As critical care nurses we’ve seen how severe COVID-19 has impacted our patients. Alterations in consciousness ranging from delirium to coma have been noted. The issue of delayed return of consciousness in survivors of severe COVID-19 was first published in November 2020. Research is emerging that may help healthcare teams and families make informed decisions regarding prognosis and outcomes for critically ill patients who survive COVID-19.
I recently read “Prolonged Unconsciousness Is Common in COVID-19 and Associated With Hypoxemia.” This three-center retrospective study conducted during the first and second COVID-19 surges notes recovery of command-following [defined as return of a motor score > 6 on the Glasgow Coma Score (GCS) following a GCS motor score < 6] is common after 30 days on the ventilator, if supportive care is provided. In the study, hypoxemia (defined as a PaO2 ≤ 55 mm Hg or PaO2 ≤ 70 mm Hg at any point in the patient’s course) was associated with prolonged unconsciousness. Each additional day when hypoxemia was present decreased the likelihood for return of consciousness and was associated with longer recovery time. The authors acknowledge that factors such as sedative use, disease severity and premorbid comorbidities could also affect prolonged unconsciousness. However, in the study, the relationship between hypoxemia and prolonged unconsciousness was independent of any other variable. The authors note that another study shows survivors have slow (over months) functional recovery of independence after universal recovery of consciousness following severe COVID-19. The authors also acknowledge the study had limitations and more research into the cause is needed.
A quote from the study’s conclusion struck me as incredibly important to guide conversations with families about prognosis and the ongoing management of these patients:
“Independent of the underlying mechanisms yet to be uncovered, our findings provide key information that should be used to guide decisions of life-sustaining therapies.”
A quote from a study co-author in a news release made me realize how much these results affect end-of-life care and withdrawal of support discussions:
“Our findings suggest that for patients with severe COVID, the decision to withdraw life support shouldn’t be based solely on prolonged periods of unconsciousness, as these patients may eventually recover.”
As nurses, we sometimes see prolonged unconsciousness and the physically debilitating effects of long ICU stays leading to futile care. What I’m finding, in the research now being published regarding outcomes for critically ill patients who survive severe COVID-19, is that full recovery is possible, but it may take months. Let’s look at some of the research being published.
A systematic review and meta-analysis looked for an association between frailty and mortality in patients with COVID-19. The results failed to show an independent association between frailty and short-term mortality risk. The review did note that non-frail patients were more likely to be admitted to the ICU, receive invasive mechanical ventilation and have a higher mortality risk than those assessed as frail. The authors hypothesized that this finding may be related to allocation decisions during the pandemic. The use of invasive mechanical ventilation showed no difference in mortality between frail and non-frail patients.
A similar systematic review and meta-analysis looking for an association between frailty and short-term mortality from COVID-19 showed an increase in all-cause mortality for frail patients and also for older patients. This analysis found no significant difference in ICU admission rates between frail and non-frail patients.
Both of these systematic reviews and meta-analyses report multiple limitations, so the data is conflicting regarding frailty and short-term mortality for patients with COVID-19.
A study conducted in Brazil assessed transitions in frailty and disability scores in critical care survivors of COVID-19. Frailty and disability were assessed two to four weeks before diagnosis of COVID-19 and at 90 days post-discharge from the hospital. The results show that disabilities increased, and 31% of survivors were frail at day 90 and 70% were not frail prior to COVID-19.
The study points out the need for long-term follow-up and rehabilitation for survivors who develop disabilities and become frail.
“Characteristics and Outcomes of US Patients Hospitalized With COVID-19,” a retrospective cohort study conducted in March/April 2020, found many patients who had an intensive care admission experienced prolonged hospital stays. At discharge, a large number of these patients received new respiratory support or new home-based or new facility-based healthcare services.
A retrospective review explored the frequency, risk factors and impact of delirium on outcomes for patients in temporary critical care hospitals in Poland during the pandemic. In patients with COVID-19 who developed delirium during their hospitalization, the results of this review show odds of mortality to be 17 times higher compared with patients who did not develop acute brain dysfunction. The review recommends monitoring for delirium regularly and implementing delirium prevention measures to help reduce the increased risk of mortality.
These studies looking at outcomes for critically ill survivors of COVID-19 remind me that these survivors also may have post-intensive care syndrome (PICS). This study demonstrates that critically ill survivors of COVID-19 have significant challenges even 90 days post-discharge. Issues include cognitive impairment, sleep disorders and inability to perform the independent activities of daily living. A tool to help screen for PICS is available. We can also help screen patients for conditions that may lead to PICS. This brief AJCC Patient Care Page has some great recommendations.
Caring for patients who are critically ill with COVID-19 is challenging. Emerging research provides us with more information to have meaningful conversations with the healthcare team, patients and families. The expectation for long-term follow-up, rehabilitation, plan of care and prognosis are essential topics, so patients and families have the information they need to make informed decisions about care. More research is being released that may inform future planning and decision-making. Keep reading!
Share your thoughts on how best to help critically ill survivors of COVID-19 cope.
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