Volatile Isoflurane in Critically Ill Coronavirus Disease 2019 Patients—A Case Series and Systematic Review

Abstract

Objectives: The ongoing coronavirus pandemic is challenging, especially in severely affected patients who require intubation and sedation. Although the potential benefits of sedation with volatile anesthetics in coronavirus disease 2019 patients are currently being discussed, the use of isoflurane in patients with coronavirus disease 2019–induced acute respiratory distress syndrome has not yet been reported. Design: We performed a retrospective analysis of critically ill patients with hypoxemic respiratory failure requiring mechanical ventilation. Setting: The study was conducted with patients admitted between April 4 and May 15, 2020 to our ICU. Patients: We included five patients who were previously diagnosed with severe acute respiratory syndrome coronavirus 2 infection. Intervention: Even with high doses of several IV sedatives, the targeted level of sedation could not be achieved. Therefore, the sedation regimen was switched to inhalational isoflurane. Clinical data were recorded using a patient data management system. We recorded demographical data, laboratory results, ventilation variables, sedative dosages, sedation level, prone positioning, duration of volatile sedation and outcomes. Measurements & Main Results: Mean age (four men, one women) was 53.0 (± 12.7) years. The mean duration of isoflurane sedation was 103.2 (± 66.2) hours. Our data demonstrate a substantial improvement in the oxygenation ratio when using isoflurane sedation. Deep sedation as assessed by the Richmond Agitation and Sedation Scale was rapidly and closely controlled in all patients, and the subsequent discontinuation of IV sedation was possible within the first 30 minutes. No adverse events were detected. Conclusions: Our findings demonstrate the feasibility of isoflurane sedation in five patients suffering from severe coronavirus disease 2019 infection. Volatile isoflurane was able to achieve the required deep sedation and reduced the need for IV sedation.

Case Report of General Anesthesia After Asymptomatic SARS-Cov-2-Infection

“…From treating COVID-patients on our intensive care unit we have learned, that patients suffering from COVID-19 with required mechanical ventilation need significantly higher doses of narcotics and analgesics to maintain an adequate level of sedation. Similar observations have been made by other colleagues [1][2][3]. It is unclear, whether these observations could be made in patients with different courses of Covid-19-infection or even after infection has ended.…”

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

“…patients with ARDS should be on a case-by-case decision. In the future, considering the challenging sedation requirements of patients with COVID-19, the use of volatile anesthetics should be considered in appropriate cases, in addition to the early use of combined sedatives [42]. Some limitations must be taken into account when interpreting our results.…”

Standard Sedation and Sedation With Isoflurane in Mechanically Ventilated Patients With Coronavirus Disease 2019

“…The addition of inhalational anesthetics (e.g., sevoflurane, isoflurane) to sedation regimens has been proposed as a strategy to conserve IV sedative agents in the setting of drug shortages and to limit exposure of patients to propofol, benzodiazepines, and opioids in order to reduce wide array of side effects of these drugs including immunosuppression, delirium, ileus, tolerance, and hyperalgesia ( 4 ). Flinspach et al ( 5 ) recently documented feasibility of isoflurane sedation in five patients with COVID-19 ARDS. Inhalational halogenated anesthetics are liquids at room temperature and require the use of anesthetic vaporizers.…”