent visitors from coming into the hospital should be followed by additional efforts to support patient-family interaction. This must include dedicated time and effort for phone and video conversations during busy ICU time. Moreover, hospital management should provide all possible novel technological options for communication, including teleconferences or portable speakerphones. All of these concepts are summarized in Fig. 1.
This patient-centered approach is especially important for delirious patients, the majority of whom are elderly, may suffer from an evolving neurocognitive disorder, be hypoactive or aphasic and cannot express their emotional or spiritual needs, and would typically receive comfort from relatives, friends, and caregivers, during a medical crisis. During these strenuous and difficult times, an even deeper sense of humanity is required from healthcare professionals and hospital management to provide quality care to critically ill patients. The workload is already increased with the volume of new and deteriorating patients, but in order to provide maximum humanitarian care and preserve the sense of dignity, we must view the fulfillment of mental and spiritual needs as a medical intervention. Yet it is obvious that during the COVID-19 pandemic, the potential for non-pharmacological interventions encapsulated in the ABCDEF bundle (e.g., mobility outside the ICU room, family engagement) may be extremely limited. All of these issues factor into the type of survivorship that our COVID-19 patients and their families will experience the months and years ahead as they face the burdens of PICS and PICS-F.
Delirium, the most frequent clinical expression of acute brain dysfunction, is especially important in the context of COVID-19. It may be regarded as an early symptom of infection, as previously described in septic patients. Therefore, delirium should be actively screened for using dedicated psychometric tools, i.e., CAM-ICU or ICDSC. It is also plausible that delirium severity, which could be measured with CAM-ICU-7 or DRS-R-98, may be associated with COVID-19 severity. The SARS-CoV-2 virus causes pneumonia, especially in elderly patients. Since advanced age is a well-described independent risk factor for delirium, it could be postulated that those who are at the greatest risk for severe pulmonary disease related to COVID-19 are likely at the greatest risk for delirium as well. It has been reported that nearly 90% of COVID-19 patients whose condition required admission to the intensive care unit need mechanical ventilation, either non-invasive (NIV) (42%) or invasive requiring intubation (48%). Currently, due to the reports of increased aerosolization of the viral load, NIV is not recommended yet still being used when ICU resources become limited.
The use of sedating medications in critically ill patients, especially sedative-hypnotics and anticholinergic agents is associated with the development of delirium. Despite advances in care bundles, such as the ABCDEF bundle, to reduce the incidence of delirium and improve the care of critically ill patients, recent reports from regions of the world hardest hit by COVID-19 suggest that a flexible approach to management algorithms may be required, due to either a strained workforce or scarcity of resources. Highlighting the importance of COVID-19-related morbidities it must be underlined that agitation associated with hyperactive delirium could theoretically be a source of intra-hospital disease spread in uncooperative patients in over-crowded settings with respiratory distress prior to intubation or awaiting admission to the ICU.
Another potential factor contributing to the occurrence of ICU delirium during the SARS-CoV-2 outbreak is social isolation created by "social distancing" strategies and quarantines, which may prove especially difficult in older adults, who have no or limited support from caregivers. In the age of COVID-19, in an attempt to "flatten the curve" and slow the spread of the virus, many hospitals have instituted no-visitation or very limited visitation policy, which may propagate a sense of isolation, ultimately contributing to disorientation and lack of awareness in the patient. What is needed now, is not only high-quality ICU care, concentrated on providing adequate respiratory support to critically ill patients, but an identification of the source and degree of mental and spiritual suffering of patients as well as their families to provide the most ethical and person-centered care during this humanitarian crisis. Many patients, coming from different religious backgrounds, will need the support of religious services that are likely to be unavailable for an extended period of time. Implementation of policies that prevent visitors from coming into the hospital should be followed by additional efforts to support patient-family interaction. This must include dedicated time and effort for phone and video conversations during busy ICU time. Moreover, hospital management should provide all possible novel technological options for communication, including teleconferences or portable speakerphones. All of these concepts are summarized in Fig. 1.
This patient-centered approach is especially important for delirious patients, the majority of whom are elderly, may suffer from an evolving neurocognitive disorder, be hypoactive or aphasic and cannot express their emotional or spiritual needs, and would typically receive comfort from relatives, friends, and caregivers, during a medical crisis. During these strenuous and difficult times, an even deeper sense of humanity is required from healthcare professionals and hospital management to provide quality care to critically ill patients. The workload is already increased with the volume of new and deteriorating patients, but in order to provide maximum humanitarian care and preserve the sense of dignity, we must view the fulfillment of mental and spiritual needs as a medical intervention. Yet it is obvious that during the COVID-19 pandemic, the potential for non-pharmacological interventions encapsulated in the ABCDEF bundle (e.g., mobility outside the ICU room, family engagement) may be extremely limited. All of these issues factor into the type of survivorship that our COVID-19 patients and their families will experience the months and years ahead as they face the burdens of PICS and PICS-F.
