Sedation Usage in COVID-19 Acute Respiratory Distress Syndrome: A Multicenter Study

Abstract

Background Patients with COVID-19 acute respiratory distress syndrome (ARDS) have been shown to have high sedation requirements. Objective The purpose of this study was to compare sedative use between patients with COVID-19 ARDS and non-COVID-19 ARDS. Methods This was a retrospective study of patients with COVID-19 ARDS compared with historical controls of non-COVID-19 ARDS who were admitted to 2 hospitals from March 1, 2020, to April 30, 2020, and April 1, 2018, to December 31, 2019, respectively. The primary outcome was median cumulative dose of propofol (µg/kg) at 24 hours after intubation. Results There were 92 patients with COVID-19 ARDS and 37 patients with non-COVID-19 ARDS included. Within the first 24 hours of intubation, patients with COVID-19 ARDS required higher total median doses of propofol: 51 045 µg/kg (interquartile range, 26 150-62 365 µg/kg) versus 33 350 µg/kg (9632-51 455 µg/kg; P = 0.004). COVID-19 patients were more likely receive intravenous lorazepam (37% vs 14%; P = 0.02) and higher cumulative median doses of midazolam by days 5 (14 vs 4 mg; P = 0.04) and 7 of intubation (89 vs 4 mg; P = 0.03) to achieve the same median Richmond Analgesia-Sedation Scale scores. COVID-19 ARDS patients required more ventilator days (10 vs 6 days; P = 0.02). There was no difference in 30-day mortality. Conclusion and Relevance Patients with COVID-19 ARDS required higher doses of propofol and benzodiazepines than patients with non-COVID-19 ARDS to achieve the same median levels of sedation.

Use of Sedatives and Neuromuscular-Blocking Agents in Mechanically Ventilated Patients with COVID-19 ARDS

“…These findings were consistent with three previous studies [6,11,12], which reported an increased need of sedative drugs in COVID-19 ARDS patients when compared to non-COVID patients; however, study groups were not comparable (i.e., different characteristics and severity; unmatched cohorts) and the control non-COVID group could not reflect the actual management of ARDS patients on MV [11]. Our findings might have some important implications for clinical practice: (a) sedation protocols, which are often based on one single drug, should be revised in COVID-19 patients with ARDS on MV (i.e., more combination therapy) to obtain the same level of sedation than in non-COVID ARDS patients; (b) if NMBAs are more frequently administered, the risk for long-term complications (i.e., ICUacquired weakness) should be carefully evaluated; (c) the high afflux of patients and the requirement for increased doses and prolonged duration of sedatives and NMBAs might result in limited drug availability and might result in significant organizational issues for drug supply and stockage during the pandemic.…”

“…Whether COVID-19 ARDS patients receive different sedation strategies to non-COVID ARDS patients remains poorly described. In one study [6], 92 patients with COVID-19 related ARDS required higher total median doses of propofol and were more likely receive intravenous lorazepam than 37 non-COVID ARDS patients; however, the two study groups were significantly unbalanced for several important variables and it remains difficult to conclude whether these differences in sedation requirement were due to COVID-19 or patients' characteristics. Similarly, neuromuscular blocking agents (NMBA) have been largely used in COVID-19 patients with severe respiratory impairment on mechanical ventilation [7]; however, limited data exist to assess whether NMBA requirements would be higher in COVID-19 and other patients.…”

A dual-center cohort study on the association between early deep sedation and clinical outcomes in mechanically ventilated patients during the COVID-19 pandemic: The COVID-SED study

“…The occurrence rate of 72.4% of early deep sedation is also higher than that seen in recent pre-COVID publications and further highlights the rapidly adopted changes in sedation practice that occurred with the COVID pandemic [ 17 , 19 ]. These findings are consistent with prior reports that documented high sedative and neuromuscular blockade use in COVID patients[ 20 , 21 , 36 – 39 ]. Further, our findings highlight the static nature in the approach to sedation in the early deep sedation group: (1) > 50% experienced deep sedation throughout the first week of mechanical ventilation; and (2) 33% were deeply sedated until death.…”

Impact of Early Tracheostomy on Weaning From Ventilation and Sedation in COVID-19 Pregnant and Early Postpartum Patient: Two Case Reports

“…The recommendations for analgesia/sedation in mechanically ventilated pregnant patients are generally similar to nonpregnant individuals [7]. Many intubated patients with severe COVID-19 infection require high doses of analgesia/sedation with or without a neuromuscular blocking agent (NMBA) [8]. This usually increases the risk of delirium and impacts weaning from ventilation, length of stay, mortality, and costs [9][10][11].…”