Analgesia and Sedation Strategies in Mechanically Ventilated Adults with COVID‐19

Abstract

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.

Approach to Sedation and Analgesia in COVID-19 Patients on Venovenous Extracorporeal Membrane Oxygenation

“…Although analgosedation principles remain the first-line management strategy, COVID-19 patients who have progressed to moderate to severe ARDS generally require significant amounts of additional sedative agents to maintain adequate ventilator synchrony and oxygenation. 1 The addition of paralytics to enhance ventilator synchrony may also increase sedation requirements and multiple agents are typically required to achieve appropriate sedation goals in these patients.…”

“…Although benzodiazepines are no longer first-line sedation agents given their safety profile, in the setting of COVID-19 ARDS, many of these agents have seen increased utilization for patients requiring heavy sedation. 1,20 Multiple retrospective analyses have demonstrated up to 50% drug loss in ECMO circuitry and significantly increased midazolam requirements despite concomitant administration of a variety of other nonbenzodiazepine sedative agents. 6,17,25 When adjusted for lower sedation goals in patients utilizing ECMO as a bridge to transplantation, a more recent retrospective study of sedation in ECMO also found similar results.…”

Analgesia and Sedation in Critically Ill Adult Patients Admitted to a COVID-19 Intensive Care Unit

“…Also, the increased use of sedatives, impact of the pandemic on manufacturing, supply chain, or stockpiling by institutions can lead to drug shortages. 27 Many institutions adopted a nontraditional approach when faced with the challenges by substituting a different agent like benzodiazepines or intermittent boluses of NMBs guided by NMB monitoring. The shift may result in nursing staff, and doctors being unfamiliar with alternative pharmacotherapies, in turn, leading to dosing errors, undersedation or oversedation regardless of patient characteristics.…”

Tailored sedation in critically ill COVID-19 patients based on lung damage, and pharmacokinetic and pharmacodynamic profiles

“…Subsequently, as respiratory mechanics improve, it is necessary to reduce the level of sedation [12]. In this state, a strategy of light sedation can reduce the time to extubation with beneficial effects on sedation-induced complications.…”