The numbers and severity of COVID-19 cases requiring ICU admission have made it challenging for clinicians to adhere to best practices in the moment, let alone to follow optimal guidelines for longer-term care. The result could be a looming crisis for COVID-19 patients leaving hospitals and returning to everyday life, say experts in ICU survivorship at Vanderbilt University Medical Center.
“We know that respiratory failure requiring prolonged mechanical ventilation, along with other factors, contributes to post-intensive care syndrome, characterized by dementia, post-traumatic stress disorder (PTSD), and depression,” said James C. Jackson, Psy.D., assistant director of the ICU Recovery Center, part of Vanderbilt’s Critical Illness, Brain Dysfunction and Survivorship (CIBS) Center.
ICU Recovery Center director Carla Sevin, M.D., worries that the crisis will lead to setbacks in adherence to evidence-based guidelines such as the ICU Liberation Bundle established by the Society of Critical Care, which has been shown to reduce delirium and improve post-discharge outcomes.
“The pandemic has caused ICU clinicians to have to throw out the window all the things we’ve learned over the last two decades.”
“The pandemic has caused ICU clinicians to have to throw out the window all the things we’ve learned over the last two decades,” Sevin said. “It’s a new virus and acts differently from some of the other forms of respiratory failure we’ve been accustomed to treating in the ICU. How do we uphold the standard that we’ve been researching and perfecting for so long?”
COVID-19 and Delirium Care
ICUs are seeing an increase in delirium among COVID-19 patients. Wes Ely, M.D., director of the CIBS Center, has hypothesized that this increase may stem from hypoxemia, resulting in acute respiratory distress syndrome, or that the virus may be migrating to the brain and causing damage.
COVID-19 presents challenges to implementing the ICU Liberation Bundle, which was developed by Ely and colleagues. The bundle outlines an ABCDEF protocol for the optimal clinical management of delirium. “We can definitely do A and B, but C – minimizing and choosing the right sedation drugs – is a problem during this crisis,” Sevin said. “We’re running out of the drugs we would prefer and we’re having to fall back on benzodiazepines and other drugs we know to cause more delirium and worsen the prognosis for survivors.”
ICU clinicians treating COVID-19 patients run into real trouble when they get to E and F in the protocol, Sevin explained. “It’s difficult to keep patients moving because we can’t bring in therapists. And being in the ICU is traumatic enough, but when you can’t have your family around you for support, it can intensify the fear and anxiety.”
Sevin says she is hopeful that digital tools can lessen the separation. “Care teams are getting creative and using mobile devices to connect ICU patients with family members. Alongside compassionate support from nurses and doctors who are doing everything they can to fill the gap, it certainly shows promise.”
Telehealth for Support and Recovery
Jackson leads a survivor support group for patients who have been in the Vanderbilt ICU and their family members. Some, like Tommy Roden, have continued to attend for several years. Roden says the group has been a lifeline for him as he has navigated the anxiety, frustration and depression that have followed several stints in the ICU.
“What I would tell people who survive COVID-19 – or anyone who’s been in the ICU – is that post-intensive care issues are something they should expect.”
“What I would tell people who survive COVID-19 – or anyone who’s been in the ICU – is that post-intensive care issues are something they should expect,” Roden said. “I felt a sense of comfort knowing my family was there to support me; these people won’t have had that. There will definitely be challenges for both patients and family members when the ordeal is over.”
Even before the pandemic, the ICU support group was transitioning to a telehealth option. Today, survivors join the weekly group from across the U.S.
“Expanding telehealth will be essential to stay connected with a large number of ICU survivors from COVID-19 who are isolated, have limited mobility, have anxiety about returning to the hospital, or who can’t travel repeatedly to Vanderbilt,” Jackson said.
Studying Long-term Effects
To test the hypothesis that COVID-19 causes lasting neuropsychological effects, Ely has teamed up with Jin Han, M.D., associate professor in emergency medicine at Vanderbilt. The researchers will use the BRAIN-ICU-2 follow-up infrastructure to collect six-month cognition, PTSD, and depression data for the ORCHID trial that is evaluating hydroxychloroquine for the treatment of COVID-19.
These data will help provide a comprehensive evaluation of COVID-19’s effect on long-term cognitive and psychological outcomes, including whether hydroxychloroquine administration is associated with improvement.