Delirium and High Sedation Levels are Common in Critically Ill Patients with COVID-19 and Associated with Poor Long-Term Outcomes

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Background We investigated delirium prevalence and potential effects of long-term sedation in critically ill COVID-19 patients; to identify opportunities for improving sedation practices and delirium prevention. Methods This prospective, single-center, observational cohort study was conducted from April-June 2020. Adult COVID-19 patients were eligible if admitted to an ICU with mechanical ventilation/intravenous sedation; or a general care unit with brain monitoring due to altered mental status. Patients were evaluated daily until discharge using the Richmond Agitation-Sedation Scale, Confusion Assessment Method for the ICU, and CAM-Severity. Cumulative doses of sedation and paralytic medications were recorded. At three months post-enrollment, cognition, mood, and quality of life were measured by the Telephone Interview for Cognitive Status (TICS), Center for Epidemiologic Studies Depression Scale 10-item (CES-10), and EuroQol 5-Dimension-3 Level (EQ-5D-3L), respectively. Results 67 patients were enrolled, with a mean (SD) age of 59 (12) years, 30 (45%) Hispanic, 43 (64%) developing acute respiratory distress syndrome, 55 (82%) mechanically ventilated (mean duration of 22.9 days), and 5 comatose for the entire study. Of the 62 patients assessed for delirium, 61 (98%) had delirium at least once, with a mean (SD) of 12.7 (13.0) days. >90% of patients received opioids, benzodiazepines, or propofol at least once; median (IQR) total dose of 37.4 (78.9) mg (fentanyl equivalents), 52.5 (813.3) mg (midazolam equivalents), and 46 (53) g (propofol), respectively. At follow-up, 40 (60%) patients were reached, while 16 (24%) were deceased/comfort measures. Patients showed reductions in cognition, mood, and quality of life with median (IQR) scores for TICS (0-41): 30 (26-33); CES-D-10 (0-30): 6 (4-12); EQ-5D-3L (1-3): 2 (mobility, self-care, usual activities, pain/discomfort). Conclusion Critically and acutely ill patients with COVID-19 early in the pandemic experienced a high rate of delirium and sedation. Large doses of sedatives may contribute to greater delirium burden during hospitalization, and lead to poor clinical outcomes.