Journal of Anaesthesia & Critical Care Case Reports

Vol 8 | Issue 2 | May-August 2022 | Page: 06-11 | Jyoti Shinde, Moosa Awladthani, Sanjay Shinde, Sathiya Murthi, Manthan Shinde

DOI: 10.13107/jaccr.2022.v08i02.199

Author: Jyoti Shinde [1], Moosa Awladthani [1], Sanjay Shinde [2], Sathiya Murthi [3], Manthan Shinde [4]

[1] Department of Anaesthesia & Intensive Care Unit, Armed Forces Hospital, Muscat.
[2] Department of Urology, Armed Forces Hospital, Muscat.
[3] Statistics Specialist, Oman Medical Speciality Board, Muscat.
[4] Maharajgunj Medical Campus, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.

Address of Correspondence
Dr. Jyoti Shinde
Specialist Anaesthetist, Department of Anaesthesia & Intensive Care Unit, Armed Forces Hospital, Muscat.
E-mail: jyotisanjay@hotmail.com

Abstract

Objectives: To study the sedation challenges in patients with COVID-19-induced acute respiratory distress syndrome.
Methods: A retrospective analysis of sedation challenges in critically ill patients due to COVID-19 pneumonia with acute respiratory distress syndrome at Armed Forces Hospital. Patients requiring continuous infusion or intermittent sedation, or oral/IV sedative therapy, were recorded. The Richmond Agitation and Sedation Scale (RASS) was used as a validated tool to assess sedation. IBM SPSS Version 25 was used for the statistical analysis. Categorical variables were presented with frequency and percentages, as well as continuous mean or SD median or interquartiles.
Results: In total, 100 patients with a mean age of 49.5 ± 14.89 years who recovered, and 67.68 ± 12.75 years who died, were included in the study. To achieve the prescribed sedation level, we observed the need for an intravenous (IV) infusion of two sedatives in 30% of the patients, and three sedatives in 27% of the patients, respectively. Apparently, oral concurrent sedation or analgesia or combinations of these were also prescribed, showing 35% of patients requiring a single drug, whereas 30% required 2-3 drug combinations. The analysis showed that the majority of COVID-19 patients admitted to the ICU required unusually high doses of sedation compared to those available in the literature for non-COVID patients.
Conclusion: The global pandemic outbreak due to SARS CoV-2 continues to affect patients with mild to severe ARDS, requiring ventilation and sedation. High dosages of sedative agents were observed in patients with COVID-19-related ARDS. Several combinations of oral and IV sedatives were used to achieve the required levels of sedation.
Keywords: Respiratory Distress Syndrome, COVID-19, Hypnotics and Sedatives, Pandemics, Analgesia, Intensive Care Units.

References

1) Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395(10223):497-506.
2) Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet. 2020;395(10223):507-513.
3) Wu C, Chen X, Cai Y, Xia J, Zhou X, Xu S, et al. Risk factors associated with acute respiratory distress syndrome and death in patients with Coronavirus Disease 2019 Pneumonia in Wuhan, China. JAMA Intern Med. 2020;180(7):1-11.
4) Devlin JW, Skrobik Y, Gelinas C, Needham DM, Slooter AJC, Pandharipande PP , et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med. 2018;46(9): e825-e873.
5) Kapp CM, Zaeh S, Niedermeyer S, Punjabi NM, Siddharthan T, Damarla M, The use of analgesia and sedation in mechanically ventilated patients with COVID-19 ARDS. Anesth Analg. 2020.
6) Alhazzani W, Evans L, Alshamsi F, Moller MH, Ostermann M, Prescott HC, et al. Surviving Sepsis Campaign Guidelines on the Management of Adults with Coronavirus Disease 2019 (COVID-19) in the ICU: First Update. Critical Care Medicine: March 2021-Volume 49-Issue 3-p e 219-e234.
7) Matos, Renee I. Chung, Kevin K. DoD COVID-19 Practice Management Guide: Clinical Management of COVID-19, Report Date: 2020-06-18.
8) Nahla E El-Ashmawy NE, Abdel-Halim A. Lashin, Kamal M. Okasha, Amal M. Abo Kamer, Tarek M. Mostafa, Mona EL-Aasr, et al. The plausible mechanisms of tramadol for treatment of COVID-19, Med Hypotheses. 2021 Jan;146:110468.Epub 2020 Dec 22.
9) Giovanni Ostuzzi, Davide Papola, Chiara Gastaldon, Georgios Schoretsanitis, Federico Bertolini, Francesco Amaddeo, et al, Safety of psychotropic medications in people with COVID-19: evidence review and practical recommendations. ed. 2020 Jul 15;18(1):215.
10) Nicolas Hoertel, Marina Sanchez-Rico, Raphael Vernet, Anne-Sophie Jannot, Antoine Neuraz, Carlos Blanco, et al. Observational study of haloperidol in hospitalized patients with COVID-19. PLOS ONE, February 19, 2021.
11) Zayed Y, Barbarawi M, Kheiri B, Kheiri B, Banifadel M, Haykal T, et al. Haloperidol for the management of delirium in adult intensive care unit patients: a systematic review and meta-analysis of randomized controlled trials. J Crit Care. 2019;50: 280–286. 10.1016/j.jcrc.2019.01.009
12) Xiong GL, Pinkhasov A, Mangal J, Huang H, Rado J, Jane Gagliardi J, et al. QTc monitoring in adults with medical and psychiatric comorbidities: Expert consensus from the Association of Medicine and Psychiatry. J Psychosom Res. 2020; 110138 10.1016/j.jpsychores.2020.110138.
13) Sampson MR, Cao KY, Gish PL, Hyon K, Mishra P, Tauber W, et al. . Dosing recommendations for quetiapine when coadministered with HIV protease inhibitors. J Clin Pharmacol 2019;59:500–9. 10.1002/jcph.1345.
14) Hanaoka K, Namiki A, Dohi S, Koga Y, Yuge O, Kayanuma Y, et al. A dose-ranging study of midazolam for postoperative sedation of patients: a randomized, double-blind, placebo-controlled trial. Crit Care Med. 2002;30(6):1256–60. Epub 2002/06/20. pmid:12072678.
15) Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. Jama. 2009;301(5):489–99. pmid:19188334
16) Hayden JC, Bardol M, Doherty DR, Dawkins I, Healy M, Breatnach CV, et al. Optimizing clonidine dosage for sedation in mechanically ventilated children: A pharmacokinetic simulation study. Paediatr Anaesth. 2019;29(10):1002–10. Epub 2019/08/03. pmid:31373752.
17) Srivastava U, Sarkar ME, Kumar A, Gupta A, Agarwal A, Singh TK, et al. Comparison of clonidine and dexmedetomidine for short-term sedation of intensive care unit patients. Indian J Crit Care Med. 2014;18(7):431–6. Epub 2014/08/07. pmid:25097355; PubMed Central PMCID: PMC4118508.
18) Farasatinasab M, Kouchek M, Sistanizad M, Goharani R, Miri M, Solouki M, et al. A Randomized Placebo-controlled Trial of Clonidine Impact on Sedation of Mechanically Ventilated ICU Patients. Iran J Pharm Res. 2015;14(1):167–75. Epub 2015/01/07.
19) Cruickshank M, Henderson L, MacLennan G, Fraser C, Campbell M, Blackwood B, et al. Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review. Health Technol Assess. 2016;20(25):v–xx, 1–117. Epub 2016/04/02.
20) Wongtangman K, Santer P, Wachtendorf LJ, Azimaraghi O, Baedorf Kassis E, Teja B, et al. Association of Sedation, Coma, and In-Hospital Mortality in Mechanically Ventilated Patients With Coronavirus Disease 2019–Related Acute Respiratory Distress Syndrome: A Retrospective Cohort Study. Critical Care Medicine. 9000;Latest Articles. 00003246-900000000-95286. pmid:33861551
21) Kapp CM, Zaeh S, Niedermeyer S, Punjabi NM, Siddharthan T, Damaria M. The use of analgesia and sedation in mechanically ventilated patients with COVID-19 ARDS. Anesth Analg. 2020.
22) Hraiech S, Forel J-M, Papazian L. The role of neuromuscular blockers in ARDS: benefits and risks. Current Opinion in Critical Care. 2012;18(5):495–502. 00075198-201210000-00013. pmid:22941207
23) Guérin C, Mancebo J. Prone positioning and neuromuscular blocking agents are part of standard care in severe ARDS patients: yes. 2015.
24) Hanidziar D, Bittner EA. Sedation of Mechanically Ventilated COVID-19 Patients: Challenges and Special Considerations. Anesth Analg. 2020: Epub 2020/04/15.
25) Nasraway SA, Jacobi J, Murray MJ, Lumb PD. Sedation, analgesia, and neuromuscular blockade of the critically ill adult: revised clinical practice guidelines for 2002. Critical care medicine. 2002;30(1):117–8.
26) Chanques G, Constantin J-M, Devlin JW, Ely EW, Fraser GL, Gellnas C, et al. Analgesia and sedation in patients with ARDS. Intensive Care Medicine. 2020:1–15. pmid:33170331
27) Martyn JAJ, Mao J, Bittner EA. Opioid tolerance in critical illness. N Engl J Med. 2019;380:365–378.
28) Alhazzani W, Møller MH, Arabi YM, Loeb M, Gong MN, Fan E, et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med. 2020; 46:854–887.
29) Schünemann HJ, Wiercioch W, Brozek J, Etxeandia-Ikobaltzeta I, Mustafa RA, Manja V, et al. GRADE evidence to decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. J Clin Epidemiol. 2017; 81:101–110.

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