COVID-19 Care Practices, Safety Protocols May Increase Delirium in ICU Patients

By Carolyn Crist

March 08, 2021

NEW YORK (Reuters Health) - Clinicians have noted a high rate of delirium in COVID-19 patients in intensive-care units (ICUs) during the pandemic, which could be due to the use of heavy sedatives and safety protocols that limit family visitation.

Delirium rates dropped dramatically in ICUs in recent years, but COVID-19 interventions have increased the rates again, which should be addressed in the coming year, according to an editorial in the journal Intensive and Critical Care Nursing.

"Less use of sedatives, the use of short-acting sedatives, and the awareness of the great value of the presence of family members contributed to decreased numbers of patients with delirium in the ICU," said lead author Dr. Mark van den Boogaard of Radboud University Medical Center, in Nijmegen, the Netherlands.

"These interventions were more or less lost in COVID-19 ICU patients, which contributed to more delirium with likely profound negative effects on mental and cognitive outcomes," he told Reuters Health by email. "As soon as we can go back to 'normal,' we need to reduce the use of sedatives again and increase the presence of family members in the ICU."

Dr. van den Boogaard and his colleague Dr. Marieke Zegers, also at Radboud University, write about the decrease in delirium in ICU patients during the past two decades. In 2001, studies found prevalences up to 90%, which decreased to about 30% by 2018.

ICUs across the world had switched to light sedation and short-acting sedatives such as propofol or dexmedetomidine rather than benzodiazepines. ICU practices also focused on keeping patients awake, increasing their activity levels, managing their pain and extending family visitation hours.

During the pandemic, however, COVID-19 patients with severe disease have required long-term ICU care and mechanical ventilation. Light sedation hasn't been enough in many cases, the authors write, and some patients have needed both deep sedation and muscle relaxers.

Family visitation hours were also restricted or not allowed, and patients haven't been able to stay awake or increase their activity levels.

In addition, the overwhelming number of severe COVID-19 patients forced some ICUs to reduce certain aspects of care, such as screening patients for delirium. After the initial COVID-19 surge in the Netherlands, for instance, ICU nurses spoke about the inability to take time to gauge delirium levels, the authors write.

"The severely sick COVID-19 ICU patients are often difficult to mechanically ventilate, and many of these patients even need prone positioning during the period of mechanical ventilation," van der Boogaard said. "As a result, many patients were deeply sedated again and for a longer time. Not surprisingly, this resulted in an increase of patients with delirium."

During interviews with COVID-19 ICU patients, the authors say, it has emerged that some think ICU clinicians wearing personal protective equipment resembled astronauts or aliens, which could also contribute to delirium.

Early studies show that 55% to 65% of COVID-19 patients in ICUs may face delirium issues, and benzodiazepines were administered in 64% to 78% of patients. Across 69 ICUs, patients were comatose for a median of 10 days, and delirium lasted for a median of three days.

Future studies may show the long-term effects that COVID-19 ICU patients with delirium could face, such as new physical, mental and cognitive problems, the authors write.

"Delirium has been associated with poor outcomes in critically ill patients without COVID-19, including mortality, cognitive dysfunction, and subsequent dementia in survivors," said Dr. Rafael Badeness of the University of Valencia in Spain. In previous research, Dr. Badeness found that more than 50% of COVID-19 ICU patients across 14 countries developed delirium.

"With severe COVID-19, delirium and coma are common and often last for twice the duration than in general ICU patients," he told Reuters Health by email. "The overuse of benzodiazepine sedative infusions and lack of family visitation (either in person or virtual) were associated with more delirium, and strategies to modify these approaches might mitigate delirium and any associated sequelae."

SOURCE: Intensive and Critical Care Nursing, online February 23, 2021.