Sevoflurane in combination with esketamine is an effective sedation regimen in COVID-19 patients enabling assisted spontaneous breathing even during prone positioning

Abstract

Coronavirus disease 2019 (COVID-19) is associated with respiratory impairment by multifocal pneumonitis. The most severe expression, when acute respiratory distress syndrome (ARDS) is present, is termed CARDS (COVID-19-ARDS). Prolonged prone positioning (PP) is an established treatment for patients with ARDS [1][2][3][4]. PP provides various effects leading to pulmonary recruitment and improvement of oxygenation [3].Most patients require analgesia and sedation to tolerate prolonged PP. Even in the supine position control of dyspnoea when applying "lung protective" ventilation parameters is facilitated and may result in desperate "air hunger" in COVID-19 patients [5].

Ventilatory Effects of Isoflurane Sedation via the Sedaconda ACD-S versus ACD-L: A Substudy of a Randomized Trial

“…We assume that the difference in volatile anesthetic consumption will become more apparent within higher ranges of tidal volumes [14]. As previously shown in L-type COVID-19 patients (high compliance, high tidal volumes, and high minute ventilation), volatile anesthetic reflection with the ACD-S may gradually become insufficient when tidal volumes exceed 800 mL and the less potent drug sevoflurane is used [23]. In addition, since the relative contribution to ventilatory dead space is less in patients with high tidal volumes, carbon dioxide rebreathing is less of a problem.…”

“…Inhaled sedation may offer several benefits for the treatment of patients suffering from acute respiratory distress syndrome (ARDS) including decreased airway resistance [20], adequate sedation depths needed for prone positioning or continuous lateral rotation [21][22][23], better maintenance of spontaneous breathing [24,25], anti-inflammatory properties [26,27], less epithelial lung injury, and improved oxygenation [28]. On the other hand, use of anesthetic conserving devices in ARDS patients was previously questioned for low tidal volume ventilation due to the larger ventilatory dead space causing higher ventilatory demands [11].…”

Sedation with Sevoflurane versus Propofol in COVID-19 Patients with Acute Respiratory Distress Syndrome: Results from a Randomized Clinical Trial

“…Few studies registered on the ICH GCP website include objectives regarding the study of sevoflurane in patients with moderate to severe ARDS diagnoses. Even so, volatile agents (sevoflurane and isoflurane) are used as alternatives to intravenous sedation in ICUs by an increasing number of physicians [ 51 ] as monotherapy or as part of a combined therapy [ 52 ]. There are some detractors because of volatile agents’ potential adverse events [ 53 ], but there is relevant literature that supports their feasibility and safety of use, without the risk of tolerance or effects on renal or liver function [ 30 , 34 , 45 , 54 , 55 ].…”

Pregnant women with COVID-19 ARDS on the intensive care unit

“…Bereits 1998 berichteten Chambers et al über einen teratogenen Effekt von Fie-ber in der Frühschwangerschaft [38]. Dreier et al beschrieben ein erhöhtes Risiko für das Auftreten von Neuralrohrdefekten, Herzfehlern und Lippen-Kiefer-Gaumen-Spalten [39]. Andere Autoren erwähnen auch ein erhöhtes Risiko für das Auftreten von atrioventrikulären Septumdefekten, rechtsseitigen obstruktiven Läsionen, Trikuspidalatresie oder Transposition der großen Arterien aufgrund von Fieber während der Schwangerschaft [36].…”

“…Vor Verbringen in die Bauchlage wurde eine inhalative Sedierung mit Sevofluran begonnen, idealerweise unter Aufrechterhaltung der assistierten Spontanatmung bis zum Erreichen eines RAAS von −4. Mit diesem Vorgehen hatten wir bei der Behandlung von Patientinnen und Patienten mit CARDS gute Erfahrungen gemacht, und das Behandlungsteam war mit der Methode vertraut [ 39 ]. Die 16-stündige Bauchlagerungstherapie wurde im direkten Wechsel mit sitzender Position in einem Mobilisationsstuhl (Mobilizer® NORBERT [Reha & Medi Hoffmann GmbH, Leipzig, Deutschland]), der für den Transfer in eine horizontale Position gebracht werden konnte, durchgeführt, sodass eine längere flache Rückenlage weitestgehend vermieden wurde.…”