Table 1 COVID-19 delirium management considerations via SCCM’s ABCDEF safety bundle framework

A

Assessment/treatment of pain

Although regarded as a priority, in intubated, deeply sedated patients, assessment and management require the use of behavioral pain scales that may at first glance seem burdensome for strained healthcare workers but which will ultimately provide the most humane care and help reduce PTSD.

Regular pain assessment (NRS, CPOT/BPS)—especially in prone position.

Provide adequate pain management, identify uncommon sources of pain.

Consider development of peripheral neuropathies from viral invasion of peripheral nerves and PICS-related complications.

B

Both SAT and SBT

Stopping both sedation and the ventilator to conduct daily spontaneous awakening trials and spontaneous breathing trials is essential. These will not be possible during paralysis in proned patients, which creates a serious risk-benefit choice of this modality of patient positioning that argues for the shortest duration possible. Precautions for early extubation must be used to lower the spread of aerosol

For patients who need NMBD infusion (paralyzed patients)—monitor NMB depth and shorten duration whenever possible.

Regularly assess patients with both SBT and SAT daily.

C

Choice of sedation

Sometimes, deep sedation may be necessary, especially when using NMBD, when providing high PEEP, and when prone positioning is implemented. GABA-agonist propofol is likely the best choice during proning, but this can be shortened via daily questioning of the necessity of this management approach

Assess with RASS/SAS regularly.

Adjust sedation to ventilation needs—priority lies in effective ventilation (RASS-4 for prone position).

As soon as possible, discontinue potent sedatives or use those agents that do not suppress the respiratory drive such as intermittent use of antipsychotics or alpha-2 agonists.

Remember prolonged ventilation is associated with poor outcomes.

D

Delirium

Hyperactive delirium and agitation can be a source of intra-hospital cross-infection, especially in agitated patients or during non-invasive ventilation (if used, not recommended).

Hypoactive delirium is likely to be missed if not monitored for using a validated instrument routinely. Thus, patients may not receive appropriate attention to delirium prevention mechanisms.

Provide regular delirium screening (CAM-ICU, ICDSC).

Provide usual non-pharmacological interventions: (1) orientation is a priority, because patients see healthcare wearing personal protective equipment; (2) support for senses (hearing aids/glasses); (3) monitor taste/smell failure due to CoV predilection to olfactory nerves (anosmia may be an early sign).

Limit the use of CNS-active medications to agitated patients.

When CAM-ICU or ICDSC positive, use the Dr. DRE mnemonic to consider chief delirium risks: Diseases (new nosocomial infections, acquired heart failure); Drug Removal, stop all unnecessary psychoactive medications, be on the lookout for withdrawal if the patient was on a prolonged course of sedatives; Environment, maximize sleep, orientation to other humans, minimize sensory deprivation.

E

Early mobility

Physiotherapy may be very limited due to heavy workload and epidemiologic precautions; infusion of NMBD may be necessary.

Physiotherapy must be adjusted to heavy workload and epidemiologic precautions.

Use passive physiotherapy interventions during the infusion of NMBD.

F

Family presence

Limited or no family presence during the pandemic due to quarantine and social distancing.

A major issue for elderly and as end-of-life problem.

Orientate both patients and family regularly, provide phone conversations and video conferences, use technology devices, headphones, and tele-medicine tools.

Provide visual and vocal contact with the family/caregivers/friends, especially for all dying patients despite isolation, lack of time, and heavy workload.