Standard Sedation and Sedation With Isoflurane in Mechanically Ventilated Patients With Coronavirus Disease 2019

Abstract

Objectives: To describe sedative and analgesic drug utilization in a cohort of critically ill patients with coronavirus disease 2019 and compare standard sedation with an alternative approach using inhaled isoflurane. Design: This was a retrospective cohort study designed to compare doses of sedatives between ICU patients receiving standard IV sedation and patients receiving mixed sedation including inhaled isoflurane. Data were obtained from electronic medical records. Setting: ICU at large academic medical center where mechanical ventilation was delivered with Draeger Apollo (Draeger Medical, Telford, PA) anesthesia machines. Patients: Consecutive adult patients (≥ 18 yr) with confirmed coronavirus disease 2019 admitted to ICU between April 2, 2020, and May 4, 2020. Interventions: None. Measurements and Main Results: Thirty-five mechanically ventilated patients were included in the study, with a mean ( sd ) age of 59.4 (12.8) years. Twenty-three patients (65.7%) were men. Seventeen patients (48.6%) received standard IV sedation, whereas 18 (51.4%) also received isoflurane. The mean duration of mechanical ventilation ( sd ) was 23.3 (11.6) days in the standard sedation group and 23.8 (12.5) days in the isoflurane group. Mean ( sd ) duration of isoflurane exposure was 5.61 (2.99) days, representing 29.1% of total sedation time ( sd , 20.4). Cumulative opioid exposure did not differ between the standard sedation and isoflurane sedation groups (mean morphine milligram equivalent 6668 [ sd , 1,346] vs 6678 [ sd , 2,000] mg). However, the initiation of isoflurane in patients was associated with decreased utilization of propofol (mean daily amount 3,656 [ sd , 1,635] before vs 950 [ sd , 1,804] mg during isoflurane) and hydromorphone (mean daily amount 48 [ sd , 30] before vs 23 [ sd , 27] mg). Conclusions: In the subjects that received isoflurane, its use was associated with significant decreases in propofol and hydromorphone infusions.

Inhaled Sedation in Patients with COVID-19-Related Acute Respiratory Distress Syndrome: An International Retrospective Study

“…In our study, inhaled sedation was not associated with improved oxygenation, in contrast to previous reports in patients without [19] and with COVID-19, [33][34][35] and our longitudinal analyses suggested a potential increase in the partial pressure of arterial carbon dioxide and dynamic inspiratory plateau pressure with inhaled sedation. However, there was no strict protocol for mechanical ventilation in our study, and time × group interactions were only significant on day 5 for carbon dioxide and on day 0 for plateau pressure, which is inconsistent with the available evidence in non-COVID-19 and COVID-19 patients [9,[23][24][25][33][34][35][36].…”

“…They also support the efficacy of volatile anesthetics for ICU sedation, as recently confirmed by a large phase 3, randomized controlled non-inferiority trial of isoflurane vs. propofol in critically ill patients without COVID-19 [25]. In that trial, as in other studies, [19,22,24] volatile anesthetics were efficacious as the sole sedatives in non-COVID-19 patients and significantly reduced the requirement for other sedative and opioid agents in COVID-19 patients [9,[33][34][35]. Consistent with these findings, the use of inhaled sedation was associated with shorter durations of intravenous sedation (regression coefficient: −0.43; Table 4) in our study.…”

Associated Factors of High Sedative Requirements within Patients with Moderate to Severe COVID-19 ARDS

“…This was reflected by both unusually high dosages and the frequent need for a combined use of sedatives [13,14]. In addition, various research groups described the use of volatile sedatives to enable patient-adapted therapy [14,15]. These results were also confirmed by a comparison with non-CARDS patients [16].…”

Computational pharmacology: New avenues for COVID-19 therapeutics search and better preparedness for future pandemic crises

“…2 ). These drugs are used in anaesthesia protocols for patients requiring mechanical ventilation and prolonged, deep sedation to optimize oxygenation and ventilation during respiratory failure from COVID-19 [ [72] , [73] , [74] , [75] ]⁠. Analgesia drugs also form a cluster through their shared action on PTGS1 and PTGS2, also known as cyclooxygenase 1 and cyclooxygenase 2 [ 76 ]⁠.…”