The Oxford English dictionary defines comatose as, “of or in a state of deep unconsciousness for a prolonged or indefinite period, especially as a result of severe injury or illness” [1]. Patients can become comatose for a number of different reasons, including but not limited to head trauma, stroke, tumors, seizures, ingestion of toxins, infections, or cerebral hypoxia. It is believed that comatose individuals have lost their ability to perceive their surroundings and perform higher-level thinking; this is why such patients are often described as being in a “persistent vegetative state.” However, lower-level cognitive functions, such as circadian rhythm and breathing, may remain intact [2]. For this reason, comatose patients are far from being dead, and in fact can be maintained in a stable state for extended periods of time with the proper medical care. On average, patients remain in a coma between two to four weeks; however, in rare cases, the comatose period may be prolonged for months [2].
Due to their inhibited cognitive state and unique needs, comatose patients require attentive care and management. In cases where it is conducive to the patient’s care (i.e., for patients in a non-medically induced coma), reversal of the comatose state remains the caring physician’s top priority. A number of different assessments may be made to determine the cause of the coma: for example, pertinent biomarkers, intracranial pressure, and presence of brain trauma. By appropriately treating the underlying issue with neurosurgery, adjustment of laboratory abnormalities, or administration of an antidote, it may be possible to bring the patient back to a conscious state.
Long-term comatose patients remain in intensive care until they either return to consciousness or require other acute interventions. In the ICU, these patients may receive active monitoring by a neurointensivist, whose main role is to care for individuals with neurocritical conditions. Often times, the neurointensivist will take charge when it comes to coordinating the patient’s care with other physicians. A large part of caring for the comatose patient involves fulfilling basic bodily needs. Patients may receive liquid food through a nasogastric tube, thus bypassing the need for chewing and swallowing by delivering both nutrition and hydration directly to the stomach. A ventilator is used to maintain proper blood oxygen levels. Urine waste can be drained from the patient using a catheter. Given that comatose patients are unable to communicate with their care providers, special attention must be taken to ensure that homeostasis is maintained. Additionally, frequent brain imaging is often performed in order to monitor cognitive developments [3].
One of the top priorities in caring for the comatose patient is mitigating the complications that can arise from prolonged intubation and immobility, including ulceration, subglottic edema, tracheal and laryngeal stenosis [4]. or pressure ulcers, pneumonia, deep vein thrombosis, and urinary tract infections, respectively [5]. It is estimated that approximately 13 percent of patients experience major complications associated with long-term immobility [5]. Moreover, prolonged ventilation is associated with a 52 percent one-year mortality rate [6]. Given the frequency and severity of these complications, it is crucial that providers frequently monitor comatose patients in order to mitigate these challenges.
References
1 Oxford English Languages. (n.d.). Comatose. Retrieved from https://languages.oup.com/google-dictionary-en/
2 “Coma Information Page.” National Institute of Neurological Disorders and Stroke, U.S. Department of Health and Human Services, https://www.ninds.nih.gov/Disorders/All-Disorders/Coma-Information-Page.
3 Haupt, W. F., Hansen, H. C., Janzen, R. W., Firsching, R., & Galldiks, N. (2015). Coma and cerebral imaging. SpringerPlus, 4, 180. https://doi.org/10.1186/s40064-015-0869-y
4 Sue, R. D., & Susanto, I. (2003). Long-term complications of artificial airways. Clinics in chest medicine, 24(3), 457–471. https://doi.org/10.1016/s0272-5231(03)00048-0
5 Wu, X., Li, Z., Cao, J., Jiao, J., Wang, Y., Liu, G., Liu, Y., Li, F., Song, B., Jin, J., Liu, Y., Wen, X., Cheng, S., & Wan, X. (2018). The association between major complications of immobility during hospitalization and quality of life among bedridden patients: A 3-month prospective multi-center study. PLOS ONE, 13(10), e0205729. https://doi.org/10.1371/journal.pone.0205729
6 Scheinhorn, D. J., Hassenpflug, M. S., Votto, J. J., Chao, D. C., Epstein, S. K., Doig, G. S., Knight, E. B., Petrak, R. A., & Ventilation Outcomes Study Group (2007). Post-ICU mechanical ventilation at 23 long-term care hospitals: a multicenter outcomes study. Chest, 131(1), 85–93. https://doi.org/10.1378/chest.06-1081
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