Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients
Delirium and encephalopathy in severe COVID-19: a cohort analysis of ICU patients
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DOI：
10.1186/s13054-020-03200-1
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发表时间：
2020-08-08
期刊：
影响因子：
15.1
通讯作者：
Meziani, Ferhat
中科院分区：
文献类型：
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作者：
Helms, Julie;Kremer, Stephane;Meziani, Ferhat
背景SARS-CoV-2的嗜神经性及其神经学表现现已得到证实。我们旨在描述ICU患者的谵妄和COVID-19神经系统症状。方法我们在斯特拉斯堡大学医院的两个法国icu中进行了一项双中心队列研究。所有在2020年3月3日至5月5日期间因SARS-CoV-2引起的急性呼吸窘迫综合征转诊的150例患者都包括在入院时。10例患者（6.7%）被排除，因为他们在整个ICU住院期间一直使用神经肌肉阻滞剂。对部分谵妄和/或神经系统检查异常的患者行神经系统检查，包括CAM-ICU、脑脊液分析、脑电图和磁共振成像（MRI）。主要终点是描述谵妄和/或异常神经检查的发生率。次要终点是描述谵妄的特征，比较有和无谵妄和/或神经系统异常症状患者的有创机械通气时间和ICU住院时间。结果140例患者年龄中位数为62岁[IQR 52；70岁，中位SAPSII为49 [IQR 37；64点。神经系统检查正常22例（15.7%）。118名患者（84.3%）出现谵妄，并伴有急性注意、意识和认知障碍。88例（69.3%）患者在高输液率镇静和抗精神病药的情况下仍出现了意想不到的躁动状态，89例（63.6%）患者出现了皮质脊髓束体征。28例脑MRI显示蛛网膜下腔强化17/28(60.7%)，脑实质内白质异常8例，灌注异常17/26（65.4%）。42例脑电图大多显示非特异性异常或弥漫性异常，尤其是双额，活动缓慢。脑脊液检查显示18/28例患者炎症紊乱，包括镜像型寡克隆带和IL-6升高。1例患者CSF RT-PCR SARS-CoV-2阳性。与没有谵妄/神经系统症状的患者相比，COVID-19患者的谵妄/神经系统症状导致机械通气时间更长。谵妄/神经系统症状可能继发于SARS-CoV-2的全身炎症反应。COVID-19患者谵妄/神经系统症状是icu的主要问题，特别是在人力物力不足的情况下。
Background Neurotropism of SARS-CoV-2 and its neurological manifestations have now been confirmed. We aimed at describing delirium and neurological symptoms of COVID-19 in ICU patients. Methods We conducted a bicentric cohort study in two French ICUs of Strasbourg University Hospital. All the 150 patients referred for acute respiratory distress syndrome due to SARS-CoV-2 between March 3 and May 5, 2020, were included at their admission. Ten patients (6.7%) were excluded because they remained under neuromuscular blockers during their entire ICU stay. Neurological examination, including CAM-ICU, and cerebrospinal fluid analysis, electroencephalography, and magnetic resonance imaging (MRI) were performed in some of the patients with delirium and/or abnormal neurological examination. The primary endpoint was to describe the incidence of delirium and/or abnormal neurological examination. The secondary endpoints were to describe the characteristics of delirium, to compare the duration of invasive mechanical ventilation and ICU length of stay in patients with and without delirium and/or abnormal neurological symptoms. Results The 140 patients were aged in median of 62 [IQR 52; 70] years old, with a median SAPSII of 49 [IQR 37; 64] points. Neurological examination was normal in 22 patients (15.7%). One hundred eighteen patients (84.3%) developed a delirium with a combination of acute attention, awareness, and cognition disturbances. Eighty-eight patients (69.3%) presented an unexpected state of agitation despite high infusion rates of sedative treatments and neuroleptics, and 89 (63.6%) patients had corticospinal tract signs. Brain MRI performed in 28 patients demonstrated enhancement of subarachnoid spaces in 17/28 patients (60.7%), intraparenchymal, predominantly white matter abnormalities in 8 patients, and perfusion abnormalities in 17/26 patients (65.4%). The 42 electroencephalograms mostly revealed unspecific abnormalities or diffuse, especially bifrontal, slow activity. Cerebrospinal fluid examination revealed inflammatory disturbances in 18/28 patients, including oligoclonal bands with mirror pattern and elevated IL-6. The CSF RT-PCR SARS-CoV-2 was positive in one patient. The delirium/neurological symptoms in COVID-19 patients were responsible for longer mechanical ventilation compared to the patients without delirium/neurological symptoms. Delirium/neurological symptoms could be secondary to systemic inflammatory reaction to SARS-CoV-2. Conclusions and relevance Delirium/neurological symptoms in COVID-19 patients are a major issue in ICUs, especially in the context of insufficient human and material resources.