Sedation in mechanically ventilated covid-19 patients: A narrative review for emergency medicine providers

Keswani, Meghana; Mehta, Nikita; Mazer‐Amirshahi, Maryann; Tran, Quincy; Pourmand, Ali

doi:10.1016/j.ajem.2021.05.030

Cited by 4 publications

(3 citation statements)

References 20 publications

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“…When data from both sites were combined, there was no statistically significant difference in terms of RASS scores before versus during the pandemic; the analysis by site showed a larger proportion of patients at the Mayo Clinic had out-of-range RASS scores making them ineligible. Overall, there had been a trend towards deeper sedation for COVID-related acute respiratory distress syndrome (ARDS) patients to avoid ventilator dyssynchrony expecting better outcomes [ 14 , 15 ]. However, results from a cohort study comparing outcomes based on level of sedation demonstrated that deeper sedation was independently linked to worse outcomes [ 16 ].…”

Section: Discussionmentioning

confidence: 99%

The impact of the COVID-19 pandemic on ICU clinical trials: a description of one research team’s experience

Chlan

Tracy

Ask

et al. 2023

Trials

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Background Disruptions to clinical trials conducted in the intensive care unit (ICU) due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2; coronavirus disease 2019 [COVID-19]) pandemic included fewer new trials activated and more trials stopped. While a number of ongoing, non-COVID-19 clinical trials remained open to enrollment, the direct impact of the pandemic on ICUs instilled chaos in this already challenging environment. The numerous challenges need to be reported so investigators can proactively plan and manage these myriad challenges. Thus, the purpose of this study was to describe the impact of the COVID-19 pandemic on screening and accrual for a non-COVID-19 parent clinical trial enrolling critically ill ICU patients receiving mechanical ventilatory support. Methods A descriptive, retrospective design using quantitative data from detailed screening logs and qualitative observations with field notes from a parent clinical trial were used to address the objectives. The primary aims of the two-site parent clinical trial (n = 190) are to test the efficacy of self-administration of sedative therapy by mechanically ventilated ICU patients on anxiety and delirium occurrence. ICUs from two academic medical centers [names removed for blinding] plus a community hospital in Minnesota were screened daily for alert patients (Richmond Agitation Sedation Scale [RASS] − 2 to + 1), following commands, hemodynamically stable with sufficient hand grip strength to depress a push-button device. Screening data were summarized based on the primary reason patients were not enrolled (screen failures, declinations of consent). Descriptive statistics (frequencies, percentages), chi-square, and Fisher’s Exact test were used to describe the data and to determine any differences among distributions of screening failures and recruitment declinations during the defined pre-pandemic (August 27, 2018–March 15, 2020, 2976 screened patients) and pandemic timeframes (March 16, 2020–February 28, 2022, 3912 screened patients). Qualitative data from varied sources such as screening logs, institutional email communications, staff field notes, and research team meeting minutes were summarized into themes. Results Despite significantly fewer screen failures due to hypotension, cognitive impairment/dementia, coma, or chemical paralysis with 938 additional patients on the screening log, more were accrued pre-pandemic (n = 55) than during the pandemic period (n = 45); declination reasons were non-significant. Pandemic burdens experienced by study personnel, ICU care providers, and patients/families were revealed that attributed to decreased accrual. Conclusions While the parent clinical trial remained opened, cumulative factors adversely impacted the trial during the pandemic period with fewer patients accrued. The human toll of the pandemic on research staff, clinicians, and patients/family members demands that investigators be proactive in managing these challenges to conduct ICU clinical trials successfully, including careful oversight of human and financial resources. Trial registration ClinicalTrials.gov NCT#02,819,141 Registered 29 June 2016.

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Section: Discussionmentioning

confidence: 99%

The impact of the COVID-19 pandemic on ICU clinical trials: a description of one research team’s experience

Chlan

Tracy

Ask

et al. 2023

Trials

View full text Add to dashboard Cite

show abstract

“…There has been growing evidence that the impact of COVID-19 on sedation practices has resulted in both positive and negative effects on patient outcomes [ 6 , 7 ]. On one hand, the reduction in the use of deep sedation has been shown to decrease the risk of adverse events such as respiratory depression and aspiration and reduce the need for intensive care unit admissions [ 8 , 9 ].…”

Section: Methodsmentioning

confidence: 99%

Up-to-date literature review and issues of sedation during digestive endoscopy.

Liu¹,

Zhang²

2023

Videosurgery and Other Miniinvasive Techniques

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Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

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“…Prolonged ICU stays and the use of mechanical ventilation along with deep sedation in COVID-19 patients has prompted concerns about PRIS in this population. 5 This case reports an unusual case of PRIS in a patient with severe COVID-19 pneumonia.…”

Section: Introductionmentioning

confidence: 91%

Unusual case of propofol-related infusion syndrome complicating severe COVID-19 ARDS

et al. 2023

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An elderly man presenting with shortness of breath and hypoxaemia was admitted with acute hypoxic respiratory failure secondary to COVID-19 pneumonia. Due to worsening hypoxaemia, he was transferred to the intensive care unit and required mechanical ventilation. Propofol was infused at 1.5–4 mg/kg/hour. Within 48 hours of initiation, we noticed worsening metabolic acidosis, acute kidney injury, hyperkalaemia, hyperphosphataemia, hypertriglyceridaemia, elevated creatine kinase and elevated myoglobin levels. Suspecting propofol-related infusion syndrome (PRIS), we discontinued his propofol infusion immediately and initiated supportive measures. In 48 hours, there was a significant improvement in metabolic acidosis, hypertriglyceridaemia, rhabdomyolysis and renal function. The propofol infusion rate and cumulative propofol dosage (under 140 mg/kg) were well below levels associated with PRIS. COVID-19’s pathogenesis, still under investigation, may have contributed to this presentation. It is imperative for clinicians to maintain a high degree of suspicion once propofol is initiated, regardless of the cumulative dose or rate of infusion.

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Sedation in mechanically ventilated covid-19 patients: A narrative review for emergency medicine providers

Cited by 4 publications

References 20 publications

The impact of the COVID-19 pandemic on ICU clinical trials: a description of one research team’s experience

The impact of the COVID-19 pandemic on ICU clinical trials: a description of one research team’s experience

Up-to-date literature review and issues of sedation during digestive endoscopy.

Unusual case of propofol-related infusion syndrome complicating severe COVID-19 ARDS

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