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ICUs Become A ‘Delirium Factory’ For COVID Patients

By Liz Szabo, a senior correspondent and enterprise reporter who focuses on the quality of patient care, has covered medicine for two decades. Her stories about cancer and overtreatment for KHN have won numerous awards, including first place in the National Headliner Awards. She also was a finalist for the Gerald Loeb and NIHCM (National Institute for Health Care Management) awards. Before coming to KHN, Szabo covered medicine for USA TODAY for nearly 13 years. Her coverage of mental health and the link between poor health and substandard housing helped her earn the Victor Cohn Prize for Excellence in Medical Science Reporting in 2016. Her investigation of dangerous doctors, written while working at The Virginian-Pilot in Norfolk, Virginia, in 2002, won two National Press Club awards and led Virginia lawmakers to toughen state laws for disciplining physicians. Originally published at Kaiser Health News

Doctors are fighting not only to save lives from COVID-19, but also to protect patients’ brains.

Although COVID-19 is best known for damaging the lungs, it also increases the risk of life-threatening brain injuries — from mental confusion to hallucinations, seizures, coma, stroke and paralysis. The virus may invade the brain, as well as starve the organ of oxygen by damaging the lungs. To fight the infection, the immune system sometimes overreacts, battering the brain and other organs it normally protects.

Yet the pandemic has severely limited the ability of doctors and nurses to prevent and treat neurological complications. The severity of the disease and the heightened risk of infection have forced medical teams to abandon many of the practices that help them protect patients from delirium, a common side effect of mechanical ventilators and intensive care.

And while COVID-19 increases the risk of strokes, the pandemic has made it harder to diagnose them.

When doctors suspect a stroke, they usually order a brain MRI — a sophisticated type of scan. But many patients hospitalized with COVID-19 are too sick or unstable to be wheeled across the hospital to a scanner, said Dr. Kevin Sheth, a professor of neurology and neurosurgery at the Yale School of Medicine.

Many doctors also hesitate to request MRIs for fear that patients will contaminate the scanner and infect other patients and staff members.

“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.

In many cases, doctors can’t even examine patients’ reflexes and coordination because patients are so heavily sedated.

“We may not know if they’ve had a stroke,” Sheth said.

A study from Wuhan, China — where the first COVID-19 cases were detected — found 36% of patients had neurological symptoms, including headaches, changes in consciousness, strokes and lack of muscle coordination.

smaller, French study observed such symptoms in 84% of patients, many of which persisted after people left the hospital.

Some hospitals are trying to get around these problems by using new technology to monitor and image the brain.

New York’s Northwell Health is using a mobile MRI machine for COVID patients, said Dr. Richard Temes, the health system’s director of neurocritical care. The scanner uses a low-field magnet, so it can be wheeled into hospital rooms and take pictures of the brain while patients are in bed.

Staffers at Northwell were also concerned about the infection risk from performing EEGs, tests that measure the brain’s electrical activity and help diagnose seizures, Temes said. Typically, technicians spend 30 to 40 minutes in close contact with patients in order to place electrodes around their skulls.

To reduce the risk of infection, Northwell is using a headband covered in electrodes, which can be placed on patients in just a couple of minutes, he said.

The Brain Under Attack

“Right now, we actually don’t know enough to say definitely how COVID-19 affects the brain and nervous system,” said Chou, who is leading an international study of neurological effects of the virus. “Until we can answer some of the most fundamental questions, it would be too early to speculate on treatments.”

Answering those questions is complicated by the limited data from patient autopsies, said Lena Al-Harthi, a professor and the chair of the microbial pathogens and immunity department at Rush Medical College in Chicago.

Authors of a recent study from Germany found the novel coronavirus in patients’ brains.

But many neuropathologists are unwilling or unable to perform brain autopsies, Al-Harthi said.

That’s because performing autopsies on patients who died of COVID-19 carries special risks, such as the aerosolization of the virus during brain removal. Pathologists need specialized facilities and equipment to conduct an autopsy safely.

Some of the best-known symptoms of COVID-19 might be caused by the virus invading the brain, said Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University.

Research shows that the coronavirus may enter a cell through a gateway known as the ACE-2 receptor. These receptors are found not only in the lung, but also on organs throughout the body, including many parts of the brain.

In a recent study, Japanese researchers reported finding the novel coronavirus in the cerebrospinal fluid that surrounds the brain and spinal cord.

Some of the most surprising symptoms of COVID-19 ― the loss of the senses of smell and taste ― remain incompletely understood, but may be related to the brain, Stevens said.

study from Europe published in May found that 87% of patients with mild or moderate COVID-19 lost their sense of smell. Patients’ loss of smell couldn’t be explained by inflammation or nasal congestion, the study said. Stevens said it’s possible that the coronavirus interacts with nerve pathways from the nose to the brain, potentially affecting systems involved with processing scent.

new study in JAMA provides additional evidence that the coronavirus invades the brain. Italian researchers found abnormalities in an MRI of the brain of a COVID-19 patient who lost her sense of smell.

Many COVID patients develop “silent hypoxia,” in which they are unaware that their oxygen levels have plummeted dangerously low, Stevens added.

When hypoxia occurs, regulatory centers in the brain stem — which control respiration — signal to the diaphragm and the muscles of the chest wall to work harder and faster to get more oxygen into the body and force out more carbon dioxide, Stevens said. The lack of this response in some patients with COVID-19 could indicate the brain stem is impaired.

Scientists suspect the virus is infecting the brain stem, preventing it from sending these signals, Temes said.

Collateral Damage

Well-intentioned efforts to save lives can also cause serious complications.

Many doctors put patients who are on mechanical ventilators into a deep sleep to prevent them from pulling out their breathing tubes, which would kill them, said Dr. Pratik Pandharipande, chief of anesthesiology and critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee.

Both the disease itself and the use of sedatives can cause hallucinations, delirium and memory problems, said Dr. Jaspal Singh, a pulmonologist and critical care specialist at Atrium Health in Charlotte, North Carolina.

Many sedated patients experience terrifying hallucinations, which may return in recovery as nightmares and post-traumatic stress disorder.

Research shows 70% to 75% of patients on ventilators traditionally develop delirium. Delirious patients often “don’t realize they’re in the hospital,” Singh said. “They don’t recognize their family.”

In the French study in the New England Journal of Medicine, one-third of discharged COVID-19 patients suffered from “dysexecutive syndrome,” which can be characterized by inattention, disorientation or poorly organized movements in response to commands.

Research shows that patients who develop delirium — which can be an early sign of brain injury — are more likely to die than others. Those who survive often endure lengthy hospitalizations and are more likely to develop a long-term disability.

Under normal circumstances, hospitals would invite family members into the ICU to reassure patients and keep them grounded, said Dr. Carla Sevin, director of the ICU Recovery Center, also at Vanderbilt.

Just allowing a family member to hold a patient’s hand can help, according to Dr. Lee Fleisher, chair of an American Society of Anesthesiologists committee on brain health. Nurses normally spend considerable time each day orienting patients by talking to them, reminding them where they are and why they’re in the hospital.

“You can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort,” Fleisher said.

These and other innovative practices — such as helping patients to move around and get off a ventilator as soon as possible — can reduce the rate of delirium to 50%.

Hospitals have banned visitors, however, to avoid spreading the virus. That leaves COVID-19 patients to suffer alone, even though it’s well known that isolation increases the risk of delirium, Fleisher said.

Although many hospitals offer patients tablets or smartphones to allow them to videoconference with family, these devices provide limited comfort and companionship.

Doctors are also positioning patients with COVID-19 on their stomachs, rather than their backs, because a prone position seems to help clear the lungs and let patients breathe more comfortably.

But a prone position also can be uncomfortable, so that patients need more medication, Pandharipande said.

All of these factors make COVID-19 patients extremely vulnerable to delirium. In a recent article in Critical Care, researchers said the intensive care unit has become a “delirium factory.”

“The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. “A lot of the things we’d like to do are just very difficult.”

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19 comments

  1. Steve Ardire

    How does coronavirus kill? Clinicians trace a ferocious rampage through the body, from brain to toes https://www.sciencemag.org/news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes #COVID19
    #Trump is an idiot

    What Does #Covid19 Do to Your Brain?
    Scientists are racing to figure out why some patients also develop neurological ailments like confusion, stroke, seizure, or loss of smell.
    https://www.wired.com/story/what-does-covid-19-do-to-your-brain/?utm_source=twitter&utm_medium=social&utm_campaign=onsite-share&utm_brand=wired&utm_social-type=earned
    #Trump is an idiot

    Images showed brain aflame with lesions filled with dead & dying neurons in regions that normally relay sensory signals, regulate alertness, access memories. Areas in electrical grid of brain go dark = acute necrotizing hemorrhagic encephalopathy.
    #Trump is an idiot

    Visualizing What COVID-19 Does to Your Body https://www.visualcapitalist.com/visualizing-what-covid-19-does-to-your-body/
    In 15-20% cases immune system’s response to inflammation in lungs can cause “cytokine storm” i.e main reason why even young healthy individuals can rapidly deteriorate
    #Trump is an idiot

    View this and you’ll want to wear a mask !
    Special camera shows cloud of micro droplets spewing out of people #covid19
    https://boingboing.net/2020/04/03/special-camera-shows-cloud-of.html
    and caveat emptor stay away from #trump and #pence

    Reply
    1. Rob Dunford

      Oxidative stress will do all this. There is some speculation that the virus interrupts a mechanism in the mitochondria whereby oxygen radicals are released instead of reduced to create energy.

      Reply
      1. furies

        I have a brain injury from prescribed benzodiazepines…6 years later some improvement on the myriad of symptoms (cognitive, physical, metabolic). All a big mystery to the medicos. There is some speculation now on the support site (BenzoBuddies) that the “O NO” is involved; 0=H=N=O=O. Mitochondria dysregulation. Symptoms come and go, ramp up then diminish only to return. (waves and windows)

        Every day is an unknown, like many with chronic conditions. It would be great if medicine could acknowledge that we are all genetically different and react differently to introduced substances and then take the proper cautions when prescribing. Vaccines too.

        Covid could be real bad news for someone like me~

        Reply
      2. Richard Burr

        Interesting. Has any research been published? I wonder if MitoQ would help by reducing excess oxygen radicals produced in mitochondria.

        Reply
  2. The Rev Kev

    Man, this virus is the stuff of nightmares if it slams you. About the only thing that it does not do is reanimate the dead, but it may be early days here. Even when you get out of the hospital, for a lot of people it is not over as the virus has caused all sort of what appears to be permanent damage on the body. You do not want to get this virus.

    I envy New Zealand at the moment. They only lost 22 people killed and discharged the last Coronavirus patient from the hospital a few days ago. At the moment they have only 1 active case in the entire country so pretty soon life will – mostly – go back to normal. By now they must be aware of how big a bullet they dodged.

    Reply
        1. MLTPB

          How do they track that?

          In S Korea, a first world country, I think when you are near a case, you are notified. Do they also monitor those in quarantine?

          Reply
          1. HotFlash

            Don’t know what they are doing for the US Marines, but NZers returning home are put up in a hotel under close watch for 14 days. No non-residents are permitted, except Marines, I guess. Here is the NZ govt’s webpage on how it works.

            Reply
  3. MLTPB

    . To fight the infection, the immune system sometimes overreacts, battering the brain and other organs it normally protects.

    ———

    A sovereign government is not a household.

    Is a government a living human body?

    It’s not often around the world that a government’s immune system batters its brain.

    And how did we humans evolve this brain battering immunity feature?

    Reply
    1. urblintz

      It’s the body’s response to Russian evil… I’m surprised you didn’t figure that one out for yourself. Putin is everywhere and our tiny minds are simply overwhelmed by his massive power/control over everything that is just and right, including our very own immune systems.

      Reply
      1. MLTPB

        I ask questions as I tend to be skeptical, in general.

        For example, I don’t assume Putin is less damaging than other humans, until proven otherwise.

        In particular, I note with interst if he, or more publicly his admirers, would want China to do all the heavy lifting in their Asia heartland allliance.

        Reply
        1. witters

          Skeptical? Thanks for that. I hadn’t noticed.

          Can you spell out the premise/assumption? Viz., “all humans are damaging”?

          Reply
  4. Ignacio

    I have been told that many Covid-19 patients that have passed through ICU and survived loose their appetite. They simply do not eat and then die.

    Reply
  5. Krystyn Podgajski

    It is slow in coming but the next treatments for all mental illnesses will be via the immune system. This is just out today

    Chronic stress? Limiting inflammatory signaling to specific brain circuits

    Chronic stress is associated with the pathogenesis of psychological disorders such as depression. A study is the first to identify the role of a neuronal receptor that straddles the intersection between social stress, inflammation, and anxiety in rodent models of stress. Findings suggest the possibility of developing better medications to treat the consequences of chronic stress by limiting inflammatory signaling not just generally, which may not be beneficial in the long run, but to specific brain circuits.

    They are looking at an Interleukin-1 receptor. And they are also looking into blocking the same receptor in COVID patients. Higher interleukin-1 means more mood issues.

    So it is not the virus that effects the brain, it is our own over active immune system that attacks the brain.

    But really who can say it is the virus at all? There are way to many variables.

    Reply
  6. John Buell

    “The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. “A lot of the things we’d like to do are just very difficult.”

    I have never seen a better or more pressing argument on behalf of a right to some form of voluntary euthanasia. I wonder how Oregon’s law could be applied in such cases. Patients who reject ventilation will die soon, but forcing them to await a “natural death” only prolongs and intensifies their agony.

    Reply
  7. cirsium

    “The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” It certainly is. Is it not time to use prophylaxis to stop the infection progressing to the second phase? Your attention is drawn to Professor Harvey Risch’s paper in the American Journal of Epidemiology https://academic.oup.com/aje/advance-article/doi/10.1093/aje/kwaa093/5847586. “Early Outpatient Treatment of Symptomatic, High-Risk Covid-19 Patients that Should be Ramped-Up Immediately as Key to the Pandemic Crisis” He makes the point that high-risk patients presenting with progressing symptomatic disease have only hospitalization treatment with its high mortality. An outpatient treatment that prevents hospitalization is desperately needed. Hydroxychloroquine+azithromycin have demonstrated significant major outpatient treatment efficacy.

    Reply

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