Long-term sedation in intensive care unit: a randomized comparison between inhaled sevoflurane and intravenous propofol or midazolam

Mesnil, Malcie; Capdevila, Xavier; Bringuier, Sophie; Trine, Pierre-Olivier; Falquet, Yoan; Charbit, Jonathan; Roustan, Jean‐Paul; Chanques, Gérald; Jaber, Samir

doi:10.1007/s00134-011-2187-3

Cited by 178 publications

(127 citation statements)

References 27 publications

(27 reference statements)

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“…5 These outcomes are attributable to the unique pharmacokinetic clearance of these agents (via pulmonary exhalation with minimal systemic accumulation) and bedside real-time end-tidal gas monitoring to aid dose titration. The role of volatile agents for ICU sedation requires further research, but this study confirmed that use of prolonged administration of these agents when using this active scavenging system can be done while maintaining workplace safety.…”

Section: To the Editormentioning

confidence: 99%

Efficacy of a simple scavenging system for long-term critical care sedation using volatile agent-based anesthesia

Wong

Wąsowicz

Grewal

et al. 2015

Can J Anesth/J Can Anesth

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Section: To the Editormentioning

confidence: 99%

Efficacy of a simple scavenging system for long-term critical care sedation using volatile agent-based anesthesia

Wong

Wąsowicz

Grewal

et al. 2015

Can J Anesth/J Can Anesth

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“…Its applicability depends on the ICU staff and their background: Anesthetists handle volatile agents daily in the operating room (OR), are familiar with the concepts of end tidal concentration and minimum alveolar concentration, and are prepared in the unlikely event of a malignant hyperthermia reaction. The paper by Capdevila et al [18] in this issue of Intensive Care Medicine is welcome and shows the feasibility of sevoflurane anesthesia in uncomplicated ICU patients. The authors show that awakening and extubation times are much shorter with sevoflurane compared with those using midazolam or propofol.…”

mentioning

confidence: 96%

Volatile agents for ICU sedation?

Bracco

Donatelli

2011

Intensive Care Med

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Sedation is a standard part of critical care and was unchallenged from 1960 to 2000. Classical sedation approaches are associated with significant post-traumatic stress traits [1]. Because of poor pharmacokinetics/pharmacodynamics and planning problems, patients in the intensive care unit (ICU) spend one-third of their duration of stay being ventilated after the resolution of the problem mandating intubation [2, 3]. The aim of sedation in the ICU is to make the patient calm and tolerant to the critical care therapies, in particular mechanical ventilation. Recently several approaches have proven beneficial for patient care and the healthcare system: prospective trials have shown that daily interruptions of sedation are associated with a decrease in length of ventilation and decrease in ICU stay [4]. If a spontaneous breathing trial is used in addition to daily sedation interruption, the 1-year survival is improved [5] without an increase in psychological consequences [6]. Recent data suggest that no sedation at all may be better [7]. This move has been made possible by the improvement in ventilator algorithms, which are increasingly flexible in dealing with variable patient efforts. Over the last 10 years, the pendulum has moved toward a decrease in sedation with proactive strategies [8]. In this frame, the quest for the ideal sedation agent is continuing. The ideal sedative agent should be fast acting, have a rapid onset, not be organ dependent in terms of degradation, not have metabolically active or toxic by-products, have little cardiovascular effects, and be cheap. Over the last 30 years, midazolam, propofol [9], and dexmedetomidine [10,11] have been rolled out with the promise of being better than the previous generation of drugs.Sedation management in the ICU is a complex process involving sedation level assessment, medication administration, and an overall strategy. These three components are essential for correct ICU sedation. No one will give norepinephrine in the ICU without measuring blood pressure and having a strategy and objectives for vasopressor use, i.e., norepinephrine up to 20 lg/min for a mean arterial pressure (MAP) of 65 mmHg. Why are we tolerating this ''art'' of sedation and analgesia in the ICU? There is confusion in the literature between sedation/ hypnosis, analgesia, delirium management, and relaxation. This is shown by a recent meta-analysis regarding dexmedetomidine [12] pooling studies on dexmedetomidine used with sedation end points, morphine-sparing end points, and delirium end points. A hypnotic is a hypnotic, an analgesic is an analgesic, an antipsychotic is a drug used to treat delirium episodes [13], and a neuromuscular blocker is a relaxant medication. Although these classes of drugs have synergistic effects they cannot be used interchangeably.Volatile anesthesia agents have been in use for 50 years in anesthesia but only marginally in the ICU [14,15]. The first volatile agents were hepatotoxic and induced significant arrhythmias, which make then unsuitable for longterm ICU...

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“…19 When compared with intravenous sedation, volatile sedation has been associated with shorter weaning times, 20 less ICU and hospital days, 21 and no difference in safety. 20,22,23 The anti-inflammatory properties of volatile anesthetics have been demonstrated in experimental (LPS-induced) lung injury. 12 However, little is known about the impact of sedatives on the course of ALI during mechanical BACKGROUND: Patients experiencing acute lung injury (ALI) often need mechanical ventilation for which sedation may be required.…”

mentioning

confidence: 99%

Sevoflurane Abolishes Oxygenation Impairment in a Long-term Rat Model of Acute Lung Injury

Kellner

Müller

Piegeler

et al. 2017

Survey of Anesthesiology

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BACKGROUND Patients experiencing acute lung injury (ALI) often need mechanical ventilation for which sedation may be required. In such patients, usually the first choice an intravenously administered drug. However, growing evidence suggests that volatile anesthetics such as sevoflurane are a valuable alternative. In this study, we evaluate pulmonary and systemic effects of long-term (24-hour) sedation with sevoflurane compared with propofol in an in vivo animal model of ALI. METHODS Adult male Wistar rats were subjected to ALI by intratracheal lipopolysaccharide (LPS) application, mechanically ventilated and sedated for varying intervals up to 24 hours with either sevoflurane or propofol. Vital parameters were monitored, and arterial blood gases were analyzed. Inflammation was assessed by the analysis of bronchoalveolar lavage fluid (BALF), cytokines (monocyte chemoattractant protein-1 [MCP-1], cytokine-induced neutrophil chemoattractant protein-1 [CINC-1], interleukin , IL-12/12a, transforming growth factor-, and IL-10) in blood and lung tissue and inflammatory cells. The alveolocapillary barrier was indirectly assessed by wet-to-dry ratio, albumin, and total protein content in BALF. Results are presented as mean ± standard deviation. RESULTS After 9 hours of ventilation and sedation, oxygenation index was higher in the LPS/sevoflurane (LPS-S) than in the LPS/propofol group (LPS-P) and reached 400 ± 67 versus 262 ± 57 mm Hg after 24 hours (P < .001). Cell count in BALF in sevoflurane-treated animals was lower after 18 hours (P = .001) and 24 hours (P < .001) than in propofol controls. Peak values of CINC-1 and IL-6 in BALF were lower in LPS-S versus LPS-P animals (CINC-1: 2.7 ± 0.7 vs 4.0 ± 0.9 ng/mL; IL-6: 9.2 ± 2.3 vs 18.9 ± 7.1 pg/mL, both P < .001), whereas IL-10 and MCP-1 did not differ. Also messenger RNAs of CINC-1, IL-6, IL-12a, and IL-10 were significantly higher in LPS-P compared with LPS-S. MCP-1 and transforming growth factor-showed no differences. Wet-to-dry ratio was lower in LPS-S (5.4 ± 0.2 vs 5.7 ± 0.2, P = .016). Total protein in BALF did not differ between P-LPS and S-LPS groups. CONCLUSIONS Long-term sedation with sevoflurane compared with propofol improves oxygenation and attenuates the inflammatory response in LPS-induced ALI. Our findings suggest that sevoflurane may improve lung function when used for sedation in patients with ALI. A cute lung injury (ALI) frequently requires both mechanical ventilation and sedation in the intensive care unit (ICU). 1,2 Currently, approximately 10% of patients treated in the ICU experience ALI or acute respiratory distress syndrome (ARDS), 3 and mortality rates of up to 50% have been described. 4 Immune activation and a massive release of proinflammatory mediators are hallmarks of ALI and ARDS, 5 and mechanical ventilation may further exacerbate the inflammatory response. 6-8 Cytokines recruit effector cells, which amplify the inflammatory response. 9 Bacterial lipopolysaccharides (LPSs) are complex glycolipids found on the outer membrane of Gr...

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Long-term sedation in intensive care unit: a randomized comparison between inhaled sevoflurane and intravenous propofol or midazolam

Abstract: Long-term inhaled sevoflurane sedation seems to be a safe and effective alternative to i.v. propofol or midazolam. It decreases wake-up and extubation times, and post extubation morphine consumption, and increases awakening quality.

Cited by 178 publications

References 27 publications

Efficacy of a simple scavenging system for long-term critical care sedation using volatile agent-based anesthesia

Efficacy of a simple scavenging system for long-term critical care sedation using volatile agent-based anesthesia

Volatile agents for ICU sedation?

Sevoflurane Abolishes Oxygenation Impairment in a Long-term Rat Model of Acute Lung Injury

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