Section 4: COVID-19: ICU delirium management:potential problems and solutions (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 4: COVID-19: ICU delirium management:potential problems and solutions
Delirium screening only takes 30 s. As such, delirium screening and treatment should follow well-established international guidelines, such as the eCASH concept and the SCCM clinical practice guidelines. Although routinely used in clinical practice, some sedation- and delirium-associated issues may be especially important when using limited resources. Standard non-pharmacological measures to treat or prevent delirium may not be possible in isolation environments, and these environments may themselves worsen delirium. Pain management remains a priority for all patients and requires the widespread implementation of behavioral pain scales (CPOT or BPS) for sedated and mechanically ventilated patients. After pain control is adequately assured, we must focus on the intersecting issues that lead a person's brain to fail in critical illness, chief among them including overuse of powerful sedatives and undue immobilization. These and other potential problems regarding ICU delirium management during the SARS-CoV-2 pandemic are identified in Table 1.
During such harrowing times at the respiratory failure that is occurring with COVID-19, it would be easy to disregard patients' brains as not being an essential concern. If we follow the critical care literature, this would be a grave error. Evidence indicates that delirium is not only a robust prognostic indicator of worse survival immediately, but also of the cost of care and quality of survival. Thus, healthcare professionals should follow local guidelines and policies regarding the monitoring and management of delirium. Implementation of easy screening methods for delirium is necessary especially in light of heavy workload because without validated assessment tools 75% of delirium will be missed during the COVID-19 crisis. It is necessary to reduce the ICU delirium risks using standard management approaches towards adequate pain management, avoiding urinary retention and gastro-intestinal problems (constipation), identification and treatment of nosocomial sepsis, and maintaining adequate oxygenation. Non-pharmacological interventions such as regular orientation despite social separation and lack of contact with family and caregivers are going to prove vitally important.
Regarding pharmacological interventions, no drugs can be recommended for the prevention or treatment of ICU delirium other than avoidance of overuse of potent psychoactive agents like sedatives and neuromuscular blockers (NMB) unless patients absolutely require such management. This component of the conversation is especially important given the early anecdotal recommendations to treat patients with COVID-19 in the prone position, which will be uncomfortable and thus likely be met with even higher than usual amounts of sedation, which could beget very high rates of delirium down the line in the management of these already high-risk patients. Additionally, it is important to review previous medications to avoid withdrawal symptoms. The ease of COVID-19 transmission and the risk of harm to others (healthcare workers, family, caregivers) may exceed risk of harm to the individual. This is an isolated example warranting earlier use of sedatives for hyperactively delirious patients who are proving harmful to self and others. ICU beds and ventilators are valuable and needed resources so it will be important to consider ways to avoid unnecessary prolongation of ventilation time and ICU length of stay that is associated with deeper sedation. Table 1 provides an overview of ABCDEF bundle adaptations to meet the needs of COVID-19.
Historically, delirium rates among mechanically ventilated ICU populations were consistently 70-75%, and the duration of delirium has consistently proven an independent predictor of longer lengths of stay, higher mortality, greater cost of care, and alarming rates of acquired dementia that lasts years following illness. Given these facts, it is important to carry into the pandemic the knowledge that delirium in mechanically ventilated patients can be reduced dramatically to 50% using a culture of lighter sedation and mobilization via the implementation of the safety bundle called the ABCDEFs promoted by the Society of Critical Care Medicine (SCCM) in their ICU Liberation Collaborative. Limitations in the ability to conform to this approach are a major component of the burden of the isolation required to limit the spread of COVID-19, prompting us to discuss specifics related to bedside care that one might keep in mind in organizing busy triage units and routine ICU care during the pandemic.
Delirium screening only takes 30 s. As such, delirium screening and treatment should follow well-established international guidelines, such as the eCASH concept and the SCCM clinical practice guidelines. Although routinely used in clinical practice, some sedation- and delirium-associated issues may be especially important when using limited resources. Standard non-pharmacological measures to treat or prevent delirium may not be possible in isolation environments, and these environments may themselves worsen delirium. Pain management remains a priority for all patients and requires the widespread implementation of behavioral pain scales (CPOT or BPS) for sedated and mechanically ventilated patients. After pain control is adequately assured, we must focus on the intersecting issues that lead a person's brain to fail in critical illness, chief among them including overuse of powerful sedatives and undue immobilization. These and other potential problems regarding ICU delirium management during the SARS-CoV-2 pandemic are identified in Table 1.
During such harrowing times at the respiratory failure that is occurring with COVID-19, it would be easy to disregard patients' brains as not being an essential concern. If we follow the critical care literature, this would be a grave error. Evidence indicates that delirium is not only a robust prognostic indicator of worse survival immediately, but also of the cost of care and quality of survival. Thus, healthcare professionals should follow local guidelines and policies regarding the monitoring and management of delirium. Implementation of easy screening methods for delirium is necessary especially in light of heavy workload because without validated assessment tools 75% of delirium will be missed during the COVID-19 crisis. It is necessary to reduce the ICU delirium risks using standard management approaches towards adequate pain management, avoiding urinary retention and gastro-intestinal problems (constipation), identification and treatment of nosocomial sepsis, and maintaining adequate oxygenation. Non-pharmacological interventions such as regular orientation despite social separation and lack of contact with family and caregivers are going to prove vitally important.
Regarding pharmacological interventions, no drugs can be recommended for the prevention or treatment of ICU delirium other than avoidance of overuse of potent psychoactive agents like sedatives and neuromuscular blockers (NMB) unless patients absolutely require such management. This component of the conversation is especially important given the early anecdotal recommendations to treat patients with COVID-19 in the prone position, which will be uncomfortable and thus likely be met with even higher than usual amounts of sedation, which could beget very high rates of delirium down the line in the management of these already high-risk patients. Additionally, it is important to review previous medications to avoid withdrawal symptoms. The ease of COVID-19 transmission and the risk of harm to others (healthcare workers, family, caregivers) may exceed risk of harm to the individual. This is an isolated example warranting earlier use of sedatives for hyperactively delirious patients who are proving harmful to self and others. ICU beds and ventilators are valuable and needed resources so it will be important to consider ways to avoid unnecessary prolongation of ventilation time and ICU length of stay that is associated with deeper sedation. Table 1 provides an overview of ABCDEF bundle adaptations to meet the needs of COVID-19.
