key: cord-0948465-c1o8t6la
authors: Payen, Jean-François; Chanques, Gérald; Futier, Emmanuel; Velly, Lionel; Jaber, Samir; Constantin, Jean-Michel
title: Sedation for critically ill patients with COVID-19: which specificities? One size does not fit all
date: 2020-04-29
journal: Anaesth Crit Care Pain Med
DOI: 10.1016/j.accpm.2020.04.010
sha: 9b3a7d0543290611102366beb872fe18461fcd0d
doc_id: 948465
cord_uid: c1o8t6la

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Sedation for critically ill patients with COVID-19: which specificities?

One size does not fit all Keywords: Pain; Sedation; Ventilation; Physicians in the intensive care unit (ICU) in charge of patients with severe acute respiratory distress syndrome (ARDS) due to coronavirus (SARS-CoV2) face a difficult dilemma: to improve gas exchange, oxygen transport and tissue oxygenation using mechanical ventilation (MV), or to limit ventilator-induced lung injury (VILI) associated with prolonged MV. In addition, while MV often requires deep sedation with or without neuromuscular blocking agents (NMBA) to tolerate MV and limit the risk of VILI, deep and/or prolonged sedation is associated with several complications, e.g. delirium, withdrawal syndromes, propofol related infusion syndrome (PRIS), haemodynamic instability, ICU acquired muscle weakness, and difficult MV weaning leading to a sustained utilisation of ICU resources [1, 2] . Because the coronavirus pandemic is associated with a shortage of sedatives and NMBA drugs in several countries including France, it is critical to discuss the role of sedation in this particular context. Using deep sedation with or without NMBA in patients with ARDS aims at improving pulmonary compliance and suppressing ventilatory drive to facilitate the adaptation of patient to the ventilator and the tolerance of hypercapnia due to the protective ventilation with low tidal volume.

However, two features characterise the COVID-related ARDS [3] : the pulmonary compliance is initially normal or even high in the absence of bacterial infection, and ventilatory drive may be altered, i.e. Alteration of the ventilatory drive, ventilator asynchrony, frequent cough, and withdrawal syndrome can hamper the liberation from ventilator and create a vicious cycle with the reuse of deep sedation and NMBA. In order to limit an excessive use of these drugs during a period at risk of shortage, and to prevent prolonged MV in a context of limited available ICU resources, other drugs such as antipsychotics, gammahydroxybutyric acid (GHB), alpha-2 agonists (clonidine, dexmedetomidin) should be considered in association with current recommended drugs, as well as other ventilator modes such as pressure modes (PVC, APRV and PSV). The ultimate challenge for the anaesthesiologist/intensivist is to adapt the ventilator to the patient, not the reverse. 

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Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU

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Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post Hoc analysis of the DOLOREA study

Immediate interruption of sedation compared with usual sedation care in critically ill postoperative patients (SOS-Ventilation): a randomised, parallel-group clinical trial