key: cord-0857814-fm5749zn authors: Waldman, Genna J.; Thakur, Kiran T.; Der Nigoghossian, Caroline; Spektor, Vadim; Mendiratta, Anil; Bell, Michelle; Bautista, Alyssa E.; Lennihan, Laura; Willey, Joshua Z.; Claassen, Jan title: Multidisciplinary guidance to manage comatose patients with severe COVID‐19 date: 2020-06-25 journal: Ann Neurol DOI: 10.1002/ana.25830 sha: 69e05432b2b6c5a2e5a1650e857d9cb58ddceab9 doc_id: 857814 cord_uid: fm5749zn nan In Spring 2020, New York City (NYC) rapidly became an epicenter of the SARS-CoV-2(COVID-19) global pandemic, with a reported 200,547 cases between March 8 and May 31, 2020. [1]. Over one fifth of hospitalized patients in NYC were critically ill, many on mechanical ventilation with multi-organ failure requiring prolonged sedation [2] . The Neurology consultation service quickly became an integral part of the care for the many critically ill COVID-19 patients with impaired consciousness. The mechanism of these disorders of consciousness in patients infected by COVID-19 is poorly understood and may be due to multiorgan failure, hypoxia, systemic inflammation, hypercoagulability and possible neuro-invasion [3] . Uncertainty about the trajectory of this novel disease as well as concerns for healthcare worker safety created challenges in relying on standard behavioral, electrophysiological, imaging, and laboratory data that guides diagnostic workup and prognostication in patients with disorders of consciousness. To provide a comprehensive weighing of the rapidly evolving body of evidence in an area of great uncertainty, we instituted a multidisciplinary COVID-19 Coma Board modeled after the tumor board concept [4] . This bi-weekly, secure web-based multidisciplinary conference first met on May 13, 2020 with participants representing neurocritical care, epilepsy, stroke, neuroradiology, neurovascular, neurohospitalist, neuroinfectious disease, rehabilitation medicine, and pharmacology. Data was presented by the consult team using a standardized data collection format (Table 1) . This study was approved by the institutional review board at Columbia University Irving Medical Center. The requirement for written informed consent was waived because of the observational study design involves no more than minimal risk. In our first 8 case discussions, 5 patients were above 60 years old (53%), 3 were women (38%), 4 had episodes of hypoxia (defined as at least one documented arterial blood gas with a PO2 below 55 mmHg), 1 suffered cardiopulmonary arrest, and 7 developed renal failure. The mean days on mechanical ventilation were 40 (+/-21 days), of sedation were 33 (+/-18 days), of treatment with opiates were 39 (+/-23 days), and 6 received neuromuscular blockade (Supplemental Table1). At the time of presentation neurological examination included eye opening (none 1, to pain 3, to voice or spontaneous in 4), pupillary light reflexes were intact in all, and corneal reflexes present in 6. Two patients followed simple verbal commands while the other 6 followed no commands. Five had no motor response, the other 3 each had one with tonic posturing, localization This article is protected by copyright. All rights reserved. to noxious stimulation, and stimulus provoked myoclonus. Three patients had positive urine toxicology for benzodiazepines at time of consultation, 3 had EEGs available (none with seizures or periodic discharges, and all with discontinuous and attenuated background activity). All had CT (N=7) or MRI (N=2) imaging of the brain available demonstrating one patient with diffuse cerebral edema on CT, restricted diffusion and increased T2 signal in the cortex and basal ganglia on MRI, and diffusion restriction in bilateral globus pallidi and cerebral peduncles on MRI. Pharmacological regimens were reviewed and factors contributing to drug accumulation were discussed including drug duration and half-life, organ dysfunction, drug interactions, body weight, and age. This article is protected by copyright. All rights reserved. a platform to share ongoing scientific literature of this novel disease and learn from our multidisciplinary specialists. This format may constitute a blueprint for expert assessments of comatose COVID-19 patients that could be scalable and applicable to broader health care systems in future pandemic surges. Long term recovery increasingly calls into question the self-fulfilling prophecy of early withdrawal of care for patients with acute disorders of consciousness. The science underlying impairment and recovery of consciousness is rapidly accelerating and increasingly complex [5] . The institution of multidisciplinary Coma Boards may serve unconscious patients with or without COVID-19 well beyond the current pandemic. This article is protected by copyright. All rights reserved. Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study Neurological manifestations and complications of COVID-19: A literature review American College of Surgeons Plum and Posner's Diagnosis and Treatment of Stupor and Coma Admission Date 2. Length of stay of current admission 3. Intubation Date 4. Extubation and/or tracheotomy date 5. Paralytics received 6. Sedation medication received 7. Duration (days) hypoxemia 8. Occurrence of cardiac arrest 9 Minimal Neurological Exam by Neurology Consultation Service 1. Level of consciousness • Arousal: eye opening • Command following: 1-step, multi-step, orientation to self, place and time 2. Brainstem function: pupillary light reflex, corneal reflex, occulocephalic reflex Motor Response: to commands, noxious stimuli, tone, reflexes