Environmental safety: Air pollution while using <scp>MIRUS</scp>™ for short‐term sedation in the <scp>ICU</scp>

Herzog-Niescery, Jennifer; Vogelsang, Heike; Gude, Philipp; Seipp, Hans-Martin; Uhl, Waldemar; Weber, Thomas P.; Bellgardt, Martin

doi:10.1111/aas.13222

Cited by 13 publications

(8 citation statements)

References 16 publications

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“…Furthermore, devices to reduce atmospheric VA pollution must be considered. Studies have shown that an air-conditioning with at least six air changes per hour and a scavenging system should be used to reach mean VA concentrations below 1 ppm in the patient room (the National Institute of Occupational Safety and Health has defined an exposure limit of 2 ppm for ISO, SEVO, and DES in the air) [16, 17].…”

Section: Discussionmentioning

confidence: 99%

Use of MIRUS™ for MAC-driven application of isoflurane, sevoflurane, and desflurane in postoperative ICU patients: a randomized controlled trial

Bellgardt

Georgevici

Klutzny

et al. 2019

Ann. Intensive Care

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BackgroundThe MIRUS™ (TIM, Koblenz, Germany) is an electronical gas delivery system, which offers an automated MAC (minimal alveolar concentration)-driven application of isoflurane, sevoflurane, or desflurane, and can be used for sedation in the intensive care unit. We investigated its consumption of volatile anesthetics at 0.5 MAC (primary endpoint) and the corresponding costs. Secondary endpoints were the technical feasibility to reach and control the MAC automatically, the depth of sedation at 0.5 MAC, and awakening times. Mechanically ventilated and sedated patients after major surgery were enrolled. Upon arrival in the intensive care unit, patients obtained intravenous propofol sedation for at least 1 h to collect ventilation and blood gas parameters, before they were switched to inhalational sedation using MIRUS™ with isoflurane, sevoflurane, or desflurane. After a minimum of 2 h, inhalational sedation was stopped, and awakening times were recorded. A multivariate electroencephalogram and the Richmond Agitation Sedation Scale (RASS) were used to assess the depth of sedation. Vital signs, ventilation parameters, gas consumption, MAC, and expiratory gas concentrations were continuously recorded.ResultsThirty patients obtained inhalational sedation for 18:08 [14:46–21:34] [median 1st–3rd quartiles] hours. The MAC was 0.58 [0.50–0.64], resulting in a Narcotrend Index of 37.1 [30.9–42.4] and a RASS of − 3.0 [− 4.0 to (− 3.0)]. The median gas consumption was significantly lowest for isoflurane ([ml h−1]: isoflurane: 3.97 [3.61–5.70]; sevoflurane: 8.91 [6.32–13.76]; and desflurane: 25.88 [20.38–30.82]; p < 0.001). This corresponds to average costs of 0.39 € h−1 for isoflurane, 2.14 € h−1 for sevoflurane, and 7.54 € h−1 for desflurane. Awakening times (eye opening [min]: isoflurane: 9:48 [4:15–20:18]; sevoflurane: 3:45 [0:30–6:30]; desflurane: 2:00 [1:00–6:30]; p = 0.043) and time to extubation ([min]: isoflurane: 10:10 [8:00–20:30]; sevoflurane: 7:30 [4:37–14:22]; desflurane: 3:00 [3:00–6:00]; p = 0.007) were significantly shortest for desflurane.ConclusionsA target-controlled, MAC-driven automated application of volatile anesthetics is technically feasible and enables an adequate depth of sedation. Gas consumption was highest for desflurane, which is also the most expensive volatile anesthetic. Although awakening times were shortest, the actual time saving of a few minutes might be negligible for most patients in the intensive care unit. Thus, using desflurane seems not rational from an economic perspective.Trial registration Clinical Trials Registry (ref.: NCT03860129). Registered 24 September 2018—Retrospectively registered.

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Section: Discussionmentioning

confidence: 99%

Use of MIRUS™ for MAC-driven application of isoflurane, sevoflurane, and desflurane in postoperative ICU patients: a randomized controlled trial

Bellgardt

Georgevici

Klutzny

et al. 2019

Ann. Intensive Care

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“…There are novel devices that have been added to classical ICU ventilators to administer inhaled anesthetics as sedatives, and thus a separate anesthesia machine is not necessary [59]. The effective collection and evacuation of the pollution to the outside atmosphere effectively ensures that the level of indoor contamination during the use of these new technologies remains below the recommended levels [61,62]. Still, careful planning of scavenging and ventilation systems is crucial to prevent excessive occupational exposure.…”

Section: Prevention Of Exposure To Wagsmentioning

confidence: 99%

Inhaled Anesthetics: Environmental Role, Occupational Risk, and Clinical Use

Costa

Kalmar

Struys

2021

JCM

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Inhaled anesthetics have been in clinical use for over 150 years and are still commonly used in daily practice. The initial view of inhaled anesthetics as indispensable for general anesthesia has evolved during the years and, currently, its general use has even been questioned. Beyond the traditional risks inherent to any drug in use, inhaled anesthetics are exceptionally strong greenhouse gases (GHG) and may pose considerable occupational risks. This emphasizes the importance of evaluating and considering its use in clinical practices. Despite the overwhelming scientific evidence of worsening climate changes, control measures are very slowly implemented. Therefore, it is the responsibility of all society sectors, including the health sector to maximally decrease GHG emissions where possible. Within the field of anesthesia, the potential to reduce GHG emissions can be briefly summarized as follows: Stop or avoid the use of nitrous oxide (N2O) and desflurane, consider the use of total intravenous or local-regional anesthesia, invest in the development of new technologies to minimize volatile anesthetics consumption, scavenging systems, and destruction of waste gas. The improved and sustained awareness of the medical community regarding the climate impact of inhaled anesthetics is mandatory to bring change in the current practice.

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“…at the exhalation outlet of the ventilator or at the oxygenator of the ECMO device. The exhalation outlet has the advantage that the gas flow can conduct viral particles and hence reduces the risk of infection for the health care personnel[ 34 , 35 ]. The oxygenator was used initially for intraoperative delivery of the anesthetic gas but modern reflection systems require containment of volatile anesthetics.…”

Section: Consumption Of Volatile Anesthetics In Covid-19 Related Ards Therapy Using Ecmomentioning

confidence: 99%

“…The CleanAir TM system (TIM, Koblenz, Germany) is recommended for gas flow conduction, because it is independent of the reflector (Figure 6 ). It operates well under vacuum, is sealed off the environment, and thus eliminates the risk of disseminating viral particles in the air[ 35 ].…”

Section: Hygiene Measures For Covid-19 Related Ardsmentioning

confidence: 99%

“…Poor air-conditioning in ICUs and inconsistent international limits for anesthetic gas concentrations amplify the problem. The United States National Institute of Occupational Safety and Health defined an exposure limit of 2 ppm for isoflurane, sevoflurane, and desflurane, but other countries use higher exposure limits[ 35 , 38 ]. Most studies on air pollution report gas concentrations of less than 2 ppm while using MIRUS TM or AnaConDa ® systems in mechanically ventilated patients; nonetheless, these studies use an air-conditioning system with at least six air exchanges per hour and a scavenging system ( e.g., vacuum-based open reservoir gas scavenging systems or adsorbers with activated charcoal)[ 35 , 38 , 39 ].…”

Section: Occupational Anesthetic Gas Exposure While Using Ecmo Therapymentioning

confidence: 99%

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Extracorporeal membrane oxygenation and inhaled sedation in coronavirus disease 2019-related acute respiratory distress syndrome

Bellgardt¹,

Özcelik²,

Breuer-Kaiser³

et al. 2021

WJCCM

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Coronavirus disease 2019 (COVID-19) related acute respiratory distress syndrome (ARDS) is a severe complication of infection with severe acute respiratory syndrome coronavirus 2, and the primary cause of death in the current pandemic. Critically ill patients often undergo extracorporeal membrane oxygenation (ECMO) therapy as the last resort over an extended period. ECMO therapy requires sedation of the patient, which is usually achieved by intravenous administration of sedatives. The shortage of intravenous sedative drugs due to the ongoing pandemic, and attempts to improve treatment outcome for COVID-19 patients, drove the application of inhaled sedation as a promising alternative for sedation during ECMO therapy. Administration of volatile anesthetics requires an appropriate delivery. Commercially available ones are the anesthetic gas reflection systems AnaConDa ® and MIRUS TM , and each should be combined with a gas scavenging system. In this review, we describe respiratory management in COVID-19 patients and the procedures for inhaled sedation during ECMO therapy of COVID-19 related ARDS. We focus particularly on the technical details of administration of volatile anesthetics. Furthermore, we describe the advantages of inhaled sedation and volatile anesthetics, and we discuss the limitations as well as the requirements for safe application in the clinical setting.

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Environmental safety: Air pollution while using MIRUS™ for short‐term sedation in the ICU

Cited by 13 publications

References 16 publications

Use of MIRUS™ for MAC-driven application of isoflurane, sevoflurane, and desflurane in postoperative ICU patients: a randomized controlled trial

Use of MIRUS™ for MAC-driven application of isoflurane, sevoflurane, and desflurane in postoperative ICU patients: a randomized controlled trial

Inhaled Anesthetics: Environmental Role, Occupational Risk, and Clinical Use

Extracorporeal membrane oxygenation and inhaled sedation in coronavirus disease 2019-related acute respiratory distress syndrome

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