While more severe hypoxemia is tied to longer recovery, patients with severe COVID-19 often recover command-following a month after intubation if they receive supportive care, according to study findings published in Annals of Neurology.
Severe COVID-19 survivors often experience prolonged re-emergency of consciousness. Doctors and families have withdrawn life-sustaining therapy without evidence-based guidance on the likelihood and time of recovery of patients. Prior research has indicated patients with acute respiratory distress syndrome (ARDS) experienced long-term cognitive deficits, but their neurocognition has not yet been assessed.
The objective of the current study was explore the association between time to recovery of consciousness and hypoxemia and other clinical predictors in patients with severe COVID-19.
Researchers analyzed data of 795 patients (aged 62±14 years; 68% men; 49% obese; 30% Hispanic or Latino; 21% White) who were admitted to New York-Presbyterian Hospital/Columbia University Irving Medical Center (CUIMC), Massachusetts General Hospital (MGH), and New York-Presbyterian Hospital/Weill Cornell Medical College (WCMC) between March and July 2020 after presenting with severe COVID-19. The patients included in the study experienced impaired consciousness (Glasgow Coma Scale motor score less than 6) on day 7 of intubation. The researchers analyzed a similar cohort (n=427) who were admitted during the second surge of COVID-19 (October 2020 to April 2021).
Command-following was recovered by 571 patients. Median time to recovery of command-following was 30 days after mechanical ventilation. Patients who had at least 1 episode of an arterial partial pressure of oxygen (PaO2) of no more than 55 mm Hg (P <.001) experienced a median 16 more days to recovery. A quarter of patients recovered at least 10 days after mechanical ventilation ended.
Time to recovery of consciousness increased as depth and duration of hypoxemia (PaO2 ≤55mmHg HR: 0.56; PaO2 ≤70 HR: 0.88). As days of hypoxemia increased, likelihood of recovery decreased. The researchers found the same results among patients without evidence of structural brain injury and those in the second surge cohort.
“Prolonged time to recovery of command-following, as observed in our study, should be considered in goals of care discussions between clinicians and surrogate decision-makers,” the researchers said.
The findings suggest that recovered command-following is often seen in severe COVID-19 survivors, but recovery may happen after a month. Moreover, it could be days or weeks after that mechanical ventilation is no longer needed.
Study limitations included forced changes in clinical practice during the initial surge due to clinical demands, use of GCS motor score, potential confounders such as interactions of medications, and lack of accounting for reason for withdrawing life-sustaining therapy and premorbid functional status or comorbidities.
The researchers emphasize their study findings “highlight the need for a cautious approach to neuroprognostication in patients with severe COVID-19.” “Decisions to withdraw life-sustaining therapies should not be based solely on prolonged periods of unconsciousness, as patients may harbor prospects for recovery. Importantly, the degree of functional recovery remains unknown and warrants further investigation.”
Disclosure: One study author declared affiliation with a Bristol Myers Squib study of a therapy for severe COVID-19.
Waldrop G, Safavynia SA, Barra ME, et al. Prolonged unconsciousness is common in COVID-19 and associated with hypoxemia. Ann Neurol. Published online March 7, 2022. doi: 10.1002/ana.26342