Evidence-based management of analgesia and sedation in COVID-19-associated acute respiratory distress syndrome remains limited. Non-guideline recommended analgesic and sedative medication regimens and deeper sedation targets have been employed for patients with COVID-19 due to exaggerated analgesia and sedation requirements with extended durations of mechanical ventilation. This, coupled with a desire to minimize nurse entry into COVID-19 patient rooms, marked obesity, altered end-organ function, and evolving medication shortages, presents numerous short-and long-term challenges. Alternative analgesic and sedative agents and regimens may pose safety risks and require judicious bedside management for appropriate use. The purpose of this commentary is to provide considerations and solutions for designing safe and effective analgesia and sedation strategies for adult patients with considerable ventilator dyssynchrony and sedation requirements, such as COVID-19.

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Ivermectin has been found to inhibit severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) replication in vitro. It is unknown whether this inhibition of SARS‐CoV‐2 replication correlates with improved clinical outcomes. To assess the effectiveness and safety of ivermectin in hospitalized patients with COVID‐19. A total of 286 patients with COVID‐19 were included in the study. Univariate analysis of the primary mortality outcome and comparisons between treatment groups were determined. Logistic regression and propensity score matching (PSM) was used to adjust for confounders. Patients in the ivermectin group received 2 doses of Ivermectin at 200 μg/kg in addition to usual clinical care on hospital Days 1 and 3. The ivermectin group had a significantly higher length of hospital stay than the control group; however, this significance did not maintain on multivariable logistic regression analysis. The length of intensive care unit (ICU) stay and duration of mechanical ventilation were longer in the control group. However, a mortality benefit was not seen with ivermectin treatment before and after PSM (p values = 0.07 and 0.11, respectively). ICU admission, and intubation rate were not significantly different between the groups (p = 0.49, and p = 1.0, respectively). No differences were found between groups regarding the length of hospital stay, ICU admission, intubation rate, and in‐hospital mortality.

Data regarding the use of corticosteroids for treatment of acute respiratory distress syndrome (ARDS) are conflicting. As the coronavirus disease 2019 (COVID-19) pandemic progresses, more literature supporting the use of corticosteroids for COVID-19 and non-COVID-19 ARDS have emerged. Glucocorticoids are proposed to attenuate the inflammatory response and prevent progression to the fibroproliferative phase of ARDS through their multiple mechanisms and anti-inflammatory properties. The purpose of this systematic review was to comprehensively evaluate the literature surrounding corticosteroid use in ARDS (non-COVID-19 and COVID-19) in addition to a narrative review of clinical considerations of corticosteroid use in these patient populations. OVID Medline and EMBASE were searched. Randomized controlled trials evaluating the use of corticosteroids for COVID-19 and non-COVID-19 ARDS in adult patients on mortality outcomes were included. Risk of bias was assessed withthe Risk of Bias 2.0 tool. There were 388 studies identified, 15 of which met the inclusion criteria that included a total of 8877 patients. The studies included in our review reported a mortality benefit in 6/15 (40%) studies with benefit being seen at varying time points of mortality follow-up (ICU survival, hospital, and 28 and 60 days) in the COVID-19 and non-COVID-19 ARDS studies. The two non-COVID19 trials assessing lung injury score improvements found that corticosteroids led to significant improvements with corticosteroid use. The number of mechanical ventilation-free days significantly were found to be increased with the use of corticosteroids in all four studies that assessed this outcome. Corticosteroids are associated with improvements in mortality and ventilator-free days in critically ill patients with both COVID-19 and non-COVID-19 ARDS, and evidence suggests their use should be encouraged in these settings. However, due to substantial differences in the corticosteroid regimens utilized in these trials, questions still remain regarding the optimal corticosteroid agent, dose, and duration in patients with ARDS.

The classic presentation of nephrolithiasis is renal colic. 1 The goal of pharmacotherapy is to provide safe and effective pain relief. 2 Typical analgesics used include nonsteroidal anti-inflammatory drugs (NSAIDs) or opioids; however, in scenarios where these medications are not viable options, alternatives are limited. 1 We present a case on the use of lidocaine for renal colic. JA was a 29-year-old Hispanic male (weight: 104 kg, height: 180 cm) who presented to the ED via taxi with rightsided flank pain. Initial vitals included temperature 98.1°F, pulse 56 beats/min, blood pressure 137/84 mm Hg, respiratory rate 21 breaths/min, and oxygen saturation 98% on room air. The severity of pain was rated as 10/10 (10 = severe). It was described as sharp shooting and radiated from the back to the testes. JA's past medical history included asthma, and his home medication included albuterol 1 to 2 puffs inhaled by mouth as needed. Also, 7 days prior to his presentation, JA was diagnosed with a 3-mm nephrolithiasis at another institution. He was prescribed oxycodone/acetaminophen 5/325 mg every 4 to 6 hours for pain and tamsulosin 0.4 mg once daily for passing of the stone. On each day during the 7-day period, JA consumed 12 tablets of oxycodone/acetaminophen and 1 capsule of tamsulosin. No adjunctive analgesics or nonpharmacological therapies were used. Over the past 2 days, he had experienced increasing episodes of pain, nausea, and vomiting. JA had also noted small traces of blood in his vomit, raising suspicion for a gastrointestinal injury. On physical examination, all parameters were within normal limits except for right lower quadrant tenderness. Initial laboratory results were also within normal limits. Because JA did not respond to outpatient pain therapy, reported of blood in his vomit, and did not have a past history of cardiovascular or liver disease, a decision was made to initiate lidocaine at 1.5 mg/ kg/dose (total dose 150 mg) IV piggyback over 20 minutes for pain. No analgesics were provided prior to the use of lidocaine. JA's pain was assessed with the Visual Analogue Scale. At baseline, his pain score was 10/10; 10 minutes after lidocaine was administered, the pain score decreased to 4/10. At 20 minutes, the pain score was 3/10, and at 30 minutes, it decreased to 2/10. No abnormalities in his vitals or cardiac rhythm were observed. No adverse events were reported. At 45 minutes after initial drug administration, JA