If a story is labeled All Rights Reserved, we cannot grant permission to republish that item. (Exception: original author replies can include all original authors of the article). Many hospitals use 72 hours, or three days, as the period for patients with a traumatic brain injury to regain consciousness before advising an end to life support. Doctors interviewed for this story urged everyone to tell their loved ones what you expect a meaningful recovery to include. Although the patients recovered from their prolonged unconscious state, it is likely that long-term cognitive or physical deficits remain present, in line with many reports on long-term outcomes in patients with COVID-19. Online ISSN:1526-632X, The most widely read and highly cited peer-reviewed neurology journal. Because her consciousness level did not improve beyond opening of her eyes, the concentrations of midazolam and its metabolites were measured and were undetectable in blood on ICU day 18. We distribute our journalism for free and without advertising through media partners of all sizes and in communities large and small. You will probably stay awake, but may not be able to speak. Leslie and her two daughters watched on FaceTime, making requests such as Smile, Daddy and Hold your thumb up!. Your email address, e.g. She had been on high-dose sedatives since intubation. The candid answer was, we don't know. For more information about these cookies and the data After two weeks of no sign that he would wake up, Frank blinked. %%EOF Additionally, adequate pain control is a . NPR transcripts are created on a rush deadline by an NPR contractor. Fox News' David Aaro contributed to this report. Thank you! 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. Submit. Some common side effects of conscious sedation may last for a few hours after the procedure, including: drowsiness. Results After cessation of sedatives, the described cases all showed a prolonged comatose state. Learn about the many ways you can get involved and support Mass General. She started opening her eyes to stimuli without other motor reactions 2 days later and did not show any signs of a higher level of consciousness (did not follow objects or persons with her eyes and did not obey commands). All rights reserved. ), Prolonged Unconsciousness Following Severe COVID-19. There are also patients who have extended hospital stays, followed by an even longer recovery period in a long-term care facility. Please preserve the hyperlinks in the story. She was ventilated in the prone position for the first 7 ICU days and subsequently in the supine position. to analyze our web traffic. 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. Do remain quietly at home for the day and rest. As a . This story is part of a partnership that includes WBUR,NPR and KHN. Leslie Cutitta recalled a doctor asking her: If it looks like Franks not going to return mentally, and hes going to be hooked up to a dialysis machine for the rest of his life in a long-term care facility, is that something that you and he could live with?. We also provide the latest in neuroscience breakthroughs, research and clinical advances. Many. Massachusetts General Hospital has prepared for this pandemic and taken every precaution to accept stroke patients in the emergency department. Earlier in the pandemic, doctors began to notice that blood clots could be another troubling complication for patients who are hospitalized with coronavirus. The persistent, coma-like state can last for weeks. Residual symptoms such as fatigue, shortness of breath, and chest pain are common in patients who have had COVID-19 (10,11).These symptoms can be present more than 60 days after diagnosis (11).In addition, COVID-19 may have long term deleterious effects on myocardial anatomy and function (12).A more thorough preoperative evaluation, scheduled further in advance of surgery with special . The goals of sedation in ARDS patients are to improve patient comfort and tolerance of supportive and therapeutic measures without contributing to adverse outcomes. Theories abound about why COVID-19 patients may take longer to regain consciousness than other ventilated patients, if they wake up at all. Doctors studying the phenomenon of prolonged unresponsiveness are concerned that medical teams are not waiting long enough for these COVID-19 patients to wake up, especially when ICU beds are in high demand during the pandemic. 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. Using techniques similar to those employed by intelligence agencies, the research team behind the study analyzed commercial satellite imagery and "observed a dramatic increase in hospital traffic outside five major Wuhan hospitals beginning late summer and early fall 2019," according to Dr. John Brownstein, the Harvard Medical professor who led the research. But with COVID-19, doctors are finding that some patients can linger unconscious for days, weeks or even longer. Do leave the healthcare facility accompanied by a responsible adult. Neurological symptoms such as loss of smell, confusion and headaches have been reported over the course of the pandemic. 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. Dr. Joseph Giacino, who directs neuropsychology at Spaulding Rehabilitation Hospital, says he's worried hospitals are using that 72-hour model now with COVID patients who may need more time. "The body mounts an enormous inflammatory response, and it turns out to be pathologic as inflammation starts to damage tissues across all organ systems. It also became clear that some patients required increased sedation to improve ventilation. Read any comments already posted on the article prior to submission. And we happened to have the latter.. 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. This text may not be in its final form and may be updated or revised in the future. Copyright 2007-2023. Mass General researchers will continue improving neurological outcomes while identifying the impact of COVID-19on the brain. So she used stories to try to describe Franks zest for life. Nearly 80% of patients who stay in the ICU for a prolonged periodoften heavily sedated and ventilatedexperience cognitive problems a year or more later, according to a new study in NEJM. 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. While he was in the ICU, Cutittas nurses played recorded messages from his family, as well as some of his favorite music from the Beach Boys and Luciano Pavarotti. 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. MA The brain imaging abnormalities found in our described case and other patients within our series are in line with recently reported series of brain imaging in patients with COVID-19 and a postmortem neuropathologic analysis, showing microbleeds and white matter abnormalities in varying degrees.2,3 Some of these abnormalities have also been reported previously in other critical illnesses, including a prolonged reversible comatose state in a case of sepsis.4,,6 The main differential diagnosis in our case was a persistent comatose state due to parainfectious autoimmune-mediated encephalitis or critical illnessrelated encephalopathy. Therapeutic hypothermia is a type of treatment. Dr. Brown notes that all werelikely contributing to these patients not waking up., A Missing Link Between Coronavirus and Hypoxic Injury. Learn about career opportunities, search for positions and apply for a job. Visit our website terms of use and permissions pages at www.npr.org for further information. Low tidal volume ventilation Every day, sometimes several times a day, she would ask Franks doctors for more information: Whats going on inside his brain? "The fundamental response to COVID-19 is inflammation," says Dr. Brown. In other scientific news on the virus: brain damage found in autopsies, the origin of the outbreak may be earlier than previously thought and the use of repeated tests is questioned. BEBINGER: It was another week before Frank could speak, before the family heard his voice. To find COVID-19 vaccine locations near you: Search vaccines.gov, text your ZIP code to 438829, or call 1-800-232-0233. A significant number of patients are going to have a prolonged recovery from the comatose state that theyre in, said Dr. Joseph Fins, chief of medical ethics at Weill Cornell Medical College. All rights reserved. Your role and/or occupation, e.g. 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. Intubation, ICU and trauma. (Folmer and Margolin, 6/8), Stat: ), and Radiology (F.J.A.M. According to the South China Morning Post, doctors at Hong Kong's Hospital Authority have noted some COVID-19 patients experience drops of 20 to 30 percent in lung function. But it was six-and-a-half days before she started opening her eyes. When that alarm rings, as painful as is, get up.". Some COVID patients are taking nearly a week to wake up. BEBINGER: Frank, for example, was on a lot of sedatives for a long time - 27 days on a ventilator. She was admitted to the hospital for oxygen therapy. 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. As with finding patients being unable to fully awake and having significant cognitive dysfunction, COVID-19 is expected to bring about the unexpected. Safe Care CommitmentGet the latest news on COVID-19, the vaccine and care at Mass General.Learn more. "We now have a bit of perspective, and we can start to put the stories together, think about pathophysiologic mechanisms and help define the symptoms that we saw," he says. KHN is an editorially independent program of KFF (Kaiser Family Foundation). You're more likely to have hypoxic injury in people who needed prolonged ventilation regardless of source, notes Dr. Mukerji. Reference 1 must be the article on which you are commenting. After five days on a ventilator because of covid-19, Susham "Rita" Singh seemed to have turned a corner. Frank Cutitta said he believes the flow of these inspiring sounds helped maintain his cognitive function. Dr. Brown is hopeful. These two male patients, one aged 59-years and another aged 53-years, both with a history of hypertension and neurologically intact on admission, developed . 2023 Kaiser Family Foundation. Search for condition information or for a specific treatment program. Click the button below to go to KFFs donation page which will provide more information and FAQs. VITAMIN K AND THE CORONAVIRUS PANDEMIC: SHOULD YOU TAKE IT? Sedation, often used for minimally invasive surgery, blocks pain and causes sleepiness, but doesn't put you to sleep. This spring, as Edlow watched dozens of patients linger in this unconscious state, he reached out to colleagues in New York to form a research group. After that, doctors often begin conversations with the family about ending life support. Some families in that situation have decided to remove other life supports so the patient can die. Low. Have questions? Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. Patients were sedated between 14 and 31 days and showed prolonged unconsciousness after the sedatives were stopped. Submissions must be < 200 words with < 5 references. Sedation is further impacted by the type of anesthetic given, as well as the inherent metabolism as a result of sedation. Market data provided by Factset. The machines require sedation, and prevent patients from moving, communicating,. Thats a conversation I will never forget having, because I was stunned.. Quotes displayed in real-time or delayed by at least 15 minutes. He didnt have a lot of them at that point, but it was just amazing, absolutely amazing.. 93 0 obj <>/Filter/FlateDecode/ID[<0033803CED91E4489BCBEDA906532D19><08FAFFAEE7118C48BD370A0976047613>]/Index[66 52]/Info 65 0 R/Length 124/Prev 168025/Root 67 0 R/Size 118/Type/XRef/W[1 3 1]>>stream Further perplexing neurologists and neuroscientists are the unknown ways that COVID-19may be impacting the brain directly. "The emphasis was placed on just trying to get the patients ventilated properly. And in some patients, COVID triggers blood clots that cause strokes. "We can likely mitigate this dysfunction by using the EEG to monitor brain state and guide anesthetic dosing," says Dr. Brown. We use cookies and other tools to enhance your experience on our website and 4: The person moves away from pain. 6 . Right now, the best cure for these side effects is time. 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. Copyright 2020 NPR. Anesthesia-induced delirium has been highly prominent in medical literature over the past decade and is associated with ventilation. A brain MRI was subsequently performed on ICU day 26, which showed a diffuse white matter abnormalities (figure). Prolonged sedation likely increases the incidence of delirium and cognitive dysfunction. Many hospitals wait 72 hours, or three days, for patients with a traumatic brain injury to regain consciousness. If the patient has not yet lost consciousness as a result of oxygen deficiency which leads to limited amount of oxygenated blood in the brain, then they need to be sedated. We couldn't argue that hypoxic injury was due to direct infection," notes Dr. Mukerji. "Physicians were describing patients with lungs like wet sponges," saysDr. Brown. "There's no consistent report that shows direct central nervous system infection, looking atPCRassay in intubated patients with prolonged sedation.". Soon, there were reports of new issues facing those with COVID-19. Fourteen days after the sedatives were stopped, she started following people with her eyes for the first time. The Need for Prolonged Ventilation in COVID-19 Patients. Its a devastating experience.. Dr. Kimchi relates that "the heavy sedation that we feel compelled to use in caring for patients with COVID-19, like other aspects of COVID-19 management, may be creating new challenges to prevent delirium.". 02114 At least some of the abnormalities appear to be linked with recent sedation," says Dr. Kimchi. Eyal Y. Kimchi, MD, PhD, neurologist and primary investigator of theDelirium Labat Mass General, seeks to determine the cause and find ways to treat delirium. We don't have numbers on that yet. JAN CLAASSEN: In our experience, approximately every fifth patient that was hospitalized was admitted to the ICU and had some degree of disorders of consciousness. 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. The effects also could lead to the development of new conditions, such as diabetes or a heart or nervous .