{"id":257033,"date":"2020-06-04T00:46:57","date_gmt":"2020-06-04T04:46:57","guid":{"rendered":"https:\/\/canadianinquirer.net\/v1\/?p=257033"},"modified":"2020-06-04T06:00:16","modified_gmt":"2020-06-04T10:00:16","slug":"icus-become-a-delirium-factory-for-covid-patients","status":"publish","type":"post","link":"https:\/\/canadianinquirer.net\/v1\/2020\/06\/04\/icus-become-a-delirium-factory-for-covid-patients\/","title":{"rendered":"ICUs Become A \u2018Delirium Factory\u2019 For COVID Patients"},"content":{"rendered":"
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The virus may invade the brain, as well as starve the organ of oxygen by damaging the lungs. (FIle photo: Natasha Connell\/Unsplash)<\/figcaption><\/figure>\n<\/div>\n
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Doctors are fighting not only to save lives from COVID-19, but also to protect patients\u2019 brains.<\/div>\n

Although COVID-19 is best known for damaging the lungs, it also increases the risk of life-threatening brain injuries<\/a> \u2014 from mental confusion to hallucinations, seizures, coma, stroke and paralysis. The virus may invade the brain<\/a>, 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.<\/p>\n

Yet the pandemic has severely limited the ability<\/a> 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.<\/p>\n

And while COVID-19 increases the risk of strokes, the pandemic has made it harder to diagnose them.<\/p>\n

When doctors suspect a stroke, they usually order a brain MRI \u2014 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.<\/p>\n

Many doctors also hesitate to request MRIs for fear that patients will contaminate the scanner and infect other patients and staff members.<\/p>\n

\u201cOur hands are much more tied right now than before the pandemic,\u201d said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.<\/p>\n

In many cases, doctors can\u2019t even examine patients\u2019 reflexes and coordination because patients are so heavily sedated.<\/p>\n

\u201cWe may not know if they\u2019ve had a stroke,\u201d Sheth said.<\/p>\n

A study from Wuhan,<\/a> China \u2014 where the first COVID-19 cases were detected \u2014 found 36% of patients had neurological symptoms, including headaches, changes in consciousness, strokes and lack of muscle coordination.<\/p>\n

A smaller, French study<\/a> observed such symptoms in 84% of patients, many of which persisted after people left the hospital.<\/p>\n

Some hospitals are trying to get around these problems by using new technology to monitor and image the brain.<\/p>\n

New York\u2019s Northwell Health is using a mobile MRI machine for COVID patients, said Dr. Richard Temes, the health system\u2019s 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.<\/p>\n

Staffers at Northwell were also concerned about the infection risk from performing EEGs, tests that measure the brain\u2019s 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.<\/p>\n

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.<\/p>\n

The Brain Under Attack<\/strong><\/p>\n

\u201cRight now, we actually don\u2019t know enough to say definitely how COVID-19 affects the brain and nervous system,\u201d said Chou, who is leading an international study of neurological effects of the virus. \u201cUntil we can answer some of the most fundamental questions, it would be too early to speculate on treatments.\u201d<\/p>\n

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

Authors of a recent study from Germany<\/a> found the novel coronavirus in patients\u2019 brains.<\/p>\n

But many neuropathologists are unwilling or unable to perform brain autopsies, Al-Harthi said.<\/p>\n

That\u2019s 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.<\/p>\n

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

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

In a recent study<\/a>, Japanese researchers reported finding the novel coronavirus in the cerebrospinal fluid that surrounds the brain and spinal cord.<\/p>\n

Some of the most surprising symptoms of COVID-19 \u2015 the loss of the senses of smell and taste \u2015 remain incompletely understood, but may be related to the brain, Stevens said.<\/p>\n

A study from Europe<\/a> published in May found that 87% of patients with mild or moderate COVID-19 lost their sense of smell<\/a>. Patients\u2019 loss of smell couldn\u2019t be explained by inflammation or nasal congestion, the study said. Stevens said it\u2019s possible that the coronavirus interacts with nerve pathways from the nose to the brain<\/a>, potentially affecting systems involved with processing scent.<\/p>\n

A new study in JAMA<\/a> 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.<\/p>\n

Many COVID patients develop \u201csilent hypoxia,\u201d in which they are unaware that their oxygen levels have plummeted dangerously low, Stevens added.<\/p>\n

When hypoxia occurs, regulatory centers in the brain stem \u2014 which control respiration \u2014 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.<\/a><\/p>\n

Scientists suspect the virus is infecting the brain stem<\/a>, preventing it from sending these signals, Temes said.<\/p>\n

Collateral Damage<\/strong><\/p>\n

Well-intentioned efforts to save lives can also cause serious complications.<\/p>\n

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.<\/p>\n

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.<\/p>\n

Many sedated patients experience terrifying hallucinations, which may return in recovery as nightmares and post-traumatic stress disorder.<\/p>\n

Research shows 70% to 75% of patients on ventilators<\/a> traditionally develop delirium. Delirious patients often \u201cdon\u2019t realize they\u2019re in the hospital,\u201d Singh said. \u201cThey don\u2019t recognize their family.\u201d<\/p>\n

In the French study in the New England Journal of Medicine<\/a>, one-third of discharged COVID-19 patients suffered from \u201cdysexecutive syndrome,\u201d which can be characterized by inattention, disorientation or poorly organized movements in response to commands.<\/p>\n

Research shows<\/a> that patients who develop delirium \u2014 which can be an early sign of brain injury \u2014 are more likely to die than others. Those who survive often endure lengthy hospitalizations and are more likely to develop a long-term disability.<\/p>\n

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

Just allowing a family member to hold a patient\u2019s 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\u2019re in the hospital.<\/p>\n

\u201cYou can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort,\u201d Fleisher said.<\/p>\n

These and other innovative practices<\/a> \u2014 such as helping patients to move around and get off a ventilator as soon as possible \u2014 can reduce the rate of delirium to 50%.<\/a><\/p>\n

Hospitals have banned visitors, however, to avoid spreading the virus. That leaves COVID-19 patients to suffer alone, even though it\u2019s well known that isolation increases the risk of delirium, Fleisher said.<\/p>\n

Although many hospitals offer patients tablets or smartphones to allow them to videoconference with family, these devices provide limited comfort and companionship.<\/p>\n

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.<\/p>\n

But a prone position also can be uncomfortable, so that patients need more medication, Pandharipande said.<\/p>\n

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 \u201cdelirium factory.\u201d<\/a><\/p>\n

\u201cThe way we\u2019re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,\u201d said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. \u201cA lot of the things we\u2019d like to do are just very difficult.\u201d<\/p>\n

Kaiser Health News<\/a>\u00a0is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.<\/i><\/p>\n","protected":false},"excerpt":{"rendered":"

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