BEBINGER: Or what their mental state might be if or when they do. Around midnight on April 8, doctors at Houston Methodist Hospital turned off the sedative drip that had kept the previously healthy 65-year-old in a medically induced coma. Leslie and Frank Cutitta have a final request: Wear a mask. You must have updated your disclosures within six months: http://submit.neurology.org. If a story is labeled All Rights Reserved, we cannot grant permission to republish that item. For some very serious surgeries, such as open-heart surgery or brain surgery, the patient is allowed to slowly wake from anesthesia with no reversal agent to bring the muscles out of paralysis. Massachusetts General Hospital investigators are using unprecedented collaboration and frontline experience to better understand the neurological effects of SARS-CoV-2 infection. The Cutittas say they feel incredibly lucky. Once the heart starts beating again, healthcare providers use cooling devices to lower your body temperature for a short time. endstream endobj startxref Patients have many emboli affecting their liver and kidneys, altering the metabolism of sedatives, which can affect the duration of sedation.". hb```f`` B@ 0S F L`>bxFv3X^gYe:g3g|-cF$F_),L@4+SlnST%@ 4 The drugs used to sedate patients seem to play a role. There was no funding agency/sponsor involved. Follow-up brain MRIs performed on ICU days 33 and 41 showed a slightly improved picture of the diffuse white matter abnormalities, while newly developed restricted diffusion was noted in the basal ganglia (figure). The work cannot be changed in any way or used commercially without permission from the journal. Motor reactions with the limbs occurred in the last phase. The infection potentially leads to an increase in blood clots in other organs, and whether micro-clots occur in the brain remains up for debate and is still a consideration.. (Branswell, 6/8), Hospital Investigated for Allegedly Denying an Emergency Abortion After Patient's Water Broke, Medicare Fines for High Hospital Readmissions Drop, but Nearly 2,300 Facilities Are Still Penalized, This Open Enrollment Season, Look Out for Health Insurance That Seems Too Good to Be True, What Looks Like Pot, Acts Like Pot, but Is Legal Nearly Everywhere? Powered and implemented by FactSet Digital Solutions. The machines require sedation, and prevent patients from moving, communicating,. Conclusion Prolonged unconsciousness in patients with severe respiratory failure due to COVID-19 can be fully reversible, warranting a cautious approach for prognostication based on a prolonged state of unconsciousness. For Covid-19 patients who respond successfully to intensive care treatment and are able to be discharged from hospital, the road to recovery can still be a lengthy one. There is much debate in the medical community as to what is causing the observed hypoxic injury, neurological symptoms and cognitive dysfunction in those with COVID-19. 'Royal Free Hospital'. All authors report no conflicts of interest or relevant financial relationships related to this manuscript. Neurologic symptoms such as headache, confusion, altered alertness, prolonged unconsciousness and loss of smell have been identified as symptomsof COVID-19. Thank you for your interest in supporting Kaiser Health News (KHN), the nations leading nonprofit newsroom focused on health and health policy. BEBINGER: They also want to know how many COVID patients end up in this prolonged sleeplike condition. Your role and/or occupation, e.g. (See "COVID-19: Epidemiology, clinical features, and prognosis of the critically ill adult", section on 'Length of stay' .) Obeying commands (mostly through facial musculature) occurred between 8 and 31 days after cessation of sedatives. Two months after first being diagnosed with Covid-19, she found her heart would start racing without warning. Market data provided by Factset. For NPR News, I'm Martha Bebinger in Boston. Joseph Giacino, director of rehabilitation neuropsychology at Spaulding, said hes worried hospitals are using that 72-hour model with COVID-19 patients who may need more time. All patients had a flaccid paralysis after awakening that remained present for the recorded days in the ICU or resolved only very slowly. 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. And in some patients, COVID triggers blood clots that cause strokes. Leslie Cutitta said yes, twice, when clinicians from Massachusetts General Hospital in Boston called asking whether she wanted them to take and then continue extreme measures to keep her husband, Frank Cutitta, alive. A coma is a state of unconsciousness where a person is unresponsive and cannot be woken. Its a big deal, he told the paper. Click the button below to go to KFFs donation page which will provide more information and FAQs. December 3, 2021. Subscribe to KHN's free Morning Briefing. "If we accelerate our emphasis on trying to use neuroscience in a more principled way, it will pay dividends for these ICU patients, whether they are being treated for COVID-19 or otherwise. BEBINGER: The doctor said most patients in Frank's condition in New York, for example, died because hospitals could not devote so much time and resources to one patient. Do not be redundant. Time and research efforts have offered some perspective on these links, though many key questions remain unanswered. Prolonged or persistent comas are just one area of research, but one getting a lot of attention. Patients were sedated between 14 and 31 days and showed prolonged unconsciousness after the sedatives were stopped. L CUTITTA: If this looks like Frank's not going to return mentally and he's going to be hooked up to a dialysis machine for the rest of his life in an acute long-term care facility, is that something that you and he could live with? "The emphasis was placed on just trying to get the patients ventilated properly. Online ISSN:1526-632X, The most widely read and highly cited peer-reviewed neurology journal. Ancillary investigations (table 1) showed a severe critical illness polyneuropathy. Quotes displayed in real-time or delayed by at least 15 minutes. After the removal, it typically takes hours, maybe a day, for the patient to return to consciousness. 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. A case reported by Edlow in July described a patient who moved between a coma and minimal consciousness for several weeks and was eventually able to follow commands. Search for condition information or for a specific treatment program. Every day, sometimes several times a day, she would ask Franks doctors for more information: Whats going on inside his brain? But for many patients, the coronavirus crisis is literally . Do take liquids first and slowly progress to a light meal. Conscious sedation is a combination of medicines to help you relax (a sedative) and to block pain (an anesthetic) during a medical or dental procedure. Diffuse leukoencephalopathy with restricted diffusion in the corona radiata and subcortical white matter on the first MRI slightly decreased on follow-up MRIs. In people with ARDS, the air sacs in the lungs fill with fluid, making breathing difficult. At Mass General, the brightest minds in medicine collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. But as COVID-19 patients fill ICUs across the country, it's not clear how long hospital staff will wait for those patients who do not wake up after a ventilator tube is removed. There are also patients who have extended hospital stays, followed by an even longer recovery period in a long-term care facility. Patients almost always lie on their backs, a position that helps nurses tend to them and allows them to look around if they're awake. So, on a Zoom call nurses arranged with his family, he wrote on paper attached to a clipboard. Many hospitals wait 72 hours, or three days, for patients with a traumatic brain injury to regain consciousness. Anesthesia-induced delirium has been highly prominent in medical literature over the past decade and is associated with ventilation. Its a devastating experience.. Hold your thumb up. "All of that has been erased by Covid," said Dr. E. Wesley Ely, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University and the Nashville Veteran's. To find COVID-19 vaccine locations near you: Search vaccines.gov, text your ZIP code to 438829, or call 1-800-232-0233. The Article Processing Charge was funded by the authors. We appreciate all forms of engagement from our readers and listeners, and welcome your support. It is very difficult for us to determine whether any given patients future will bring a quality of life that would be acceptable to them, Edlow said, based on what theyve told their families or written in a prior directive.. In this case series, prolonged level of unconsciousness with full recovery of the unconsciousness in patients with severe COVID-19 is shown. Newly developed restricted diffusion of the globus pallidus and substantia nigra was seen on the second and third MRIs. Intubation, ICU and trauma. Open. 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. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. (Jesse Costa/WBUR). Brown and his colleagues are working to develop drugs to help patients more quickly emerge and recover from general anesthesia. (6/5), ABC News: Everybody was reaching in the dark because they hadn't seen anything like this before, saysEmery Brown, MD, PhD, anesthesiologist in theDepartment of Anesthesia, Critical Care and Pain Medicine. Chou said families want to know whether a patient can wake up and be themselves. Answering that question depends on how accurate we are at predicting the future, and we know were not very accurate right now., A CT scan of Frank Cutittas brain showed residue from blood clots but was otherwise clean.. The enigmatic links between COVID-19, neurological symptoms and underlying brain dysfunction are complex. It was very tough, very tough. You can support KHN by making a contribution to KFF, a non-profit charitable organization that is not associated with Kaiser Permanente. In 5 of the 6 patients, a mixed or hypoactive delirium was diagnosed after recovery of the unconsciousness. Submissions should not have more than 5 authors. BEBINGER: The doctors eventually discharged Frank, but he had to spend a month at Spaulding, the rehab hospital. NOTE: The first author must also be the corresponding author of the comment. COVID-19 patients appear to need larger doses of sedatives while on a ventilator, and they're often intubated for longer periods than is typical for other diseases that cause pneumonia. COVID-19 patients appear to need larger doses of sedatives while on a ventilator, and they're often intubated for longer periods of time than is typical for other diseases that cause pneumonia.. ), Radboud University Medical Center, Nijmegen; Departments of Intensive Care (B.P.G. Submit. (Folmer and Margolin, 6/8), Stat: Dramatic spikes in auto traffic around major hospitals in Wuhan last fall suggest the novel coronavirus may have been present and spreading through central China long before the outbreak was first reported to the world, according to a new Harvard Medical School study. Edlow cant say how many. A brain MRI was subsequently performed on ICU day 26, which showed a diffuse white matter abnormalities (figure). But it was six-and-a-half days before she started opening her eyes. 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. The goals of sedation in ARDS patients are to improve patient comfort and tolerance of supportive and therapeutic measures without contributing to adverse outcomes. "That's still up for debate and that's still a consideration.". In many cases, sedation was prolonged and sometimes for several weeks; this was much longer than for common treatments requiring sedation, such as surgery. MA For the study, Vanderbilt University researchers studied 821 patients with respiratory failure or septic shock who stayed in an ICU for a median of five days. As with finding patients being unable to fully awake and having significant cognitive dysfunction, COVID-19 is expected to bring about the unexpected. Around midnight on April 8, doctors at Houston Methodist Hospital turned off the. 6.25 mg - 12.5 mg SC/IV can be used to begin with especially if nausea is a feature. loss of memory of what happened during . Soon, there were reports of new issues facing those with COVID-19. Severe cases of the disease cause acute respiratory distress syndrome, or ARDS. She was admitted to the hospital for oxygen therapy. The effects also could lead to the development of new conditions, such as diabetes or a heart or nervous . Whatever caused his extended period of unconsciousness cleared. "SARS-CoV-2 damages blood vessels, which affects blood pressure, inflammation and blood clotting. Boston, Conscious sedation lets you recover quickly and return to your everyday activities soon after your procedure. Some patients, like Frank Cutitta, do not appear to have any brain damage. The evidence we have currently does not indicate a direct central nervous system infection for the majority of cases with neurological symptoms, says Dr. Mukerji. Because the virus has the potential to cause extensive damage to the lungs, some patients may be unable to breathe on their own, and require intubation and subsequent ventilation in order to bring oxygen into the body. Experts Question Use Of Repeated Covid-19 Tests After A Patient Recovers Melatonin also has been reported in COVID-19 patients to spare sedatives and treat agitation.6 The message for sedation and analgesia in the pandemic is to follow our usual evidence-based critical care guidelines, but be flexible and creative if adjunctive therapy is needed based on the patient . Dr. Sherry Chou, a neurologist at the University of Pittsburgh Medical Center, is leading the international effort. Subsequently, 1 to 17 days later, patients started to obey commands for the first time, which always began with facial musculature such as closing and opening of the eyes or mouth. Over the next eight weeks, the only time she saw her baby was when the NICU staff sent photos, or when a nurse FaceTimed her while the baby was being bathed. Some medical ethicists also urge clinicians not to rush when it comes to decisions about how quickly COVID-19 patients may return to consciousness. The clinical pattern from unconsciousness to awakening occurred in a similar sequence in all patients. Have questions? Objective We report a case series of patients with prolonged but reversible unconsciousness after coronavirus disease 2019 (COVID-19)related severe respiratory failure. Members of the medical community are concerned over the cognitive effects of coronavirus infections. Copyright 2020 NPR. Go to Neurology.org/N for full disclosures. For the sickest COVID-19 patients, getting on a ventilator to help them breathe can be a life-saving process. Prolonged sedation likely increases the incidence of delirium and cognitive dysfunction. Neurological symptoms such as loss of smell, confusion and headaches have been reported over the course of the pandemic. But how many of those actually took a long time to wake up, we dont have numbers on that yet.. and apply to letter. We describe how the protracted recovery of unconsciousness followed a similar clinical sequence. This eye opening was not accompanied by any other motor reactions, making any contact, or following objects. Her brain MRI was normal, which was great, but then the question became: Whats going on? (Hurley, 6/7), CIDRAP: Blood clots are thought to bea critical factor in brain trauma and symptoms. The researchers are sharing their data to determine the cause of prolonged coma in COVID-19 patients, find treatments and better predict which patients might eventually recover, given enough time and treatment. So there are many potential contributing factors, Edlow said. Tables 1 and 2 and supplementary table e-1 (available on Dryad, doi.org/10.5061/dryad.866t1g1pb) show the characteristics of 6 patients. "It could be in the middle of . HONOLULU (KHON2) KHON2 first told you about 37-year-old Coby Torda when he was in the ICU with coronavirus in March. BEBINGER: Frank, for example, was on a lot of sedatives for a long time - 27 days on a ventilator. or redistributed. The Cutittas said they feel incredibly lucky. You (and co-authors) do not need to fill out forms or check disclosures as author forms are still valid We offer diagnostic and treatment options for common and complex medical conditions. We don't have numbers on that yet. 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?. Even before the coronavirus pandemic, some neurologists questioned that model. Acute inflammation can become severe enough to cause organ damage and failure. Dr. Mukerji does find that those with COVID-19 had hypoxic injurymeaning that brain cells in these patients died due to lack of oxygen. "But from a brain standpoint, you are paying a price for it. Do leave the healthcare facility accompanied by a responsible adult. Thank you for your interest in supporting Kaiser Health News (KHN), the nations leading nonprofit newsroom focused on health and health policy. Theories abound about why COVID-19 patients may take longer to regain consciousness than other ventilated patients, if they wake up at all. If confronted with this situation, family members should ask doctors about their levels of certainty for each possible outcome. Because the world is still dealing with this spreading pandemic, this finding has important implications for the consulting neurologists trying to evaluate and prognosticate patients with COVID-19 with unconsciousness after prolonged periods of mechanical ventilation in the ICU. [email protected]. Their respiratory systems improved, but they were comatose.. BEBINGER: Claassen says he's guardedly optimistic about recovery for these patients, but there's growing concern about whether hospitals overwhelmed by COVID patients are giving them enough time to recover. "It is worse in older patients, those who are quite ill and is associated with certain drugs such as midazolam, haloperidol and opiates like hydromorphone," says Dr. Brown. %%EOF It's lowered to around 89F to 93F (32C to 34C). Neurologists are frequently consulted due to neurologic symptomatology in patients with COVID-19. Because long-term sedation for COVID-19 patients could last several weeks, prolonged sedation increases the chance of hypoxia and causes neurological trauma. From the Departments of Intensive Care (W.F.A., J.G.v.d.H. Some covid-19 patients taken off ventilators are taking days or even weeks to wake up 'It's a big deal,' says a Weill Cornell neurologist. Autopsies Show Brain Damage In COVID-19 Patients, ABC News: For patients who are hospitalized with COVID-19, surviving the disease may just the start of their troubles. It was another week before Frank could speak and the Cutittas got to hear his voice. Given all the unknowns, doctors at the hospital have had a hard time advising families of a patient who has remained unresponsive for weeks, post-ventilator. Neurological symptoms such as loss of smell, confusion and headaches have been reported over the course of the pandemic. This disease is nothing to be trifled with, Leslie Cutitta said. Thats a conversation I will never forget having, because I was stunned.. [email protected], A coma can also be caused by severe alcohol poisoning or a brain infection ( encephalitis ). The anesthesiologist also plays a key role in critical care and treatment and trauma. Some COVID patients are taking nearly a week to wake up. We use cookies and other tools to enhance your experience on our website and And then, on May 4, after two weeks with no signs that Frank would wake up, he blinked. 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. Your organization or institution (if applicable), e.g. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Neurology. Still, those with COVID-19 present a unique challenge when treating delirium. Generally - low doses e.g. COVID-19 patients appear to need larger doses of sedatives while on a ventilator, and theyre often intubated for longer periods than is typical for other diseases that cause pneumonia. 'Orthopedic Surgeon'. Although he no longer needed the ventilator, he still required a feeding tube, intravenous fluids, catheters for bodily waste and some oxygen support. Autopsies Show Brain Damage In COVID-19 Patients The very premature infant was born via cesarean section and quickly whisked away to the neonatal intensive care unit before his mother could even lay eyes on him. I personally have observed, and have had cases referred to me, of people with eyes-closed coma for two to three weeks. 3: The reaction to pain is unusual. MARTHA BEBINGER, BYLINE: While Frank Cutitta lay in an ICU at Massachusetts General Hospital, doctors called his wife Leslie Cutitta twice to have what she remembers as the end-of-life conversation. We appreciate all forms of engagement from our readers and listeners, and welcome your support. Next, 5 to 12 days later, all patients started to follow objects spontaneously with their eyes, which was still not accompanied by obeying commands. She had been on high-dose sedatives since intubation. 2023 Kaiser Family Foundation. Low oxygen levels, due to the viruss effect on the lungs, may damage the brain. Dr. Brian Edlow is a critical care neurologist at Mass General. When things were calming down in the Northeast, there were reports of patients who were not waking up, says Dr. Brown. Learn about the many ways you can get involved and support Mass General. Heres what we ask: You must credit us as the original publisher, with a hyperlink to our khn.org site. He didnt have a lot of them at that point, but it was just amazing, absolutely amazing.. LULU. BEBINGER: Every day, sometimes several times a day, Leslie Cutitta would ask Frank's doctors, what's going on inside his brain? After nearly a month, Frank's lungs had recovered enough to come off a ventilator. It's sometimes used for people who have a cardiac arrest. More guidelines and information on Disputes & Debates, Neuromuscular Features in XL-MTM Carriers: Leslie and her two daughters watched on a screen, elated, making requests. During the following weeks, her level of consciousness improved, and she eventually started obeying commands adequately with her eyes and facial musculature in combination with a flaccid tetraparesis. Haroon Siddique. Informed consent was obtained from the patient described in detail. In light of this turmoil, the importance of sleep has often flown under the radar. Researchers have made significant gains understanding the mechanisms of delirium. 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. "We didn't find the virus in neurons using immunohistochemistry. 55 Fruit Street When might something change? Why this happens is unclear. A recent study in theNew England Journal of Medicineby Shibani Mukerji, MD, PhD, associate director of theNeuro-Infectious Diseases Unitat Mass General, shows that post-mortem brains of ventilated COVID-19 patients have hypoxic injury. Frank Cutitta spent a month at Spaulding Rehabilitation Hospital. Patients coming off a ventilator typically take hours, even a day to wake up as the drugs that help them tolerate the machine wear off. Dr. Brown is hopeful. By Martha Bebinger, WBUR The young mother, who gave birth at Montreals Sainte-Justine Hospital, tested positive for Covid-19 when her baby was born. BRIAN EDLOW: Because this disease is so new and because there are so many unanswered questions about COVID-19, we currently do not have reliable tools to predict how long it's going to take any individual patient to recover consciousness. The Need for Prolonged Ventilation in COVID-19 Patients. But doctors across the U.S. and in other countries have noted a troubling phenomenon associated with some COVID cases: Even after extubation, some patients remain unconscious for days, weeks or longer. It was very, very tough., From Dialysis not working to Spoke for first time, Frank Cutittas family kept a calendar marking his progress in the hospital from March until his return home on July 3. Department of Anesthesia, Critical Care and Pain Medicine, acute respiratory distress syndrome (ARDS), Stroke-Risk, COVID-19 and When to Seek Emergency Care, Understanding COVID-19's Neurological Effects, The symptoms behind neurological sequelae from SARS-CoV-2 infection are starting to be understood, but the direct and indirect effects of SARS-CoV-2 on the brain remain unclear, The COVID-19 pandemic has helped reveal the complex interaction between inflammation, sedation and cognitive dysfunction, Long-term sedation for COVID-19 patients could last several weeks, increases the chance of cognitive dysfunction and is linked to hypoxic injury, Prolonged sedation is linked to the incidence of delirium, and cognitive dysfunction; Now, many COVID-19 patients are struggling with delirium, Clinicians are working to find ways to mitigate the effects of sedation. 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. She subsequently developed several episodes of high fever with constantly negative blood and sputum cultures with improving infection parameters (C-reactive protein, ferritin, procalcitonin, cell counts) and was treated with antibiotics. It's not a mistake but one funny part of my job is seeing patients when they wake up from anesthesia. The effectiveness of sedation has traditionally been evaluated in terms of patient and surgeon satisfaction, but the most important goal is not to induce a deep sleep in the patient, but rather to ensure that the surgery is performed safely and as planned. Ventilation, which requires sedation to prevent injury, has become a common part of respiratory treatment in those with COVID-19. She started to move her fingers for the first time on ICU day 63. Leslie and her two daughters watched on FaceTime, making requests such as Smile, Daddy and Hold your thumb up!.