Inhaled Sedation for Invasively Ventilated COVID-19 Patients: A Systematic Review

Abstract

Background: Volatile anesthetics were used as sedative agents in COVID-19 (Coronavirus Disease 2019) invasively ventilated patients for their potentially beneficial pharmacological effects and due to the temporary shortages of intravenous agents during the pandemic crisis. Methods: Online databases (PubMed, EMBASE, The Cochrane Central Register of Controlled Trial) and the “clinicaltrials.gov” website were searched for studies reporting the use of isoflurane, sevoflurane or desflurane. Results: We identified three manuscripts describing the beneficial effects of isoflurane on 41 COVID-19 patients with acute respiratory distress syndrome (ARDS) in Germany (n = 2) and in the USA (n = 1), in terms of reduction in the use of opioids and other sedatives. We also found a case report of two patients with transient nephrogenic diabetes insipidus, which started after 6 and 8 days of sevoflurane sedation. We identified two randomized controlled trials (RCTs; 92 patients overall), two observational studies (238 patients) on the use of volatile anesthetics in COVID-19 patients that were completed but not yet published, and one RCT interrupted for a low recruitment ratio (19 patients) and thus not published. We also identified five ongoing RCTs on the use of inhaled sedation in ARDS, which are also likely to be recruiting COVID-19 patients and which have currently enrolled a total of >1643 patients. Conclusion: Isoflurane was the most frequently used volatile agent in COVID-19 patients and allowed a reduction in the use of other sedative and analgesic drugs. Randomized evidence is building up and will be useful to confirm or challenge these findings.

Minimización de costos de sedación usando anestesia inhalada. Análisis en la UTI durante la pandemia por COVID-19

“…Para el segundo año de pandemia en México se nos brindó la alternativa de los anestésicos volátiles administrados por medio de dispositivos desechables, contando en un inicio con sevoflurano y poco después exclusivamente con isoflurano, el más económico y el que más se usó durante la pandemia. 11 Sin encontrar diferencias en las características basales de ambos grupos, pudimos observar que el consumo de midazolam, propofol y dexmedetomidina se redujo significativamente y que los costos sumados de sedoanalgesia fueron menores en los pacientes que recibieron isoflurano en más de $4,100.00 M.N. por día por paciente sin afectar significativamente la mortalidad ni la estancia en la UTI u hospitalaria.…”

Trends in the Use of Sedative-Hypnotics, Opioids, and Neuromuscular Blockers in Hospitalized Patients During the COVID-19 Pandemic: Observational Retrospective Study

“…This situation even led the Colombian Ministry of Health to recommend the use of single doses of sedatives, anesthetics, and other drugs at risk of shortages, in services other than ICUs [14]. Likewise, the Colombian Association of Intensive Care Medicine and the Colombian Society of Anesthesiology generated specific documents with recommendations for the sedation and analgesia approach in the context of the pandemic and drug shortages [15], which included the use of inhaled sedatives (a suggestion also reviewed by other authors [16,17]). The call for the rational use of pharmaceutical resources was widely described in the world, taking as example some publications in Singapore [18], the United States [19,20], India [21], and Italy [22].…”

Patient Self-Inflicted Lung Injury—A Narrative Review of Pathophysiology, Early Recognition, and Management Options

“…However, long-term sedation is accompanied with increased risk of ventilator-associated pneumonia, muscle weakness (including diaphragm), and subsequent delirium. During the COVID-19 pandemic, high doses of intravenous sedatives and opioids were reported to achieve sedation and suppress patient-ventilator dyssynchronies [59]. It is noteworthy that sedation scales used in intensive medicine are markers of arousal but do not correspond to the intensity of respiratory drive.…”