Are there alternative sedation protocols for ventilated patients if there is a shortage of common medications

Posted on April 10, 2020 by Raymond Cho

Summary

Ventilated COVID-19 patients have higher requirements for sedation, causing a shortage of common medications. Rural and community institutions may create individualized analgosedative ladders/protocols using the diagram below and table of alternative medications as a reference.

I.   GENERAL GUIDELINES FOR SEDATION IN VENTILATED PATIENTS

  • Frequent reassessments and stepwise approach for pain and sedation requirements. 
  • The 2018 Clinical Practice guidelines from the Society of Critical Care Medicine use an analgesic-sedative (“analgosedative”) approach to sedation in critically-ill patients to minimize the sedation requirements and their associated adverse drug reactions. Multimodal adjuvants to opioids (e.g. acetaminophen, gabapentin, low-dose ketamine) are recommended to minimize opioid requirements. Minimizing benzodiazepines is recommended to improve outcomes such as ICU length-of-stay and duration of ventilation (1).
  • Use the least amount of sedation possible in ventilated patients. However, COVID-19 patients may require deeper sedation due to respiratory distress and ARDS (2,3).

II.   CHALLENGES IN SEDATION FOR COVID-19 PATIENTS (3)

  • Given COVID-19 patients’ propensity for developing ARDS and respiratory distress, deeper sedation is required to reduce respiratory rate and promote lung-protective ventilation. COVID-19 patients also remain on ventilators for long periods of time (more than 7-14 days), and this prolonged use may cause dependence. 
  • These challenges may lead to shortages in sedative/analgesic medications, necessitating transition to 2nd or 3rd line and oral agents.

III.   ANALGESIA AND SEDATION FOR VENTILATED COVID-19 PATIENTS

  • Main goal is to use low doses of multiple medications to create a synergistic effect.
  • Brigham and Women’s Hospital COVID-19 Clinical Guidelines recommends targeting sedation to ventricular synchrony to prevent ventilator-induced lung injury. Neuromuscular blocking agents (paralytics) should only be used if the patient remains dyssynchronous despite deep sedation (RASS Score -5). Their preferred initial sedation regimen is Fentanyl/Hydromorphone (bolus +/- infusion) + propofol. If triglycerides, lipase or CK levels rise significantly, consider switching to an alternative sedative such as midazolam (4,5,6).
  • EM Crit shows an example of analgosedation for COVID-19, adding analgesics for pain and sedatives for agitation/anxiety in a stepwise approach (Figure 1) (see their website for details on this protocol). Medications on this ladder may be substituted based on availability (3).
  • EM RAP has produced a table for alternative medications for analgesia and sedation reproduced below (Table 1) (7).

Figure 1: EM Crit Analgosedative protocol for intubated COVID-19 Patients (3).

 

Table 1: Sedation/Analgesia Alternative Medications (Drs. Alexis LaPietra, Sergey Motov and Bryan Hayes) (8)

Bolus (typical dose) Loading Dose Infusion
Analgesia Options
Fentanyl 1-3 mcg/kg (50-100 mcg) 0.5-1.5 mcg/kg/hr
Morphine 0.1 mg/kg (6-8 mg) 0.025-0.05 mg/kg/hr
Hydromorphone 0.5-1 mg 0.01-0.02 mg/kg/hr
Remifentanil NO BOLUS (Bradycardia + Chest Wall Rigidity) 1 mcg/kg over 10 minutes* 0.1-1 mcg/kg/hr
Sedative Options
Propofol 0.5-1 mg/kg 10 mcg/kg/min + titrate up
Ketamine 0.5-1 mg/kg 0.15-2.5 mg/kg/hr
Dexmedetomidine** NO BOLUS (Bradycardia) 1 mcg/kg over 10 minutes* 0.1-1 mcg/kg/hr
Midazolam 0.3-0.35 mg/kg (20 mg) 20-50 mcg/kg/hr
Lorazepam 0.05 mg/kg (4 mg) 0.05 mg/kg/hr
Phenobarbital 15-20 mg/kg 0.5-1 mg/kg/hr
*Can reduce to 0.5 mcg/kg in frail patients

**Dexmedetomidine can cause bradycardia if given as a bolus. Additionally, dexmedetomidine does not suppress the respiratory drive and, thus, does not foster vent synchrony.

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Devlin J, Skrobik Y, Gélinas C, Needham D, Slooter A, Pandharipande P 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. Critical Care Medicine [Internet]. 2018;46(9):e825-e873. Available from: https://journals.lww.com/ccmjournal/fulltext/2018/09000/Clinical_Practice_Guidelines_for_the_Prevention.29.aspx
  2. Rochwerg B. Pain, Agitation and Delirium in the ICU [Internet]. 2020 [cited 10 April 2020]. Available from: https://www.youtube.com/watch?time_continue=151&v=GnkAgbSx6n4&feature=emb_logo
  3. Farkas J. COVID-19 [Internet]. Internet Book of Critical Care. 2020 [cited 10 April 2020]. Available from: https://emcrit.org/ibcc/covid19/
  4. COVID-19 Protocols [Internet]. Brigham and Women’s Hospital COVID-19 Clinical Guidelines. 2020 [cited 10 April 2020]. Available from: https://covidprotocols.org/protocols/03-respiratory-and-pulmonology/?highlight=sedation
  5. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected [Internet]. World Health Organization. 2020 [cited 10 April 2020]. Available from: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf
  6. Alhazzani W, Møller M, Arabi Y, Loeb M, Gong M, Fan E et al. Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19). Critical Care Medicine [Internet]. 2020;. Available from: https://www.sccm.org/getattachment/Disaster/SSC-COVID19-Critical-Care-Guidelines.pdf?lang=en-US
  7. Mason J, Herbert M, Nordt S, Schirger D, Weingart S, Talan D et al. Novel Coronavirus 2019 (COVID-19) [Internet]. EM:RAP. 2020 [cited 10 April 2020]. Available from: https://www.emrap.org/corependium/chapter/rec906m1mD6SRH9np/Novel-Coronavirus-2019-COVID-19

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.