Brianna Burlock, MD, MPH; Eric C. Lawson, MD (@EricLawson90)
Authors: @GreerWaldrop, @sas_mdphd, @MeganRx1
Link to Twitter Thread: https://twitter.com/neurocritical/status/1503728992792231940?s=21
March’s Twitter journal club, done in conjunction with the Curing Coma Campaign (@CuringComa) and American Neurological Association (@TheNewANA1), featured a discussion on the article, “Prolonged unconsciousness is common in COVID-19 and associated with hypoxemia” by Greer Waldrop et al. This was a multi-center, retrospective, cohort study that sought to estimate time to recovery of command-following, and associations between hypoxemia with time to recovery of command-following in intubated patients with COVID-19. The authors discovered that even after accounting for confounding factors such as sedation and abnormal brain imaging, “time to command-following increases with duration of hypoxemia.” The authors concluded that “recovery of consciousness is common but may be delayed, particularly in hypoxemic patients.”
The discussion on #NCSTJC Twitterverse was lively -- let’s review some of the conclusions and key points.
This month’s journal club kicked off with a question. The poll results showed that most participants have cared for COVID-19 patients with prolonged consciousness, revealing the relevance of topic for discussion.
Among participants, there was a consensus that analgesics and sedatives play a role in prolonged unconsciousness. There were great comments about pharmacokinetics and how critical illness can alter how medications are metabolized also adding to encephalopathy. Some felt that “balance is needed” (@vasisht) and one commenter (@kvthomassian) even said that [clinicians] “use too much mind-altering medications”. Several commenters mentioned how difficult it is to establish the impact sedatives have on consciousness but @theABofPharmaC is hopeful that “future research can assist in identifying labs/biomarkers to better quantify the prolonged effects of sedatives despite their discontinuation”.
All commenters investigated structural lesions in patients with prolonged consciousness after COVID-19 pneumonia. Many agreed that MRI brain is most ideal however, it is sometimes difficult to get this type of imaging on critical care patients that may be unstable. Furthermore, as stated by @EderCaceres5 the ultimate decision for further work up is a “case by case decision, depending on exam, comorbidity, interventions, coags[sic]”. However, CT head was usually the first step and some participants also reported using EEG to evaluate brain abnormalities.
Some reported there does seem to be a relationship between hypoxemia in a dose-dependent manner and the time to recovery in command-following in severe COVID-19 patients. However, there was mention that several other factors likely impact recovery as well. Many participants commented that a higher PaO2 goal could be more harmful to the patient’s lungs, based on our current knowledge of COVID-19 pneumonia and acute respiratory distress syndrome.
Authors @ColumbiaNCC reminded us that “Plum and Posner in Diagnosis and Treatment of Stupor and Coma have long established the harmful interaction between hypoxemia and hypotension” although it was difficult to investigate the relationship to prolonged coma independently in the study.
Interestingly, @ColumbiaNCC reported that studies show that “seizures are not a common cause for prolonged unconsciousness in these patients” however EEGs can show covert consciousness which “has been associated with long term recovery”. This suggests that EEGs may be helpful in gaining information concerning recovery. @ComaRecoveryLab took the opportunity to show "gratitude to the #EEG techs who, like countless health care professionals, risked their safety to care for these patients” as we would not have the current data from the initial waves of COVID-19 without them.
The discussion closed out with a bang as the commentors brought up many good points to consider in prognosis for these patients. @ColumbiaNCC reports that the study showed that “delayed recovery of consciousness is common and should be considered” in similar clinical scenarios. Others commented that there is little information on the natural history and how COVID-19 affects the brain making it difficult to predict outcomes and prognosis. Moderator, @gdomeni mentioned how scarcity and lack of resources limits hospital systems in other countries from being able to continue supportive care for long periods of time. @josemdominguezr emphasized that “repetitive clinical examinations must be used ALWAYS for prognosis” and diagnostic tests should only be used in support of clinical examinations.
The March edition of the #NCSTJC generated great discussion regarding patients diagnosed with severe COVID-19 with prolonged unconsciousness and aspects of diagnostic workup, confounding factors, and prognosis. The discussion revealed the uncertainty that generally exists with patients diagnosed with COVID-19 and how brain function is affected. Fitting with the theme of the @CuringComa campaign there was hope among participants that although patients may have a prolonged period of unconsciousness, patients can have meaningful recovery.
Access the full article here: https://onlinelibrary.wiley.com/doi/10.1002/ana.26342