Table 1.
Characteristics of patients with Covid-19 who had catastrophic brain injury.
| Characteristic | Patient 1 | Patient 2 | Patient 3 | Patient 4 | Patient 5 | Patient 6 |
|---|---|---|---|---|---|---|
| Age | 46 | 68 | 66 | 37 | 74 | 51 |
| Sex | M | F | F | M | M | M |
| Cause of catastrophic brain injury | Brainstem and cerebellar infarction followed by global hypoxic-ischemic injury | Global anoxic injury due to cardiac arrest | Global anoxic injury due to cardiac arrest | Multifocal intracerebral hemorrhage with diffuse cerebral edema and brain compression | Multifocal intracerebral hemorrhage with diffuse cerebral edema and brain compression | Global anoxic injury due to cardiac arrest and catastrophic cerebellar hemorrhage with diffuse cerebral edema and brain compression |
| Number of days from viral symptom onset to consult for catastrophic brain injury | 7 | 20 | 16 | 31 | 21 | 32 |
| Number of days from admission to consult for catastrophic brain injury | 7 | 14 | 13 | 28 | 18 | 26 |
| Sedative/narcotic drips | Fentanyl, Midazolam | Dexmedetomidine, Fentanyl, Midazolam | Fentanyl | Hydromorphone, Ketamine, Propofol, Midazolam | Dexmedetomidine, Fentanyl, Ketamine, Midazolam, Propofol | Dexmedetomidine, Hydromorphone, Ketamine, Midazolam |
| Number of days on sedative/narcotic drips | 7 | 7 | 1 | 21 | 14 | 18 |
| Number of days off sedative/narcotic drips prior to consult for catastrophic brain injury | 1.5 | 4 | 1 | 2 | 4 | 1 |
| Paralytics | Rocuronium | Rocuronium | N/A | Rocuronium | Rocuronium | Rocuronium, Cisatracurium |
| Number of days off paralytics prior to consult for catastrophic brain injury | 5 | 8 | N/A | 19 | 8 | 3 |
| Blood pressure prior to final neurologic examination (mm Hg) | 130/56 | 110/62 | 115/52 | 88/30 | 141/60 | 96/56 |
| Vasopressors prior to final neurologic examination | Norepinephrine, Vasopressin, Phenylephrine | Epinephrine, Norepinephrine, Vasopressin | Norepinephrine | Norepinephrine, Phenylephrine, Vasopressin | Norepinephrine | Norepinephrine, Vasopressin, Dopamine |
| Temperature prior to final neurologic examination (˚C) | 36.6 | 35 | 37.4 | 37.8 | 37.1 | 36.5 |
| pH prior to final neurologic examination | 7.23 | 7.46 | 7.34 | 6.95 | 7.36 | 7.39 |
| PaCO2 prior to final neurologic examination (mm Hg) | 40 | 39 | 43.6 | 40 | 43 | 44 |
| PaO2 prior to final neurologic examination (mm Hg) | 106 | 182 | 125 | 100 | 148 | 81 |
| FiO2 prior to final neurologic examination (%) | 40 | 100 | 60 | 100 | 60 | 50 |
| Creatinine prior to final neurologic examination (mg/dl) | 15.4 | 1.4 | 5.5 | 1.45 | 1.66 | 2.68 |
| Peak D-Dimer (ng/ml) | >10,000 | 11,402 | 47,803 | 9887 | 4488 | >10,000 |
| Peak C-reactive protein (mg/l) | 226 | 136 | 446 | 307 | 416 | 368 |
| Peak IL-6 (pg/ml) | N/A | 61.7 | 152.4 | 569 | N/A | 126 |
| Evaluation for spontaneous breathing | No spontaneous breaths seen; formal testing deferred due to acidosis | No spontaneous breaths seen; formal testing deferred due to hemodynamic instability | Attempted using t-piece and PEEP valve, but aborted after 90 seconds due to hypoxia to 85% and MAP of 55mm Hg | No spontaneous breaths seen; formal testing deferred due to decision to withdraw treatment | Occasional spontaneous breaths seen with respiratory rate on ventilator adjusted to 4 breaths/ minute | No spontaneous breaths seen; formal testing deferred due to decision to withdraw treatment |
| Formal assessment for brain death performed | Yes | Yes | Yes | No: prerequisites not met (acidemia, hypothermia, hypotension); cardiac arrest | No: family withdrew care prior to brain death testing | No: family withdrew care prior to brain death testing |
| Time between consult for catastrophic brain injury and formal brain death assessment | 8 days | 3 days: delay waiting for family to be ready to accept this determination | 1 day | N/A | N/A | N/A |
| Ancillary testing | TCDs | EEG and CT angiography | EEG | N/A | N/A | N/A |
| Criteria to declare death | Neurologic | Neurologic | Neurologic | Cardiopulmonary | Cardiopulmonary | Cardiopulmonary |
| Family visitation prior to brain death assessment | No | Yes | Yes | N/A | N/A | N/A |
| Family visitation prior to cardiopulmonary arrest/after brain death assessment and prior to discontinuation of organ support |
Yes | N/A | N/A | No in-person visit, but family was able to see patient via video | Yes | Yes |
| Time between brain death declaration and discontinuation of organ support | 32 h: Accommodation of family’s request to delay pending their visit | 3 h | 2 days: Accommodation of religious objections | N/A | N/A | N/A |