High sedation needs of critically ill COVID-19 ARDS patients—A monocentric observational study

Abstract

Background Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). Methods We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used. Results In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature. Conclusion The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.

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

“…As already shown before, CARDS patients demonstrate an unusually high need for sedation. This also has been shown in the comparison of sedative needs between viral ARDS and CARDS [13,16,28].…”

“…In addition to published data (including ours from PLoS ONE) [28] that revealed signs of increased sedation need, we want to investigate whether there are underlying factors that explain these increased sedation dosages.…”

Impact of a Multimodal Analgesia Protocol in an Intensive Care Unit: A Pre-post Cohort Study

“…Our findings showed a decrease in the consumption of midazolam after intervention with a subsequent increase in 2020, plausibly explained by the inevitable inclusion of 43 patients with COVID-19 in this analysis. Patients with severe COVID-19 have abnormally high needs for sedative medications, as well as the use of combined sedation therapies and strategies, leading to a major challenge [28]. On the other hand, there was an increase in the consumption of propofol and dexmedetomidine after the intervention.…”

Post-Intubation Empirical Fluid Resuscitation as an Early Step to Prevent Acute Kidney Injury in Mechanically Ventilated COVID-19 Patient

“…There is paucity of knowledge regarding prevention of postintubation hypotension and oliguria in COVID-19 patients. Flinspach et al [14] in a monocentric observational study found that, there is unusual high requirement of sedatives in mechanically ventilated patients with COVID-19 compared to those available in the literature. In these patients we can extrapolate knowledge of perioperative fluid management in form of Compensatory Intravascular Volume Expansion (CVE) to counteract venodilation and cardiac depression from anesthesia as well as the hemodynamic effects of positive-pressure ventilation.…”