Inhaled Sedation with Volatile Anesthetics for Mechanically Ventilated Patients in Intensive Care Units: A Narrative Review

Abstract

Inhaled sedation was recently approved in Europe as an alternative to intravenous sedative drugs for intensive care unit (ICU) sedation. The aim of this narrative review was to summarize the available data from the literature published between 2005 and 2023 in terms of the efficacy, safety, and potential clinical benefits of inhaled sedation for ICU mechanically ventilated patients. The results indicated that inhaled sedation reduces the time to extubation and weaning from mechanical ventilation and reduces opioid and muscle relaxant consumption, thereby possibly enhancing recovery. Several researchers have reported its potential cardio-protective, anti-inflammatory or bronchodilator properties, alongside its minimal metabolism by the liver and kidney. The reflection devices used with inhaled sedation may increase the instrumental dead space volume and could lead to hypercapnia if the ventilator settings are not optimal and the end tidal carbon dioxide is not monitored. The risk of air pollution can be prevented by the adequate scavenging of the expired gases. Minimizing atmospheric pollution can be achieved through the judicious use of the inhalation sedation for selected groups of ICU patients, where the benefits are maximized compared to intravenous sedation. Very rarely, inhaled sedation can induce malignant hyperthermia, which prompts urgent diagnosis and treatment by the ICU staff. Overall, there is growing evidence to support the benefits of inhaled sedation as an alternative for intravenous sedation in ICU mechanically ventilated patients. The indication and management of any side effects should be clearly set and protocolized by each ICU. More randomized controlled trials (RCTs) are still required to investigate whether inhaled sedation should be prioritized over the current practice of intravenous sedation.

Influence of Sevoflurane on the Neurological Pupil Index in Surgical and Critically Ill Patients: A Pilot Study

“…However, it is important to consider that a decrease in NPi values could also be influenced by the interaction of sevoflurane with rocuronium and sufentanil on pupillary function [ 19 , 20 ]. The use of inhaled anesthetics in critically ill patients remains relatively rare [ 21 ], although it has been an area of interest in recent years because of several potential advantages, including its rapid onset and offset of action, minimal metabolism in the body, and low potential for hepatic and renal toxicity [ 22 ]. One potential benefit of using inhaled sevoflurane in this patient population is its bronchodilator effect, which can help improve oxygenation and decrease airway resistance, such as in severe asthma [ 23 ].…”

“…Moreover, in patients suffering from acute respiratory distress syndrome, the use of inhaled sevoflurane improved oxygenation and decreased the levels of a marker of epithelial injury and inflammation when compared to midazolam [ 26 ]. However, the use of inhaled anesthetics can also contribute to the development of hypercapnia in some cases, which occurs due to the dead space resulting from the delivery device, air pollution, requiring the implementation of a dedicated scavenging system, and, although less commonly, the occurrence of malignant hyperthermia and diabetes insipidus [ 22 ]. Together with altered NPi values, these findings indicate the potential benefits of utilizing inhaled sevoflurane in critically ill patients; however, the administration of sevoflurane should be tailored to each patient and carefully evaluated through a comprehensive assessment of the associated risks and benefits.…”

Real Evidence and Misconceptions about Malignant Hyperthermia in Children: A Narrative Review

“…Another unusual situation at risk of MH is sedation with inhaled anesthetics in the pediatric intensive care unit (PICU) [ 66 , 67 , 68 ]. If these types of sedation devices are used, children susceptible to MH in the PICU may be at risk for such exposure, highlighting the significance of MH differential diagnosis in intensive care patients admitted for other conditions [ 69 ].…”

Sedation for Patients with Sepsis: Towards a Personalised Approach

“…Currently, there are several devices available that would allow the administration of volatile anaesthetics in ICUs: Sedaconda ® (Sedaconda-ACD. Sedana Medical, Danderyd, Sweden) and the MIRUS ® system (Pall Medical, Dreieich, Germany) [45]. Both devices use a so-called reflector to enable the re-use of exhaled anaesthetic in the subsequent inspiration cycle.…”