ICU patients who are receiving invasive mechanical ventilation and noninvasive ventilation often require sedation and analgesia. COVID-19 pneumonia / ARDS induced acute respiratory failure patients are not indifferent in this aspect. Sometimes, it also feels that these patients need more sedation, even on NIV. I shall be delighted to know the sedation practices, drugs, single or combinations you are using in your set-up.
After intubation before proning, i use muscle relaxants infusion+ opoids+ bezodiazpine infusion
If concerned with keeping the ventilatory drive the choice will be between haloperidol then dexmedetomidine or No Sedation at all. If the patient is mechanically ventilated the choice is wide. Narcotics, benzodiazepines, propofol or dexmedetomidine may be used.
I do not change my standard sedation practice for patients with COVID-19.
For a adult agitated patient on niv 2.5 mg im and 2.5 mg iv haloperidol is seems to very effective in some patients
Rajkumar Rajendram sir, Please share your standard practice of sedation in ICU patients. What is experience? Is it equally effective in COVID-19 patients too?
We are using fentamidaz infusion in aduptive support ventilation (ASV) mode comfortably.
My sedation practice tailors sedation to a patient's need for organ support, comorbidities, phase of illness, need for neurological assessment, expected trajectory and weaning strategies. COVID-19 has not changed my practice.
However, the reduced availability of medications due to surges in case load did occasionally require use of midazolam and morphine rather my preferred options of propofol and alfentanil.
Propofol is the best choice especially if you have patients with HFNC or NIV. You can make a good ratio between sedation and spontaneous breathing. Dexmedetomidine is also have good results, except if patient needs deeper sedation (problems with blood pressure...). Midazolam is not preferable in COVID - 19 patients.
In non-intubated patients, if sedation is required due to agitation use of dexmedetomidine to target RASS around -2 is effective. For intubated patients, combination of propofol, dexmedetomidine and intermittent or continuous atracurium is preferable. Least preferred are nubain and midazolam.
Non intubated patients: Quetiapine
Intubated: combination of propofol plus minus Fentanyl....or Dexmedetomidine and Vecuronium as required only in case selective basis...Tab Quetiapine is also added if required
We use least of BZD for regular sedation
Dexmedetomidine as a cooperative sedation agent in non intubate patients. Some times - morphine. Intubated patients - propofol.
In NIV with patients not collaborating or rejecting the mask, ketamine would be the optimal drug, but due to its hallucinatory effect more than for the antisialogue effect bufferable with glycopyrrolate and the increase of tachycardia, must be used very carefully and in a titrated response amount. Dexmedetomidine, Droperidol, and Remifentanyl are good options too. I would not use BZD or opioids, though if carefully used are also effective. The drawback is if you need to increase the sedation with ketamine you can do it safely were it not for the heart rate increase, with the other drugs their side effects are quite detrimental to pt condition. Preparing the pt with a calm and reassuring assertive preventive demeanour remains the best preventive measure. Agitation due to physiological deterioration of the pt calls for consideration for mechanical ventilation in ICU. Sedation in this scenario facilitates and introduces them to mechanical ventilation.
After one year of battle with COVID infection, as an intensivist I saw many bad days and things. Mainly point is that global agreement that DO NOT use midazolam and/or BDZs’ is absolutely right! Unfortunately, some of my colleagues are still insist on continuous midazolam sedation. After discontinuation of midazolam, huge number of patients are never woke up, even if we used high doses of flumazenil! Does anyone have reasonable explanation? I did not see the same negative effect with any other sedation treatment.
Thank you for your answers and opinions.
i) hypercapnia?! ii) metabolism problems!? Midazolam if remember well is metabolized in the liver. In northern Uganda, the ones who loved alcohol could not be anesthetized with ketamine!! At a certain point, I excluded them from my study...iii) third option pt deterioration as a natural process of the underlying disorder
Dead high: Until I contracted Covid-19 myself, I have been in command of a Covid Care Unit (vaccinating, treating patients with it at all levels and, of course, sedating myself -both to intubate , as in sedation in Palliative Care -PC- including deep and irreversible sedation, if necessary, and with all the legal and bioethical guidelines required).
Francisco Javier Gala thank you for your insight into the palliative care aspect of COVID-19 patients. I do believe that some patient who requires end-of-life care should receive deep sedation and analgesia so that their journey to the death is smoother and less with lesser suffering. However, in many countries, legal and ethical aspects are not very clear.