Keywords COVID-19 pandemic - SARS-CoV-2 - neurological manifestations - critically ill neurological
patients - neurocritical care management
Introduction
The pandemic of coronavirus disease 2019 (COVID-19) has rapidly spread throughout
the world leading to a global health crisis. The fast-rising numbers of COVID-19 patients
has stressed the health care system. The management of non-COVID patients is also
significantly affected as the limited health care resources are diverted toward managing
the patients with COVID-19. Medical emergencies including neuro-emergencies continue
unabated during this period and require immediate care to save lives and avoid irreversible
consequences. Neurocritical care involves time-sensitive interventions where rapid
workup and prompt management improve patient outcomes. Management of these patients
should not be delayed for lack of test for COVID-19.
A patient with neurological disease may acquire COVID-19 infection, or neurological
illness may be a manifestation of COVID-19. Management of such patients poses unique
challenges. These patients need isolation and critical care in dedicated COVID intensive
care units (ICUs). Currently, there is limited data to guide neurocritical care unit
(NCCU) management of patients with suspected/confirmed COVID-19 infection. The purpose
of this position statement and advisory is to guide clinicians on the practice of
neurocritical care during the ongoing COVID-19 pandemic.
Methodology
The Governing Councils of the Neurocritical Care Society of India and the Indian Society
of Neuroanaesthesiology and Critical Care formed an expert committee of neurointensivists
from across India to formulate this advisory. A detailed search of PubMed, Embase,
Medline, OVID, and Google Scholar databases were done for the available information
from original investigations, case series, and special articles. The search included
these specific words: COVID-19 and neurocritical care, neurological emergencies, stroke,
spinal cord injury, and mechanical ventilation. Information was also obtained from
the guidelines and practice advisories of allied specialties of neurology, neurosurgery,
and intensive care. Additional information was retrieved from the references of these
articles.
Directives from the Ministry of Health and Family Welfare (MoHFW), Government of India
and the Indian Council of Medical Research were obtained from respective Web sites.
Since definitive evidences were not available, the committee members contacted experts
in the field of neurocritical care across India to obtain their views. The expert
committee held multiple web-based discussions to formulate this consensus statement.
General Principles of Management during COVID-19
General Principles of Management during COVID-19
Triage
The neurocritical care team should work closely with the emergency department and
the COVID-19 team to screen, test, and isolate suspected COVID-19 patients with critical
neurological illness contemplating admission. Symptoms described as influenza-like
illness (ILI) such as fever (temperature > 38°C) and cough are typical manifestations
of COVID-19 and it is recommended to isolate these patients in the screening area
itself. Apart from these symptoms, patients may present with atypical manifestations
like myalgia, sore throat, alteration in taste or smell, diarrhea, and cardiovascular
manifestations. Many of the COVID-19 patients may have low oxygen saturation without
dyspnea (silent hypoxia). The diabetic and older patients with COVID-19 are more likely
to suffer silent hypoxia.[1 ] Confirmed COVID-19 patients, irrespective of the symptoms, should be managed in
a dedicated COVID ICU. If a hospital does not have such a facility, they should transfer
the patient to a designated COVID-19 facility after resuscitation and stabilization.
The COVID-19 suspects (patients with ILI, fever, exposure to high-risk contacts, and
from containment zones) should be isolated and cared for in an isolation ICU till
the reverse transcriptase polymerase chain reaction (RT-PCR) results are available
([Fig. 1 ]). As approximately 20% of RT-PCR results are false negative such patients with severe
acute respiratory illness (SARI), with no other explainable cause, should continue
to receive care in isolation and should undergo repeat test.[2 ] Any patient admitted with critical neurological illness who develops SARI later,
should also be isolated and investigated for COVID-19.
Fig. 1 Triage and transport of critically ill neurological patients during management in
the hospital.
Preparedness of Neurocritical Care Services and Surge Response
The numbers of COVID-19 cases in India are currently increasing. At the same time,
neurologic emergencies such as acute ischemic stroke (AIS), intracranial hemorrhage
(ICH), traumatic brain injury (TBI), spinal cord injury (SCI), and aneurysmal subarachnoid
hemorrhage (aSAH) continue to present to NCCU. Additionally, COVID-19 patients who
develop acute neurologic illness such as viral meningitis, encephalitis, or Guillain–Barre
syndrome (GBS) may require NCCU admission. Moreover, patients with autoimmune disorders
such as multiple sclerosis, myasthenia gravis (MG), and sarcoidosis, who receive immunosuppressive
therapies, are more prone to COVID-19 infection. Thus, there will be an increased
requirement for neurocritical care support which necessitates optimization of resources
during the pandemic.[3 ] This requires innovative measures with regards to space, staff, supplies, and equipment.
Emphasis should be on reorganizing health care teams, enhancing hospital and ICU capacity,
and acquisition of personal protective equipment (PPE) and ventilators. Focusing on
safety and resilience of health care professionals (HCPs) during pandemic-related
surge is essential to enhance disaster preparedness.[4 ]
Some of the strategies to scale-up preparedness in this situation include:
Using clearly defined clinical management algorithms for neurological emergencies.
This limits exposure of team member, while ensuring optimal patient care.
Creating separate care areas within the NCCU (isolation ICU within ICU) for treating
suspected and confirmed COVID-19 patients till test results are available.
HCPs should work in a safe environment, with adequate PPEs and appropriate training
in its use.
Video-laryngoscope should be available for airway management.
Provision of tiered staffing plan with availability of reserve team and alternate
staffing resources.
Adopting electronic-ICU monitoring (remote patient monitoring by intensivists at an
offsite facility) to support on-site staff. Utilizing telemedicine and videoconferencing
for taking rounds and consultations, and for training and education of trainees and
staff.
Providing ready access to hospital isolation guidelines and testing protocols.
Providing access to psychological support to worried, anxious, and stressed staff.
The World Health Organization (WHO) has developed the Adaptt Surge Planning Support
Tool to support surge planning.[5 ] It is accompanied by technical guidance which outlines actions and policies to increase
available hospital capacity for an influx of COVID-19 patients, while continuing to
maintain essential services.
Environmental Cleaning and Disinfection
During COVID-19, cleaning and disinfection becomes more important to control the pandemic.
(1) Cleaning: The surfaces should be thoroughly scrubbed with water and soap or detergent.
(2) Disinfection: Various agents have viricidal activity when used in right concentration,
for right contact time, and in right amount. A list of these agents is available from
Environmental Protection Agency USA,[6 ] MoHFW India,[7 ]
[8 ]
[9 ] and National Centre for Disease Control.[10 ]
Personal Protective Equipment in Neurocritical Care
The MoHFW has provided guidelines for the appropriate and rational use of PPE in different
care areas ([Table 1 ]).[11 ]
[12 ] All HCPs should use appropriate PPE depending on the work area and risk profile
and also appropriately dispose used PPE according to guidelines.[13 ] Standard precautions should always be followed as PPEs are not alternative to basic
preventive public health measures such as hand hygiene and respiratory etiquettes.
Table 1
The recommendations for PPE based on the work area and risk profile for HCPs
No.
Location
Activity
Risk
Recommended PPE
Remarks
Abbreviations: AGPs, aerosol-generating procedures; ED, emergency department; HCP,
health care professionals; ICU, intensive care unit; NCCU, neurocritical care unit;
OR, operating room; PPE, personal protective equipment; RT-PCR, reverse transcriptase
polymerase chain reaction; SARI, severe acute respiratory illness.
a Full complement of PPE = N95 mask, coverall, nitrile/latex examination gloves, shoe
cover, eye goggles (with or without face shields).
1
Triage area
Triaging patients
Moderate
N95 mask, gloves
Patients to wear triple layered mask
2
Transporting patients to/from NCCU to other areas of hospital like ED, radiology,
OR
Transporting patients not on any assisted ventilation
Low
Triple layer medical mask, Latex examination gloves
No AGPs
(patients to wear triple layered mask)
SARI patient with or without assisted ventilation
High
Full complement of PPEa
Potential AGPs
3
NCCU (non-COVID area)
Critical care management
Moderate
N95 mask, goggles, nitrile examination gloves + face shield
Potential AGPs
Face shield, when a splash of body fluid is expected
Critical care management (patient develop fever or SARI during NCCU stay)
High risk
Full complement of PPEa
Isolation in NCCU (ICU within ICU concept) till the RT-PCR results
Dead body packing/transport to mortuary
Low
Triple layered medical mask, latex gloves
No AGPs
4
COVID ICU
Critical care management
High
Full complement of PPEa
Potential AGPs
Cardiopulmonary resuscitation
High
Full complement of PPEa
Potential AGPs
Dead body packing
High
Full complement of PPEa
No AGPs
Dead body transport to mortuary
Low
Triple layered medical mask, latex gloves
No AGPs
Donning and Doffing
Proper donning (wearing) and doffing (removing) of PPE is crucial to prevent infection
transmission among HCPs. The procedure of donning and doffing should be followed as
per instructions from Centers for Disease Control and Prevention[14 ] and WHO.[15 ] HCPs are at increased risk of infection during doffing; hence, it should always
be supervised. Any breach in the PPE or procedure should be reported immediately to
the concerned authority.
Transport of Patient to and from Neurocritical Care Unit
All persons involved in transport of suspected/confirmed COVID-19 patients should
don appropriate PPE before shifting the patient. All procedures and investigations
for these patients should preferably be performed at bedside and transport within
the hospital should be avoided unless absolutely necessary. During transport, a dedicated
shortest route corridor with separate entry and exit for COVID-19 patients is preferable
to reduce transmission of infection. Else, the entire pathway should be disinfected
after transport. Intubated patients on mechanical ventilation should have a viral
filter attached between the endotracheal tube (ETT) and the circuit while all nonintubated
patients should wear a triple-layer surgical mask while being transported.
Before the arrival of suspected/confirmed COVID-19 patient to the NCCU, the following
preparations and precautions are suggested:
(1) Prepare negative pressure room (NPR), if possible.
(2) The attending team should don appropriate PPE.
(3) Nonintubated patient must wear a surgical mask and receive supplemental oxygen
if SpO2 is < 92% via a facemask placed over the surgical mask.
(4) For intubated patients, one viral filter is positioned between the ETT and the
ventilator circuit, and another at the expiratory port of the ventilator.
(5) Intubated patients should have closed suction system to minimize circuit disconnection.
(6) Necessary precautions should be taken during any aerosol-generating procedures
(AGPs).
(7) If surgery is planned in suspected/confirmed COVID-19 patient, the NCCU team should
inform the operation theater personnel in advance.
(8) For all COVID-19 suspects, nasopharyngeal swab for RT-PCR test should be sent
at the earliest. The patient should be considered as positive till the results are
obtained.
Management in Neurocritical Care Unit
Management in Neurocritical Care Unit
Airway Management
Airway management is a crucial part of care in critically ill neurological patients.
Handling of airway is an AGP, which predisposes HCPs to the risk of infection. One
in 10 HCPs contracted COVID-19 during intubation of suspected/confirmed COVID-19 patients
despite wearing PPE conforming to WHO standards.[16 ] Various AGPs performed in the NCCU are intubation and extubation, bronchoscopy,
open suctioning, nebulization, manual ventilation, disconnection of patient from the
ventilator, noninvasive positive pressure ventilation (NIPPV), tracheostomy, prone
positioning, and cardiopulmonary resuscitation (CPR). In suspected/confirmed COVID-19
patient, we recommend the following:
AGPs in the NCCU should be performed in NPR (if available) to prevent spread of contagious
airborne pathogens outside the room. WHO recommends the use of NPR with at least 12
air changes per hour.[17 ]
Minimum number of personnel should remain inside the room during AGPs.[18 ]
Intubation should be performed by an experienced person to maximize the chances of
success, and minimize the number of attempts. Rapid-sequence intubation is preferable.
Video-laryngoscope is recommended (if available and provider is skilled in its use)
to minimize distance between patient and intensivist, and reduce the transmission
risk of COVID-19.[18 ]
Additionally, barrier devices (transparent intubation boxes or sheets) may be used
while performing AGPs. However, use of these devices may make intubation difficult,
prolonging the intubation time. Hence, caution should be exercised in hypoxemic patients.
Mechanical Ventilation
The true incidence of hypoxic respiratory failure in COVID-19 patients remains unknown.
However, available data indicates that approximately 14% of COVID-19 patients develop
severe disease needing oxygen administration, and approximately 5% require ICU admission
and mechanical ventilation.[18 ]
[19 ] High-flow nasal oxygen or NIPPV is used if conventional oxygen therapy fails to
improve oxygenation in these patients with hypoxic respiratory failure. However, early
intubation in a controlled setting is recommended over an emergency intubation.[18 ]
[20 ]
Hypoxia is deleterious and is linked to poor outcome in critically ill patients.[21 ] Supplemental oxygen should be administered if peripheral oxygen saturation (SpO2 ) falls below 92%. SpO2 between 92 and 96% is desirable for acutely ill medical patients.[18 ] However, in patients of acute neuronal injury, hypoxemia and hypotension can worsen
neurologic injury. In the absence of literature, oxygenation strategy based on cerebral
oxygenation monitor (cerebral oximetry) may be considered to improve neurologic outcome.
Acute respiratory distress syndrome (ARDS) has been reported to develop in 42% of
patients presenting with COVID-19 pneumonia, and 61 to 81% of those requiring ICU
care.[22 ] In patients of COVID-19 with ARDS requiring mechanical ventilation, a low tidal
volume (4–8 mL/kg) is recommended and plateau pressure (Pplat) < 30 cm H2 O should be targeted.[18 ] In moderate to severe ARDS use of higher positive end-expiratory pressure (PEEP)
is suggested over lower PEEP while monitoring for barotrauma and hemodynamic. However,
in neurological patients with raised intracranial pressure (ICP), high PEEP or low
tidal volume ventilation can cause hypercapnia, increase ICP, and worsen neurologic
outcome. Hence, ICP monitoring is advisable for implementing this strategy.
Prone Ventilation
The COVID-19 patients with moderate-to-severe ARDS (i.e., PaO2 /FiO2 ≤ 200 mm Hg) and on mechanical ventilation, 12 to 16 hours of prone ventilation
is recommended.[18 ] Prone ventilation minimizes distension of ventral and collapse of dorsal alveoli,
making ventilation more homogeneous.[23 ] Recent meta-analyses have demonstrated a decrease in mortality with at least 12
hours of prone ventilation in patients with moderate-to-severe ARDS.[24 ]
[25 ]
[26 ]
[27 ] In neurological patients, prone ventilation improves oxygenation but also increases
ICP.[28 ]
[29 ] Therefore in neurological patients with COVID-19, prone ventilation should be used
with ICP monitoring and only when beneficial effects of prone ventilation outweigh
potential harms from increase in ICP. In addition, neurological patients with absolute
contraindications (unstable spine) should not receive prone ventilation.[18 ]
Hemodynamic Management
Neurological patients in the NCCU may develop hemodynamic instability or shock. The
prevalence of shock in COVID-19 infection varies with severity of illness and may
reach 20 to 35% in ICU patients.[30 ]
[31 ] Cardiac enzymes are raised in 7 to 23% of patients with COVID-19.[30 ]
[31 ]
[32 ] In approximately 40% of patients, shock from fulminant myocarditis results in mortality.[33 ] Data in COVID-19 patients suggest that older age, associated comorbidities (diabetes
and hypertension), reduced lymphocyte count, increased D-dimer level, and cardiac
injury predispose to the development of shock.[18 ]
[19 ]
[30 ]
[33 ]
The advocated management of shock in COVID-19 patients is based on literature from
non-COVID critically ill patients. Fluid responsiveness should be assessed using peripheral
temperature, capillary refill time, and/or serum lactate levels.[18 ] Since hypotension independently predicts mortality in neurocritical care patients,
it should be aggressively treated using fluid resuscitation and vasopressor therapy.
For initial resuscitation, balanced crystalloid solution is recommended.[18 ] If unavailable, 0.9% saline is a reasonable alternative.[18 ] For those not responding to fluid therapy, norepinephrine is the first-line vasoactive
drug.[18 ] Alternatively, vasopressin or epinephrine may be used. In COVID-19 patients with
shock, mean arterial pressure between 60 and 65 mm Hg should be targeted. In refractory
shock, low-dose corticosteroid (intravenous hydrocortisone 200 mg/day) is recommended
(“shock-reversal” therapy). Advanced hemodynamic monitoring tools will be helpful
in goal-directed therapy.
Neurological Manifestations of COVID-19
Neurological Manifestations of COVID-19
COVID-19-related neurological manifestations include stroke, headache, seizures, impaired
consciousness, myalgia, and neuropathy (paresthesia and bowel/bladder dysfunction).[34 ]
[35 ] COVID-19 patients have the likelihood of developing neurological problems such as
critical illness myopathy and neuropathy, cerebrovascular disease, encephalopathy,
and GBS.[36 ]
[37 ] Distinguishing symptoms specific to COVID-19 from common complications of critical
illness may be difficult.
Fever is common in NCCU and is associated with worse outcomes in patients with neurologic
illness. Fever is mostly due to infection or underlying acute brain injury but COVID-19
can further complicate correct diagnosis. Fever should be managed utilizing both pharmacotherapy
and device-related temperature therapies to reduce secondary brain injury from hyperthermia.
COVID-19 patients may have higher risk of developing seizures.[38 ] Epileptiform abnormalities are detected in COVID-19 patients with encephalopathy.[39 ] However, it is still unclear whether COVID-19 infection is directly responsible
for seizures and if epileptiform activity affects outcome in these patients.
Specific Neurological Conditions
Specific Neurological Conditions
Acute Ischemic Stroke
Stroke is a frequent neurological manifestation in COVID-19 patients and they may
develop AIS despite anticoagulant chemoprophylaxis. Data of COVID patients from China[35 ]
[40 ] showed that AIS occurred in the elderly or middle aged with known vascular risk
factors. Whereas COVID-19 AIS patients from New York were younger, and had more severe
strokes (predominantly cryptogenic variety), higher D-dimer levels, and increased
mortality vis-a-vis non-COVID strokes.[41 ] Comorbidities (diabetes, hypertension, obesity, and cardiovascular disease) increase
the risk of stroke in COVID-19 patients.
Recent literature suggests stroke in COVID-19 to be either due to endothelitis[42 ] from direct viral infection via angiotensin-converting enzyme 2 (ACE2) receptors
(hence the possible use of anticytokine drugs [tocilizumab, sarilumab],[43 ]
[44 ] statins,[45 ]
[46 ]
[47 ] and anti-inflammatory drugs[48 ]
[49 ]) and/or through COVID-19-associated coagulopathy[50 ] reflected by increased fibrinogen and D-dimer (consequently, low molecular weight
heparin [LMWH] or unfractionated heparin [UFH] is used for thromboprophylaxis).
In COVID-19 era, a predefined protocol for stroke management reduces the risk to HCPs
and improves delivery of patient care. On hospital arrival, stroke patients should
be screened for clinical symptoms of SARI (cough and fever > 38°C), headache, dyspnea/tachypnea
(respiratory rate > 24/min), chest pain, myalgia, vomiting, and diarrhea, contact
with COVID-19 patient, international travel in the preceding 2 weeks, and residence
in high-risk/containment zone. If the above are positive or cannot be ascertained,
“Protected Code Stroke” (PCS) should be activated[51 ] which includes the following:
(1) Evaluation of the patient (wearing surgical mask) simultaneously by neurologist
or member of stroke/intervention team and anesthesiologist/intensivist (using appropriate
PPE).
(2) If there is a high demand for oxygen (FiO2 > 0.5) or decreased consciousness, elective intubation (with recommended precautions)
should be done, before shifting to radiology or interventional neuroradiology (INR)
suite. Choices of drugs include ketamine or etomidate to maintain blood pressure (BP).
Any decline in BP should prompt early vasopressor use.
Emergency management and referral of AIS patients in COVID-19 pandemic:
Covid-19 designated hospital with stroke facility: If the patient is asymptomatic,
negative on screening, and is not from a hot spot/containment zone, the hospital’s
“code-stroke” pathway may be followed. For COVID-19 suspect, emergency services should
not be delayed for lack of test. However, swab should be sent for testing and PCS
should be activated.
Non-COVID hospital with stroke facility: If COVID-19 is suspected, PCS should be activated.
Patient should be stabilized (including thrombolysis if within time window) and referred
to the nearest COVID-19 designated hospital with stroke unit.
Non-COVID hospital without stroke facility: Suspected COVID-19 AIS patient should
be immediately referred to the nearest COVID-19 designated hospital with stroke unit.
Imaging in COVID-19: There should be a predesignated computed tomography (CT) and
INR suite for COVID-19 suspect/confirmed patients (Stroke Green Pathway).[52 ] If this is not possible, disinfection of the suite is performed between the cases.
CT suite should be prenotified before shifting of the patient to allow for preparation.
The preferred imaging is noncontrast CT[53 ] of brain within 20 minutes of arrival with follow-up CT scan repeated after 24 hours.
All patients with suspected/confirmed COVID-19 should additionally undergo CT imaging
of the lungs as typical lesions (subsegmental ground glass opacities) are seen in
up to 82% of cases.
Thrombectomy in INR suite may either be performed under general anesthesia (GA) or
monitored anesthesia care (MAC) and the decision should be individualized based on
patient condition.[54 ] GA should be administered to those already intubated, those with active cough/vomiting,
posterior circulation or dominant hemisphere stroke, severe stroke, Glasgow Coma Scale
(GCS) score < 9, and agitated/aphasic/uncooperative patient. MAC should be provided
to others. For patients undergoing thrombectomy with MAC, oxygen should be provided
with nasal prongs below the surgical mask and capnography must be monitored continuously.
No or minimal sedation should be used to minimize rescue airway maneuvers. For urgent
conversion from MAC to GA, airborne precautions should be followed, intubation should
be performed by an experienced anesthesiologist using video-laryngoscope, and systolic
BP should be maintained > 140 mm Hg. Extubation should be done in NPR; however, if
performed in INR suite, all precautions should be followed. Postprocedure care: Dyna
or cone-beam head CT imaging should be done in INR suite to avoid transfer to CT room.
In the NCCU, suspected/confirmed COVID-19 patient should be cared in NPR, if available.
If trachea is not extubated, the patient should be sedated and ventilated in the NCCU
with sedation breaks every 8 hours for neurological examination. Invasive BP monitoring
should preferably be done. Early extubation should be considered to optimize scarce
NCCU resources.
Traumatic Brain Injury
With increasing numbers of COVID-19 patients, changes in admission policies are required
to optimally utilize NCCU beds and manpower for both COVID-19 and non-COVID patients.
TBI patients with minor lesions (undisplaced fractures or traumatic SAH with GCS of
15) may not require NCCU admission.[55 ]
Once NCCU receives information regarding arrival of TBI patient, “Protected Code Brain”
should be activated including protective measures against COVID-19 infection, mentioned
earlier. NCCU management of TBI should follow existing norms of care.[56 ] Morbidity and mortality in COVID-19 patients could be from end-organ involvement
which can worsen in presence of severe TBI.
Acute Spinal Cord Injury
Respiratory dysfunction leading to increased risk of pulmonary infection is the main
reason for complications and death in SCI. SCI-induced respiratory dysfunction further
increases the patient’s susceptibility to COVID-19 pneumonia. Patients of SCI may
not present with typical symptoms of COVID-19 due to altered physiology (such as temperature
dysregulation, impaired cough, and abnormal sensations below the neurological level
of injury) which may pose a unique diagnostic challenge during the current pandemic.
Given an already reduced lung capacity and impaired cough, a high level of suspicion
for respiratory illness is needed to ensure an early diagnosis of COVID-19 infection
in this population.[57 ]
All patients with SCI should be screened for COVID-19 at admission and treated as
per the standard protocols of acute SCI. Appropriate precautions against the disease
including use of PPE should be undertaken especially during assisted coughing to avoid
exposure to aerosolized secretions.[58 ]
[59 ]
[60 ]
[61 ]
Subarachnoid Hemorrhage
aSAH is a neurologic emergency and carries significant morbidity and mortality. The
neuroanesthesiologist and/or neurointensivist may be involved in managing these patients
during resuscitation (poor grade), diagnostic cerebral angiography, aneurysm clipping
or endovascular coiling, postoperative care in the NCCU, transportation to/from imaging
suite, and vasospasm management in the INR suite.
Following aSAH, there is heightened sympathetic drive and inflammation resulting in
heart and lung dysfunction. This can manifest as breathlessness, oxygen desaturation,
fever, and bilateral lung infiltrates due to neurogenic pulmonary edema. These features
could mimic COVID-19 infection. Misdiagnosing potential COVID-19 lung manifestations
for aSAH-related pulmonary complications can predispose HCPs to COVID-19 infection.
There are isolated reports of SAH following COVID-19 infection[62 ] though; it is difficult to say if they are causal or coincidental.[63 ] Published data shows increased postoperative mortality in COVID-19 infected patients.[64 ] Based on history and clinical features, COVID-19 infection should be suspected.
However, SAH management (clipping or coiling) should not wait till laboratory confirmation
of COVID-19 infection.
COVID-19 affects the endothelial/epithelial ACE2 receptors. It is currently unclear
whether this increases the possibility of vasospasm/thrombosis leading to delayed
cerebral ischemia. Vasospasm management after aSAH often requires intra-arterial administration
of nimodipine or milrinone. Transporting COVID-19 patient repeatedly from NCCU to
INR suite for intra-arterial therapy may be challenging with regards to sanitization
of the pathway and extra care required during transport of such patients. In such
situations, to minimize transfers, intravenous milrinone or nimodipine may be more
suitable. When necessary, angiography may be considered in discussion with the INR
team.
In the NCCU, respiratory failure and hypoxemia can accelerate cerebral ischemia. Where
available, ventilation and oxygenation can be titrated based on cerebral oxygenation
monitoring.
Status Epilepticus
Focal status epilepticus (SE) has been reported as an initial manifestation of COVID-19
infection.[65 ] There are no other similar reports. However, caution should be exercised in patients
presenting with SE requiring NCCU admission.
Neuromuscular Disorders
Neuromuscular complications may be encountered during the pandemic. COVID-19 presents
as myalgia in 44 to 70% of patients.[31 ]
[66 ] Patients with motor neuron disease who have underlying respiratory muscle weakness
and immunocompromised patients are at increased risk of contracting COVID-19.[31 ]
[66 ] Patients with neuromuscular disorders (NMDs) receive immunosuppressant and immunomodulating
therapy, thereby increasing their susceptibility. Therefore, patients with neuromuscular
weakness of new-onset or from underlying known disorder should be evaluated for COVID-19
during this pandemic.
Viral infections with Epstein–Barr virus, H1N1, influenza, and Zika virus are associated
with development of GBS. GBS is also reported with other corona virus infections.[67 ]
[68 ] Though GBS has been reported with COVID-19, causality is uncertain.[69 ]
Pulmonary infection is one of the triggers for myasthenia crisis leading to NCCU admission.
Clinical suspicion and laboratory testing for COVID-19 is essential during this pandemic.
Hydroxychloroquine and chloroquine, which are used for prophylaxis and/or treatment
of COVID-19, may cause exacerbation of MG.[70 ]
[71 ]
[72 ] Hydroxychloroquine is not recommended in patients with Duchenne or Becker muscular
dystrophy.[70 ]
Close monitoring for worsening of underlying disease or respiratory function is recommended
in moderate-to-high risk patients with NMD. Currently, no NMD-specific recommendations
are available for COVID-19 patients. Use of corticosteroids and other immunosuppressants
is based on clinical status of COVID-19 patient and seriousness of underlying NMD.
Postoperative Neurosurgical Patients
Patients with brain tumors receive steroids to reduce cerebral edema which can lead
to immune suppression. Although few experts suggest using steroids during early phase
of COVID-19 infection, consensus is lacking. Immune-suppressed neurosurgical patients
have increased risk of developing severe COVID-19 infection in the perioperative period
requiring NCCU care. Hence, judicious decisions are needed regarding dose and duration
of steroid therapy. Studies have reported increased postoperative pulmonary complications
and higher mortality following surgery in COVID-19 patients.[64 ]
[73 ]
[74 ] This should be considered during postoperative care in the NCCU.
Nonneurological Issues and Their Management in NCCU
Nonneurological Issues and Their Management in NCCU
Thromboprophylaxis in COVID-19
Observational data have suggested increased thrombotic complications in COVID-19,
particularly in those with ARDS.[75 ]
[76 ]
[77 ]
[78 ]
[79 ] As a standard-of-care, nonambulant COVID-19 patients in NCCU with respiratory failure
or coexisting cancer, diabetes mellitus, hypertension, or heart failure, should receive
prophylactic anticoagulation with daily LMWHs or twice-daily subcutaneous UFH, unless
contraindicated.[80 ]
[81 ]
[82 ] Intermittent pneumatic compression should be considered when pharmacological prophylaxis
is contraindicated.
The role of thromboprophylaxis for asymptomatic COVID-19 patients or those with mild
symptoms, but significant comorbidities, is uncertain. Since supporting data are lacking,
pharmacological prophylaxis should be restricted to high-risk patients (bedridden,
prior thromboembolism, and/or active malignancy).[83 ]
There are no data to demonstrate improved clinical outcomes with high-dose anticoagulation.[83 ] The most important consideration during anticoagulation is risk of bleeding, particularly,
ICH in postoperative patients and aggravation of bleed in SAH patients. COVID-19 patients
with high risk for thrombosis also have increased bleeding possibility.[82 ] Therefore, anticoagulation should be administered after understanding the risk of
ICH.[84 ]
Nutrition
Frailty and malnourishment may contribute to increased morbidity and mortality in
COVID-19. Early nutritional assessment and institution of appropriate feeds (preferably
enteral) is vital.[85 ] Prone position, which is often used in COVID-19 patients, does not contraindicate
enteral nutrition.[86 ] Dysphagia is common after neurological injury such as stroke and muscle weakness
from critical illness. Therefore, careful assessment of swallowing after decannulation
or extubation is needed, followed by gradual feeding.
Tracheostomy
Where possible, an early extubation is desirable. However, coughing and open T-piece
weaning, which generate aerosols, should be avoided. Drugs such as dexmedetomidine
facilitate smooth extubation without significant cardiorespiratory system activation.
Extubation can be performed directly from low pressure support ventilation if the
patient fulfills extubation criteria. Tracheostomy in NCCU is indicated when extubation
is not possible or ventilator weaning trials fail. Mortality in ventilated patients
with COVID-19 pneumonitis is approximately 50%.87 Literature suggests that acute
lung injury phase of COVID-19 pneumonitis lasts for approximately 10 to 14 days.[87 ] Viral load is likely to be low after 3 weeks of first symptoms. Since tracheostomy
is AGP with high risk for infection transmission to HCPs, it is recommended to delay
tracheostomy if possible in COVID-19 patients.[87 ] However, some COVID-19 neurological patients may require early tracheostomy such
as those predicted to fail primary extubation (lower cranial involvement, poor GCS
score, severe stroke, difficult airway, high cervical SCI). There is however no guideline
to inform timing of tracheostomy in COVID-19 patients. Decision about timing must
balance the risks of prolonged intubation for the patient against risks to the HCPs
involved in tracheostomy.[87 ]
[88 ]
Both percutaneous and surgical tracheostomy can be performed in COVID-19 neurological
patients. The procedure should be performed with recommended precautions in a NPR
with closed suction and minimum staff.[87 ]
[88 ] Use of fiberoptic scope during percutaneous tracheostomy is not recommended in COVID-19
patients.[87 ] Preoxygenation (100% oxygen for 5 minutes) before the procedure is recommended.
Aerosol generation can be minimized by the following:
Prevent breach of ETT cuff during tracheostomy.
Clamp ETT before disconnecting the circuit.
Reduce ventilator pressure and/or frequency when trachea is punctured, dilated, or
opened surgically (consider suspending ventilation if patient condition allows) and
resume ventilation once cuff is inflated.
Prefer surgical ties to diathermy to reduce vapor plumes.[87 ]
In tracheostomized patients, triple layer surgical mask should be applied over the
face to minimize spread of COVID-19 infection.[87 ]
Extracorporeal Membrane Oxygenation
At present, data are insufficient to recommend extracorporeal membrane oxygenation
(ECMO) in COVID-19 patients with refractory hypoxemia.[20 ] In mechanically ventilated COVID-19 patients with severe ARDS and refractory hypoxemia
notwithstanding various treatments to optimize ventilation and improve oxygenation,
veno-venous ECMO may be considered in carefully selected patients.[18 ] However, due to high cost, limited availability, and need for trained staff and
infrastructure, it remains an extremely limited resource-intense technique. At present,
ECMO should be restricted to carefully chosen patients. Studies reporting outcomes
in COVID-19 patients receiving ECMO will guide future practice.[18 ]
[20 ]
[89 ]
Cardiopulmonary Resuscitation
CPR is a life-saving procedure. However, it poses risks of COVID-19 transmission to
the administering HCPs.[90 ] American Heart Association has issued the interim guidance on CPR for the HCPs during
COVID-19 outbreak.[91 ] The decision to perform CPR during pandemic should be based on likely neurological
outcome of the patients. In patients with poor outcome, family should be counseled
about prognosis, goals of care, and do-not-resuscitate status. To protect the CPR
team, resuscitation should be performed only after the response team has donned appropriate
PPE.
Targeted Temperature Management during COVID-19 Pandemic
Targeted temperature management (TTM) is an important component of acute care of unresponsive
postcardiac arrest patients. There is no literature regarding the practice of TTM
during COVID pandemic. Best practices as per existing guidelines and discussions with
family regarding outcome should guide its use.
Communication and Psychological Aspects in NCCU
Most patients in NCCU are critically ill. Constant communication with the family is
often required to update them about the patient status and for consent for procedures
and care. However, if family members are also COVID-19 positive, they are likely to
be at home or institutional quarantine making communication and shared decision-making
difficult.
Patients with positive COVID-19 status are likely to be stressed about the prognosis.
This can affect systemic physiology, and in turn, neurological outcomes. Children
and postoperative patients are more vulnerable to psychological issues if parents
or family members are unable to visit them in the NCCU due to quarantine or their
own hospitalization. Patients dying in adjacent beds in the NCCU can adversely affect
patients and may even develop new-onset neuropsychiatric manifestations. Stress is
also likely among HCPs caring for COVID-19 patients in the NCCU. Early recognition,
prompt psychological support, and rotation in postings are crucial for restoring HCP’s
wellness.
COVID-19 Retesting in NCCU
Neurological COVID-19 patients are likely to stay in the NCCU for a long time. Repeat
testing for COVID-19 helps optimize resources and plan patient care. There is no clarity
on the timing and frequency of retesting in NCCU. It should be performed as per local
guidelines.
Conclusion
Management of critically ill neurological patients during COVID-19 pandemic is challenging
and requires a good understanding of pathophysiology and management aspects of COVID-19
along with that of the primary neurological condition. Strategies to streamline workflows,
robust infection control measures, and ensuring safety of HCPs are crucial in the
NCCU management of critically ill neurological patients during this pandemic.
