Early Neurorehabilitation and Recovery from Disorders of Consciousness After Severe COVID-19

Abstract

Background Early neurorehabilitation improves outcomes in patients with disorders of consciousness (DoC) after brain injury, but its applicability in COVID-19 is unknown. We describe our experience implementing an early neurorehabilitation protocol for patients with COVID-19-associated DoC in the intensive care unit (ICU) and evaluate factors associated with recovery. Methods During the initial COVID-19 surge in New York City between March 10 and May 20, 2020, faced with a disproportionately high number of ICU patients with prolonged unresponsiveness, we developed and implemented an early neurorehabilitation protocol, applying standard practices from brain injury rehabilitation care to the ICU setting. Twenty-one patients with delayed recovery of consciousness after severe COVID-19 participated in a pilot early neurorehabilitation program that included serial Coma Recovery Scale-Revised (CRS-R) assessments, multimodal treatment, and access to clinicians specializing in brain injury medicine. We retrospectively compared clinical features of patients who did and did not recover to the minimally conscious state (MCS) or better, defined as a CRS-R total score (TS) ≥ 8, before discharge. We additionally examined factors associated with best CRS-R TS, last CRS-R TS, hospital length of stay, and time on mechanical ventilation. Results Patients underwent CRS-R assessments a median of six (interquartile range [IQR] 3–10) times before discharge, beginning a median of 48 days (IQR 40–55) from admission. Twelve (57%) patients recovered to MCS after a median of 8 days (IQR 2–14) off continuous sedation; they had lower body mass index ( p = 0.009), lower peak serum C-reactive protein levels ( p = 0.023), higher minimum arterial partial pressure of oxygen ( p = 0.028), and earlier fentanyl discontinuation ( p = 0.018). CRS-R scores fluctuated over time, and the best CRS-R TS was significantly higher than the last CRS-R TS (median 8 [IQR 5–23] vs. 5 [IQR 3–18], p = 0.002). Earlier fentanyl ( p = 0.001) and neuromuscular blockade ( p = 0.015) discontinuation correlated with a higher last CRS-R TS. Conclusions More than half of our cohort of patients with prolonged unresponsiveness following severe COVID-19 recovered to MCS or better before hospital discharge, achieving a clinical benchmark known to have relatively favorable long-term prognostic implications in DoC of other etiologies. Hypoxia, systemic inflammation, sedation, and neuromuscular blockade may impact diagnostic assessment and prognosis, and fluctuations in level of consciousness make serial assessments essential. Early neurorehabilitation of these patients in the ICU can be accomplished but is associated with unique challenges. Further research should evaluate factors associated...

Neurologic Manifestations of Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Hospitalized Patients During the First Year of the COVID-19 Pandemic

“…Little is known about the prognosis of critically ill COVID survivors with encephalopathy at hospital discharge. Growing literature provides optimism about delayed recovery of consciousness and benefit of intensive rehabilitation ( 20 , 21 ).…”

Early Rehabilitation for Patients with Disorders of Consciousness after Severe COVID-19

“…The present study by Gurin and colleagues [7] thus makes an important contribution to the field of COVID-19 DoC (and DoC more broadly) by highlighting the importance of performing multiple comprehensive behavioral assessments to detect consciousness in the ICU. Although the study does not provide mechanistic evidence linking early rehabilitation to recovery of consciousness, it provides a blueprint for optimizing rehabilitative care in the ICU.…”

“…In this context, it is noteworthy that a median of six CRS-R assessments were performed in the 21 patients with COVID-19 DoC, exceeding the recommended number of assessments necessary to establish an accurate diagnosis of level of consciousness in patients with chronic DoC [13]. The optimal number and frequency of CRS-R assessments in patients with acute DoC is unknown, but the high level of variability in CRS-R scores observed by Gurin and colleagues [7] suggests that multiple CRS-R assessments may similarly be needed to optimize detection of consciousness in the ICU.…”

“…In this issue of Neurocritical Care, Gurin and colleagues [7] shed new light on the natural history of recovery and optimal rehabilitative care for patients with COVID-19 DoC. The authors report results from 21 patients who participated in a comprehensive rehabilitation program developed for patients with COVID-19 DoC in the intensive care unit (ICU).…”

“…The study by Gurin and colleagues [7] raises profound ethical questions about resource allocation and the appropriateness of early rehabilitation for patients with acute DoC in the ICU. If signs of consciousness are often missed by the Glasgow Coma Scale and if early emergence of consciousness is associated with better longterm outcomes [14][15][16], should every ICU patient with a DoC be assessed with the CRS-R prior to decisions about continuation of life-sustaining therapy?…”