Intensive Care Unit Delirium in COVID-19 Case Report

It’s been a long week of processing COVID-19 patient blood. After handling vial after vial of blood in a very controlled laboratory environment, it’s easy to forget the unpredictable nature of this virus’s presentation in clinical settings, so I’m excited to be able to sit down at the end of the week and learn more about what clinicians are dealing with.

This week brings a new case report coming out of Stanford published in Psychosomatics, describing hyperactive intensive care unit (ICU) delirium in a 70-year-old woman with COVID-19 (Sher et al., 2020). The patient  presented to the clinic with 5 days of fever, cough, headache, and malaise. Chest x-ray revealed opacities in the right lung and her shortness of breath worsened over the next day. PCR test came back  positive for SARS-CoV-2. The patient  was transferred to the ICU on day 3 of hospitalization due to hypoxic respiratory failure and intubated the following day. To facilitate the mechanical ventilation and alleviate her discomfort, she was started  on a variety of sedative medications (and other psychotropic medications) including dexmedetomidine, hydromorphone, propofol, midazolam, ketamine, oxycodone, chlordiazepoxide, quetiapine, and melatonin. On hospital day 29, psychiatry was consulted, as the patient was experiencing impaired cognition, disturbed attention and awareness, agitation, and sleep-wake cycle dysregulation. A diagnosis of delirium was made based on virtual assessment, chart review, and discussions with ICU staff and family members. On hospital day 30, a tracheostomy placement took place.

Based on psychiatric assessment, melatonin was increased and suvorexant (orexin agonist) was added to assist with regulating sleep-wake cycles. Guanfacine and valproic acid were also added to assist with agitation and help wean off deliriogenic medications. Haloperidol was added later to assist with hyperactive delirium. Within a week, she was off all sedative medications. By day 10 of consultation, she was fully aware, alert, and cognizant. By hospital day 52, she was discharged to a long-term care facility. It is unclear if the stoma was removed and COVID symptoms had completely subsided by this point.

The authors mention that up to 82% of all ICU patients develop delirium and they expect the incidence for COVID-19 and ARDS to be similarly high. In the case of their patient, they suggested that the mixture of propofol, multiple opioids, and high doses of benzodiazepines likely contributed to the patient’s agitation and delirium. They also mention that severe agitation could be a direct result of the cytokine storm that occurs in some patients, and the associated release of catecholamines (norepinephrine) might exacerbate symptoms of agitation as well. The last point that the authors made about potential mechanisms for delirium, which I found the most striking and upsetting, is the environment of the ICU. Because ICU staff are extremely busy during the pandemic, they are unable to offer consistent reorientation and cognitive stimulation to patients – and even when they do, the extensive PPE they are wearing makes it difficult for patients to recognize faces and individuals. Adding to this issue, families are unable to visit and offer emotional support during the current COVID-19 hospital restrictions on visitations. The cumulative effects from lack of a stimulating environment paired with sleep disturbances in an ICU setting, where lights and machine alarms are on all day/night, may exacerbate a patient’s confusion and disorientation. Perhaps telemedicine may offer some help in such situations by allowing delirious patients to access stimulation or see human faces, but it may also distort their sense of reality. It seems like there are not any clear answers yet for how to prevent this surprisingly common issue with COVID-19 hospitalizations.