Prolonged Unconsciousness Following Severe COVID-19

Abdo, Wilson F.; Broerse, Catharina I.; Grady, Bart; Wertenbroek, Agnes A.A.C.M.; Vijlbrief, Onno; Buise, Marc P.; Beukema, Menno; Kuil, Mark van der; Tuladhar, Anil M.; Meijer, Frederick J. A.; Hoeven, Johannes G. van der

doi:10.1212/wnl.0000000000011355

Cited by 22 publications

(31 citation statements)

References 8 publications

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“…Notably, all patients who survived severe COVID-19 recovered consciousness. This observation corroborates prior reports that consciousness recovery from COVID-DoC is possible, [9][10][11] and indicates that such recovery is highly likely. Moreover, enrolling patients prospectively, soon after patients developed an unexplained DoC, revealed that the weeks-or months-long DoC described in previous reports is not common in COVID-DoC, with 50% of patients regaining consciousness within a week after continuous sedation was discontinued.…”

Section: Discussionsupporting

confidence: 92%

Disorders of Consciousness Associated With COVID-19

et al. 2022

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Background and Objectives:In patients with severe coronavirus disease 2019 (COVID-19), disorders of consciousness (COVID-DoC) have emerged as a serious complication. The prognosis and pathophysiology of COVID-DoC remain unclear, complicating decisions about continuing life-sustaining treatment. We describe the natural history of COVID-DoC and investigate its associated brain connectivity profile.Methods:In a prospective, longitudinal study, we screened consecutive patients with COVID-19 at our institution. We enrolled critically ill adult patients with a DoC unexplained by sedation or structural brain injury, and who were planned to undergo a brain MRI. We performed resting state functional MRI and diffusion MRI to evaluate functional and structural connectivity, as compared to healthy controls and patients with DoC resulting from severe traumatic brain injury (TBI). We assessed the recovery of consciousness (command-following) and functional outcomes (Glasgow Outcome Scale Extended [GOSE] and the Disability Rating Scale [DRS]) at hospital discharge, three months post-discharge, and six months post-discharge. We also explored whether clinical variables were associated with recovery from COVID-DoC.Results:After screening 1,105 patients with COVID-19, we enrolled twelve with COVID-DoC. The median age was 63.5 years [interquartile range 55-76.3]. Excluding one who died shortly after enrollment, all of the remaining eleven patients recovered consciousness, after 0-25 days (median 7 [5-14.5]) following the cessation of continuous intravenous sedation. At discharge, all surviving patients remained dependent – median GOSE 3 [1-3], median DRS 23 [16-30]. However ultimately, except for two patients with severe polyneuropathy, all returned home with normal cognition and minimal disability – at three months, median GOSE 3 [3-3], median DRS 7 [5-13]; at six months, median GOSE 4 [4-5], median DRS 3 [3-5]. Ten patients with COVID-DoC underwent advanced neuroimaging; functional and structural brain connectivity in COVID-DoC was diminished compared to healthy controls, and structural connectivity was comparable to patients with severe TBI.Discussion:Patients who survived invariably recovered consciousness after COVID-DoC. Though disability was common following hospitalization, functional status improved over the ensuing months. While future research is necessary, these prospective findings inform the prognosis and pathophysiology of COVID-DoC.Trial Registration Information:Clinicaltrials.gov, NCT04476589, submitted 7/2020, first enrolled 7/20/2020, https://clinicaltrials.gov/ct2/show/NCT04476589

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Section: Discussionsupporting

confidence: 92%

Disorders of Consciousness Associated With COVID-19

et al. 2022

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“…Knowledge about DoC has advanced in the past decade [ 1 , 2 ], and data increasingly suggest that early neurorehabilitation improves outcomes [ 3 , 4 ]. Some patients with severe COVID-19 have impaired arousal and/or awareness after discontinuation of sedation [ 5 , 6 ], consistent with DoC, which may contribute to the prolonged mechanical ventilation times [ 7 ] and ICU stays [ 8 ] that are characteristic of COVID-19 critical illness. There are calls for increased early neurorehabilitation efforts in this population [ 9 ].…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2021

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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...

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“…Notably, a high exposure to sedatives, mainly benzodiazepines has been independently associated with higher rates of delirium [ 7 ]. After cessation of sedatives, patients with severe respiratory failure secondary to COVID-19 may have a prolonged period of unconsciousness which may be weeks before complete recovery [ 8 ]. Caution is therefore advised when prognosticating in these patients.…”

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confidence: 99%