When researchers surveyed ICUs around the world in mid-2020, they found implementation of the checklist had fallen below 20% from about 80% before the pandemic. One survey of 212 ICUs worldwide in a single day found that only 1% were implementing all the strategies meant to shield patients from delirium. Among the least-observed guidelines was one for spontaneous awakening and breathing trials.
One of the chief goals of the guidance is preventing the kind of delirium McCarthy suffered. It used to afflict about 80% of patients on ventilators, but the rate fell below 50% when the checklist was followed. As the pandemic went on, “delirium went through the roof, and I think dementia went through the roof,” Ely says. “The key modifiable component of all of this was the overuse of the sedation.”
Inflammation and blood-vessel damage induced by the coronavirus infection may also have played a role in brain injuries, Toronto General’s Herridge says. But Covid patients were often difficult to assist because their struggles to breathe put them out of sync with the devices. Some pulled out their breathing tubes, cutting their oxygen supply and blasting infectious virus particles into the air, says Frederick Mihm, a professor of anesthesiology at Stanford University Medical Center.
“We had three self-extubations within 24 hours early on in the epidemic,” Mihm recalls. “I said, wow, that is not going to happen again.”
The solution was often to deepen sedation. In the first 48 hours after admission, Covid ICU patients were given about eight times as much midazolam and twice as much propofol, another sedative, as non-Covid patients, according to a study of two US hospitals in the first six months of the pandemic.
“I’ve never used drugs like this in my whole career, and it just felt completely wrong,” Herridge says. “It was just like the systematic de-adoption of everything we’ve spent decades showing improves patient management and ultimate outcome.”
After a month of intubation at Sturdy, McCarthy’s condition worsened. On March 12, her husband received a call from the hospital: It was time for the family to say goodbye.
Trauma extends beyond the patient. Brenda Reed, McCarthy’s mother, says she finds it difficult to talk about her daughter’s illness without getting emotional. A study in France found 35% of family members had symptoms of post-traumatic stress four months after a relative was hospitalized for respiratory distress from Covid.
“Those memories are seared in my brain,” Reed says. “I will hear something or see something or not even be thinking about Kellie, but it’ll pop into my brain and I will start to cry. Not sobbing, not uncontrollably, but I will get very sad.”
Reed contacted a funeral home and prepared an obituary. Still, she insisted on having McCarthy transferred to a bigger hospital for a possible lung transplant. The 800-bed Brigham and Women’s Hospital in Boston agreed to take her. At the time, McCarthy was paralyzed and receiving heavy doses of midazolam and fentanyl, her medical records show.
“We’re like, I don’t think she needs a transplant, but she just needs her sedation turned off…slowly,” said Daniela Lamas, the intensive-care physician who took McCarthy’s case. The pandemic changed how care was delivered in the ICU, Lamas says. The repercussions of that are now becoming apparent.
“The junior doctors who trained during Covid are a lot more liberal with sedation and slow to make sure that they wake people up every day,” she says. “There is a difference that we need to be careful about.”