Volatile Sedation for Acute Respiratory Distress Syndrome Patients on Venovenous Extracorporeal Membrane Oxygenation and Ultraprotective Ventilation

Abstract

Objectives: Patients on extracorporeal support for severe acute respiratory distress syndrome may require a prolonged period of deep sedation. In these patients, volatile sedation may represent a valid alternative to IV drugs. The aim of our study was to describe the feasibility of volatile sedation in a large cohort of acute respiratory distress syndrome patients undergoing venovenous extracorporeal membrane oxygenation and ultraprotective ventilation. Design: Retrospective monocentric study. Setting: Adult ICU, ASST Monza, Italy. Patients: Adult patients who underwent volatile sedation with isoflurane during venovenous extracorporeal membrane oxygenation between 2009 and 2019. Interventions: Isoflurane was delivered via the AnaConDa system. The sedation level, hemodynamics, and laboratory tests were compared between the volatile sedation phase and the IV sedation phases before and after the isoflurane sedation period. Measurements and Main Results: About 74 patients (50 yr [43–56 yr]) were included. Median duration of venovenous extracorporeal membrane oxygenation support was 22 days (14–51 d). Volatile sedation started on day 3 (2–6) of extracorporeal membrane oxygenation support, and its median duration was 7 days (4–13 d), ranging from 1 to 38 days. A total of 970 venovenous extracorporeal membrane oxygenation days were analyzed. During the volatile phase, the sedation level was slightly deeper (bispectral index 39 ± 6) compared with the IV phase before and after isoflurane (42 ± 8 and 43 ± 9, respectively, p < 0.001). Requirements of fentanyl and remifentanyl were reduced during the volatile phase. Minor differences in hemodynamics were observed during volatile sedation: mean arterial pressure was lower (75 ± 13 vs 79 ± 14 and 80 ± 15; p < 0.001), whereas cardiac output was higher (8.5 ± 1.9 vs 7.9 ± 1.8 and 8.0 ± 1.8; p = 0.003). Aspartate aminotransferase levels were lower during the volatile sedation phases (p < 0.001), whereas alanine aminotransferase, triglycerides, and creatine phosphokinase were more altered during the IV sedation phase before isoflurane (p < 0.001). Conclusions: Volatile sedation represents an alternative to IV agents to achieve long-term deep sedation in critically ill patients on extracorporeal membrane oxygenation undergoing ultraprotective ventilation.

Sevoflurane sedation in COVID-19 acute respiratory distress syndrome: an observational study with a propensity score matching model

“…Ferrando et al observed that the use of sevo urane resulted in a greater immunosuppressive effect than propofol, with less alteration in the permeability of alveolar capillaries and consequent improvement in oxygenation [31]. The use of halogenated anesthetics has also shown bene ts in patients with ARDS undergoing extracorporeal membrane oxygenation (ECMO) [32].…”

Propofol-Associated Hypertriglyceridemia in Adults With Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation

“…This study showed increased depth of sedation with isoflurane, reduced need for opiates and neuromuscular blockade, less adverse effects, and similar outcomes when compared to intravenous (iv) sedation with midazolam or propofol. 27 Although these findings are exploratory, volatile sedation may be a future feasible therapeutic alternative for patients receiving ECMO for ARDS. 27 Although the lack of propofol-associated HTG complications demonstrated in our study could be attributed to the prompt discontinuation of propofol in approximately 51.7% of patients, and reduction in rate in 29.3% of patients, another possible conclusion remains that propofol-associated pancreatitis, even in the setting of HTG, is rare in congruence with published literature.…”

Case report: Isoflurane therapy in a case of status asthmaticus requiring extracorporeal membrane oxygenation

“…The coordination of care in this case was complex, and the time spent by multiple providers, both in consultation with each other and individually, would likely limit the possibility of isoflurane delivery becoming a common practice. Anesthetic delivery systems that administer volatile anesthetics directly into endotracheal tubes have been developed and are being researched for the delivery of anesthetics to invasively ventilated patients ( 22 ). In a retrospective study of 74 patients, Grasselli et al found that inhaled volatile anesthetic (isoflurane) delivered via the inhalation route using one of these anesthetic delivery systems can be a safe alternative to continuous IV sedation in patients on VV ECMO for ARDS.…”

“…There are multiple postulated mechanisms regarding how these agents work, including direct relaxation of bronchial smooth muscle, inhibition of the release of inflammatory mediators, beta adrenergic receptor stimulation, reduction of vagal tone and vagal-mediated reflexes and antagonism of the effects of histamine and methacholine (19)(20)(21). The use of inhaled anesthetics in patients requiring ECMO has been reported more recently, both in severe refractory SA and acute respiratory distress syndrome (ARDS) (19,22); however, the literature is limited. In previously reported cases of utilization of inhaled volatile anesthetics for severe SA, the anesthetics were delivered via the inhalational route utilizing an anesthesia ventilator (19,23).…”