Im not considering myself one of those, he said, but there are many, many people who would rather be dead than left with what they have after this., Martha Bebinger, WBUR: August 27, 2020. "The fundamental response to COVID-19 is inflammation," says Dr. Brown. ), Radboud University Medical Center, Nijmegen; Departments of Intensive Care (B.P.G. The degree to which each of those factors is playing a role in any given patient is still something were trying to understand.. In her delirium, Diana Aguilar was sure the strangers hovering over her, in their masks and gowns, were angels before they morphed into menacing aliens. Claassen published a study in 2019 that found that 15% of unresponsive patients showed brain activity in response to verbal commands. Pets and anesthesia. So the Cutittas hung on and a small army of ICU caregivers kept working. Copyright 2020 The Author(s). JOSEPH GIACINO: We need to really go slow because we are not at a point where we have prognostic indicators that approach the level of certainty that we should stop treatment because there is no chance of meaningful recovery. Patients were sedated between 14 and 31 days and showed prolonged unconsciousness after the sedatives were stopped. collected, please refer to our Privacy Policy. But for many patients, the coronavirus crisis is literally . Mutual Fund and ETF data provided by Refinitiv Lipper. If confronted with this situation, family members should ask doctors about their levels of certainty for each possible outcome. ), Prolonged Unconsciousness Following Severe COVID-19. Some common side effects of conscious sedation may last for a few hours after the procedure, including: drowsiness. All rights reserved. Critical and emergency care and other roles. We offer diagnostic and treatment options for common and complex medical conditions. Given all the unknowns, doctors at the hospital have had a hard time advising families of a patient who has remained unresponsive for weeks, post-ventilator. Patients almost always lie on their backs, a position that helps nurses tend to them and allows them to look around if they're awake. Ancillary investigations (table 1) showed a severe critical illness polyneuropathy. In this case series, prolonged level of unconsciousness with full recovery of the unconsciousness in patients with severe COVID-19 is shown. KHN is an editorially independent program of KFF (Kaiser Family Foundation). Frank used to joke that he wanted to be frozen, like Ted Williams, until they could figure out what was wrong with him if he died, said Leslie Cutitta. Covid-19 has made doctors much more likely to leave patients on sedation too long to avoid the hypothetical risk that patients might pull out their breathing tubes and the shortages of. The latest . All authors report no conflicts of interest or relevant financial relationships related to this manuscript. Some medical ethicists also urge clinicians not to rush when it comes to decisions about how quickly COVID-19 patients may return to consciousness. This text may not be in its final form and may be updated or revised in the future. A number of different techniques were employed, such as turning patients prone and starting patients on ventilators as early as possible.". 'Royal Free Hospital'. Objective We report a case series of patients with prolonged but reversible unconsciousness after coronavirus disease 2019 (COVID-19)related severe respiratory failure. Many. Some of these patients have inflammation related to COVID-19 that may disrupt signals in the brain, and some experience blood clots that have caused strokes. "The body mounts an enormous inflammatory response, and it turns out to be pathologic as inflammation starts to damage tissues across all organ systems. BEBINGER: The doctors eventually discharged Frank, but he had to spend a month at Spaulding, the rehab hospital. NOTE: The first author must also be the corresponding author of the comment. A coma can also be caused by severe alcohol poisoning or a brain infection ( encephalitis ). "But from a brain standpoint, you are paying a price for it. Read any comments already posted on the article prior to submission. The effectiveness of sedation has traditionally been evaluated in terms of patient and surgeon satisfaction, but the most important goal is not to induce a deep sleep in the patient, but rather to ensure that the surgery is performed safely and as planned. Hes back home now, in a Boston suburb, doing physical therapy to strengthen his arms and legs. All six had evidence of extensive brain pathologies at the time of death. This is a multicenter case series of patients with severe respiratory failure due to COVID-19 with prolonged unconsciousness after cessation of sedatives. About 40% of elderly patients and up to one-third of children have lingering confusion and thinking problems for several days after surgery and anesthesia. The anesthesiologist also plays a key role in critical care and treatment and trauma. Some COVID patients are taking nearly a week to wake up. "We have studied brain rhythms in patients with COVID-19 using EEG, and have found that patients with COVID-19 have abnormal brain rhythms. In 16 of 104 (15%) unresponsive patients, a machine-learning algorithm that analyzed EEG recordings detected brain activation following researchers' verbal commands a median of 4 days after. It was another week before Frank could speak and the Cutittas got to hear his voice. 66 0 obj <> endobj Your email address, e.g. Being ventilated increases the prevalence of hypoxiaa state wherein the body is deprived of oxygen, causes blood clots and alters the way the body metabolizes medication. feelings of heaviness or sluggishness. For the study, Vanderbilt University researchers studied 821 patients with respiratory failure or septic shock who stayed in an ICU for a median of five days. If possible, please include the original author(s) and Kaiser Health News in the byline. "There's no consistent report that shows direct central nervous system infection, looking atPCRassay in intubated patients with prolonged sedation.". Obeying commands (mostly through facial musculature) occurred between 8 and 31 days after cessation of sedatives. This suggests that other causes besides the virus directly infecting the brain were the reason for neurological symptoms during infection. Frank Cutitta spent a month at Spaulding Rehabilitation Hospital. Visit our website terms of use and permissions pages at www.npr.org for further information. Market data provided by Factset. This article describes the clinical course, radiological findings, and outcome of two patients with the novel 2019 coronavirus disease (COVID-19) who remained comatose for a prolonged duration following discontinuation of all sedation. When the patient develops a respiratory failure due to a lung infection related to covid-19, several things have to be done. Dr. Mukerji does find that those with COVID-19 had hypoxic injurymeaning that brain cells in these patients died due to lack of oxygen. "All of that has been erased by Covid," said Dr. E. Wesley Ely, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University and the Nashville Veteran's. The General Hospital Corporation. Get the latest news on COVID-19, the vaccine and care at Mass General. Patients with COVID-19 who require intubation and ventilation have witnessed a number of stressful events in the ICU, such as emergency resuscitation procedures and deaths. In all of our patients, a similar clinical pattern was observed during recovery of their unconsciousness. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. The evidence we have currently does not indicate a direct central nervous system infection for the majority of cases with neurological symptoms, says Dr. Mukerji. A study yesterday in The Lancet presents the clinical findings of autopsies conducted on six German patients (four men and two women, aged 58 to 82 years) who died from COVID-19 in April. So, on a Zoom call nurses arranged with his family, he wrote on paper attached to a clipboard. Sedation is further impacted by the type of anesthetic given, as well as the inherent metabolism as a result of sedation. The researchers are sharing their data to determine the cause of prolonged coma in COVID-19 patients, find treatments and better predict which patients might eventually recover, given enough time and treatment. Prolonged or persistent comas are just one area of research, but one getting a lot of attention. But doctors across the U.S. and in other countries have noted a troubling phenomenon associated with some COVID cases: Even after extubation, some patients remain unconscious for days, weeks or longer. A 41-year-old woman with a medical history of diabetes mellitus, hypothyroidism, and severe obesity (body mass index 43.5 kg/m2) presented to the emergency department with a 3-day history of respiratory symptoms and bilateral infiltrates on her chest x-ray. Many hospitals wait 72 hours, or three days, for patients with a traumatic brain injury to regain consciousness. Why is this happening? Although the links between COVID-19, neurological symptoms and underlying brain dysfunction remain unclear, researchers are refining treatment plans for patients, clarifying the effects of SARS-CoV-2 on the brain and linking neurological symptoms like delirium to brain activity. Quotes displayed in real-time or delayed by at least 15 minutes. Schiff said while its certainly known that prolonged sedation can extend the time it takes for patients to wake up, 12 days after sedation ends is not typical.. They assess patients, make diagnoses, provide support for . This eye opening was not accompanied by any other motor reactions, making any contact, or following objects. So she used stories to try to describe Franks zest for life. Motor reactions with the limbs occurred in the last phase. Error: Please enter a valid email address. to analyze our web traffic. Physicians and researchers at Mass General will continue to work on disentangling the effects of sedation on the neurological impacts of COVID-19and to improve patient treatment. And we happened to have the latter.. Copyright 2007-2023. For NPR News, I'm Martha Bebinger in Boston. This is a time for prudence because what we dont know can hurt us and can hurt patients.. You will probably stay awake, but may not be able to speak. Dr. Brown relates, I think that where we're going to see residual effects, over the next several years we will see patients with a broad range of symptoms.. This spring, as Edlow observed dozens of Mass General COVID-19 patients linger in this unresponsive state, he joined Claassen and other colleagues from Weill Cornell Medical College to form a research consortium. Around midnight on April 8, doctors at Houston Methodist Hospital turned off the. The clinical pattern of awakening started with early eye opening without obeying commands and persistent flaccid weakness in all cases. F CUTITTA: Who could have gone the other way and said, look; this guy's just way too sick, and we've got other patients that need this equipment, or we have an advocate who says, throw the kitchen sink at it. You must have updated your disclosures within six months: http://submit.neurology.org. Your last, or family, name, e.g. "That's still up for debate and that's still a consideration.". Conclusion Prolonged unconsciousness in patients with severe respiratory failure due to COVID-19 can be fully reversible, warranting a cautious approach for prognostication based on a prolonged state of unconsciousness. Two months after first being diagnosed with Covid-19, she found her heart would start racing without warning. Clinical researchers thought that SARS-CoV-2 would infect the brain and that injury to the brain would be due, in part, to blood clots. When things were calming down in the Northeast, there were reports of patients who were not waking up, says Dr. Brown. Right now, the best cure for these side effects is time. and apply to letter. Their candid and consistent answer was: We dont know. Diagnostic neurologic workup did not show signs of devastating brain injury. "Don't sleep in or stay up late. Most patients with COVID-19 have delirium, which is the medical way of saying they are confused, can't pay attention, and have trouble organizing their thinking. You can support KHN by making a contribution to KFF, a non-profit charitable organization that is not associated with Kaiser Permanente. Because she did, the hospital would not allow her to return after she was discharged meaning she could not hold or nurse her baby for the first two months of his life. It's sometimes used for people who have a cardiac arrest. MA The Cutittas say they feel incredibly lucky. BEBINGER: Every day, sometimes several times a day, Leslie Cutitta would ask Frank's doctors, what's going on inside his brain? This was followed by visual tracking of people within 2 weeks after cessation of sedatives. After that, doctors often begin conversations with the family about ending life support. 4: The person moves away from pain. In the large majority of patients with COVID-19 that are admitted to the intensive care unit (ICU) for a respiratory distress, an encephalopathy most notably in the form of delirium occurs in up to 84% of those patients.1 Brain MRI studies in patients on the ICU with COVID- "Physicians were describing patients with lungs like wet sponges," saysDr. Brown. There was no funding agency/sponsor involved. The pneumonia associated with novel coronavirus disease 2019 (COVID-19 or nCoV-2) can lead to respiratory failure with profound hypoxemia requiring endotracheal This site uses cookies. From the Departments of Intensive Care (W.F.A., J.G.v.d.H. For the sickest COVID-19 patients, getting on a ventilator to help them breathe can be a life-saving process. We found global injury in the frontal lobe, hippocampus and cerebellum," says Dr. Mukerji. "It is worse in older patients, those who are quite ill and is associated with certain drugs such as midazolam, haloperidol and opiates like hydromorphone," says Dr. Brown. marthab@wbur.org, The global research effort has grown to include more than 222 sites in 45 countries. Some patients, like Frank Cutitta, do not appear to have any brain damage. You've successfully subscribed to this newsletter! If you are responding to a comment that was written about an article you originally authored: ;lrV) DHF0pCR?7t@ | Open. She was admitted to the hospital for oxygen therapy. Diffuse leukoencephalopathy with restricted diffusion in the corona radiata and subcortical white matter on the first MRI slightly decreased on follow-up MRIs. (Exception: original author replies can include all original authors of the article). (6/5), ABC News: Schiff told the paper many of the patients show no sign of a stroke. Click the button below to go to KFFs donation page which will provide more information and FAQs. There is much debate in the medical community as to what is causing the observed hypoxic injury, neurological symptoms and cognitive dysfunction in those with COVID-19. "You're more likely to have hypoxic-ischemic injury in prolonged ventilation patients. But how many of those actually took a long time to wake up, we dont have numbers on that yet.. "We can likely mitigate this dysfunction by using the EEG to monitor brain state and guide anesthetic dosing," says Dr. Brown. In 5 of the 6 patients, a mixed or hypoactive delirium was diagnosed after recovery of the unconsciousness. After nearly a month, Frank's lungs had recovered enough to come off a ventilator. People who had severe illness with COVID-19 might experience organ damage affecting the heart, kidneys, skin and brain. We couldn't argue that hypoxic injury was due to direct infection," notes Dr. Mukerji. In light of this turmoil, the importance of sleep has often flown under the radar. It was very, very tough., From Dialysis not working to Spoke for first time, Frank Cutittas family kept a calendar marking his progress in the hospital from March until his return home on July 3. Email Address Some covid-19 patients taken off ventilators are taking days or even weeks to wake up 'It's a big deal,' says a Weill Cornell neurologist. Explore fellowships, residencies, internships and other educational opportunities. EDLOW: So there are many different potential contributing factors, and the degree to which each of those factors is playing a role in any given patient is something that we're still trying to understand. SARS-CoV-2 readily infects the upper respiratory tract and lungs. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License 4.0 (CC BY-NC-ND), which permits downloading and sharing the work provided it is properly cited. It wasnt a serious end-of-life discussion, but Cutitta knew her husband would want every possible lifesaving measure deployed. The expectation is that you should start waking up after six hours, 12 hours or a day, said her daughter, Silky Singh Pahlajani, a neurologist in New York City. In our experience, approximately every fifth patient that was hospitalized was admitted to the ICU and had some degree of disorders of consciousness, said Dr. Jan Claassen, director of neurocritical care at New Yorks Columbia University Medical Center. Please preserve the hyperlinks in the story. People have been seriously harmed and even died after taking products not approved for use to treat or prevent COVID-19, even products approved or prescribed for other uses. On April 21, after 27 days on a ventilator, Franks lungs had recovered enough to remove the breathing tube. Bud O'Neal, left and Marla Heintze, a surgical ICU nurse, use a cell phone camera to zoom in on a ventilator to get a patient's information at Our Lady of the . All rights reserved. 55 Fruit Street Though most patients' symptoms slowly improve with time, speaking with your healthcare provider about the symptoms you are experiencing post-COVID could help identify new medical conditions. LESLIE CUTITTA: It was a long, difficult period of just not knowing whether he was really going to come back to the Frank we knew and loved. BEBINGER: The first data is expected out soon of known COVID patients like Frank who linger in a prolonged coma. This story is part of a partnership that includes WBUR,NPR and KHN. Here are more sleep tips: Keep a normal daily routine: "If you're working from home, keep the same schedule as if you were going to work," Hardin said. Intubation, ICU and trauma. When might something change? December 3, 2021. Acute inflammation can become severe enough to cause organ damage and failure. Researchers are identifying the links between infection and strokerisk. The young mother, who gave birth at Montreals Sainte-Justine Hospital, tested positive for Covid-19 when her baby was born. The machines require sedation, and prevent patients from moving, communicating,. Submit only on articles published within 6 months of issue date. One of the first questions researchers hope to answer is how many COVID-19 patients end up in this prolonged, sleeplike condition after coming off the ventilator. Because this disease is so new and because there are so many unanswered questions about COVID-19, we currently do not have reliable tools to predict how long it will take any individual patient to recover consciousness, said Dr. Brian Edlow, a critical care neurologist at Mass General. At Mass General, the brightest minds in medicine collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine. The infection potentially leads to an increase in blood clots in other organs, and whether micro-clots occur in the brain remains up for debate and is still a consideration.. Your organization or institution (if applicable), e.g. To mitigate exposure to Covid-19, Dr. Around midnight on April 8, doctors at Houston Methodist Hospital turned off the sedative drip that had kept the previously healthy 65-year-old in a medically induced coma. Inthis autopsy series, there was no evidence of the virus that causes COVID-19 in the brain tissue of ventilated COVID-19 patients. She started to move her fingers for the first time on ICU day 63. Your co-authors must send a completed Publishing Agreement Form to Neurology Staff (not necessary for the lead/corresponding author as the form below will suffice) before you upload your comment. Coronavirusinfection starts with inhalation of the virus and its eventual spread to the lungs. In patients with coronavirus disease 2019 (COVID-19) who are admitted to the intensive care unit (ICU) for respiratory distress, an encephalopathy, most notably in the form of delirium, occurs in up to 84%.1 Brain MRI studies in patients in the ICU with COVID-19, including those with prolonged comatose state, reported varying degrees of MRI abnormalities, although few to no details were reported on the clinical picture, course, and prognosis of prolonged unconsciousness in such patients.2 Here, we report a case series of patients with COVID-19 admitted to the ICU for respiratory failure who, after cessation of sedatives, remained unconscious for longer than expected periods. Let us help you navigate your in-person or virtual visit to Mass General. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Even before the coronavirus pandemic, some neurologists questioned that model. In eight patients, spinal anesthesia was repeated due to . In 2018, the American Academy of Neurology updated its guidelines for treating prolonged disorders of consciousness, noting that some situations may require more time and assessment. In many cases, sedation was prolonged and sometimes for several weeks; this was much longer than for common treatments requiring sedation, such as surgery. Implant surgery is a lengthy dental procedure, and sedation is often used to reduce discomfort. Learn about career opportunities, search for positions and apply for a job. Edlow cant say how many. Dr. Brian Edlow is a critical care neurologist at Mass General. For some people, post-COVID conditions can last weeks, months, or years after COVID-19 illness and can sometimes result in disability. It was a long, difficult period of not just not knowing whether he was going to come back to the Frank we knew and loved, said Leslie Cutitta. higgs-boson@gmail.com. 6 . Heitz says anesthesia remains a mystery on many levels, for example, it is not yet understood how exactly the process works, and there is no serious research on what aspect of going under makes some people cry when they wake up. This has prompted physicians and researchers at Massachusetts General Hospital to study the effects of sedation on neurological outcomes in COVID-19 patients. Joseph Giacino, director of rehabilitation neuropsychology at Spaulding, said hes worried hospitals are using that 72-hour model with COVID-19 patients who may need more time. 2023 Kaiser Family Foundation. As COVID-19 patients fill ICUs across the country, it's not clear how long hospital staff will wait beyond that point for those patients who do not wake up after a ventilator tube is removed.