How to Manage Withdrawal of Sedation and Analgesia in Mechanically Ventilated COVID-19 Patients?

Abstract

COVID-19 patients suffering from severe acute respiratory distress syndrome (ARDS) require mechanical ventilation (MV) for respiratory failure. To achieve these ventilatory goals, it has been observed that COVID-19 patients in particular require high regimens and prolonged use of sedatives, analgesics and neuromuscular blocking agents (NMBA). Withdrawal from analgo-sedation may induce a “drug withdrawal syndrome” (DWS), i.e., clinical symptoms of anxiety, tremor, agitation, hallucinations and vomiting, as a result of adrenergic activation and hyperalgesia. We describe the epidemiology, mechanisms leading to this syndrome and our strategies to prevent and treat it.

Risk Factors Associated With Opioid/Benzodiazepine Iatrogenic Withdrawal Syndrome in COVID-19 Acute Respiratory Distress Syndrome

“…Despite current recommendations, deviations in sedation practices in COVID-19 patients across many ICUs have been reported. [1][2][3][4][5] While sedative/analgesic overuse in COVID-19 ARDS patients and its potential for development of IWS have been well-described by previous authors, 7,8 this is the first study to assess potential risk factors associated with iatrogenic opioid/ benzodiazepine withdrawal in COVID-19 patients to our knowledge.…”

“… 1 - 5 These increased exposures may also place patients at greater risk for development of iatrogenic withdrawal syndrome (IWS), as repeated and sustained administration of opioids and/or benzodiazepines (BZDs) can result in reduced sensitivity and increased tolerance. 6 - 8 Development of IWS in the critically ill has been associated with worse patient outcomes, such as longer intensive care unit (ICU) and hospital length of stay (LOS), longer duration of mechanical ventilation (MV), and increased risk of delirium. 2 , 9 , 10 Current practice guidelines on ICU analgesia and sedation recommend light sedation targets with a focus on pain-management, minimization of BZD use, and regular sedation assessments.…”

Neurorecovery after Critical COVID-19 Illness

“…Many COVID-19 ICU patients require high and prolonged amounts of sedatives, analgesics, and neuromuscular blocking agents to achieve lung protective ventilation in the setting of ARDS. 92 These medications should be minimized as much as possible to allow for serial neurologic examinations, which are important to allow monitoring for neurologic complications. Neurology consultation should be sought if there is suspicion of a new neurologic syndrome.…”

Avoiding, Not Managing, Drug Withdrawal Syndrome in the Setting of COVID-19 Acute Respiratory Distress Syndrome. Comment on Ego et al. How to Manage Withdrawal of Sedation and Analgesia in Mechanically Ventilated COVID-19 Patients? J. Clin. Med. 2021, 10, 4917

“…The management of sedation in the setting of COVID-19 (“COVID”) by Ego et al [ 1 ] does not combine pathophysiology and pharmacology. Their premise rests on « decreasing the work of breathing, applying lung protective ventilation and limiting asynchronies [to] minimize the risk of ventilator-induced lung injury (VILI)……COVID-19 patients require high [doses] of sedatives, analgesics and neuromuscular blocking agents (NMBA)……frequently for more than 7 days » [ 1 ]. Ego manages the drug withdrawal syndrome but does not avoid it.…”

“…Spontaneous breathing avoids ventilator-induced lung injury. First-line, high-dose alpha-2 agonists combined to low normal temperature and normalized inflammation do not lead to « high regimen and prolonged use of sedative, analgesics and neuromuscular agents » [ 1 ]. In our hands [ 3 ], breaking up the SILI is achieved within 2 days with a low toll (mortality: 8.5% [ 3 ]), at variance with general anesthesia, paralysis and proning for weeks with critical care clogging and societal consequences.…”