Sedation and analgesia in critically ill patients with COVID-19: a cohort retrospective study
1Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", 80011 Naples, Italy
2Intensive Care Unit, AORN Ospedali dei Colli-Monaldi Hospital, 80133 Naples, Italy
3Cotugno Hospital, AORN Ospedali dei Colli, 80133 Napoli, Italy
4Department MESVA, University of L'Aquila, 67100 L'Aquila, Italy
Submitted: 12 May 2021 Accepted: 28 June 2021
Online publish date: 14 July 2021
Introduction: The global pandemic of novel coronavirus disease 2019 (COVID-19) began in Wuhan, China in December 2019 and spread worldwide. This retrospective study summarizes clinical experience and analgo-sedation treatment used for this novel epidemic in an Italian ICU between February to May 2020.
Methods: This is a retrospective trial of 72 patients with laboratory-confirmed SARS-CoV-2 infection (COVID-19) admitted to ICU between February15, 2020 and May 15, 2020. Main Outcomes are demographic, clinical data (age, sex, medical comorbidities, respiratory supports, positive end-expiratory pressure values (PEEP), fraction of inspired oxygen (FiO2), arterial partial pressure of oxygen (PaO2), sedatives and analgesic drugs, their dosage and way of administration, medical treatments and patients mortality), ventilation strategies, sedation management in ICUs and patient mortality.
Results: The mean age of the 72 patients included in the study was 69 years (SD ±12), 77% were male. All patients required respiratory support and sedation management according to different techniques of ventilation: 100% received deep sedation (RASS -4) before intubation and invasive mechanical ventilation and 19% received light sedation (RASS -1) and noninvasive ventilation).
Conclusions: Of the 72 patients admitted in ICUs, 92% died. A total of 608 patients admitted to the AORN dei Colli “Naples” with confirmed COVID-19. In this restrospective study we have analyzed 72 (out of 608) patients that were admitted to intensive care due to worsening clinical conditions. All patients required tracheal intubation and mechanical ventilation with deep sedation (RASS -4), while only 19%(patients required light sedation so RASS -1) were subsequentely swiched to light sedation because of the need of compliance with non-invasive ventilation. Sedation was obtained with propofol, remifentanil, midazolam and dexmedetomidine, according to hospital guidelines.
COVID-19; Naso-pharyngeal swab; Pneumonia; Acute respiratory failure; Interstitial lung disease; Sedation
Caterina Aurilio,Antonio Corcione,Fiorentino Fraganza,Pasquale Sansone,Antonella Paladini,Maria Beatrice Passavanti,Vincenzo Pota,Francesco Coppolino,Francesca Molino,Maria Caterina Pace. Sedation and analgesia in critically ill patients with COVID-19: a cohort retrospective study. Signa Vitae. 2021.doi:10.22514/sv.2021.129.
 Lai C, Shih T, Ko W, Tang H, Hsueh P. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges. International Journal of Antimicrobial Agents. 2020; 55: 105924.
 Park SE. Epidemiology, virology, and clinical features of severe acute respiratory syndrome -coronavirus-2 (SARS-CoV-2; Coronavirus Disease-19). Clinic Experimetal Pediatrics. 2020; 63: 119–124.
 Li X, Ma X. Acute respiratory failure in COVID-19: is it “typical” ARDS? Critical Care. 2020; 24: 198.
 Gattinoni L, Chiumello D, Rossi S. COVID-19 pneumonia: ARDS or not? Critical Care. 2020; 24: 154.
 Grasselli G, Zangrillo A, Zanella A, Antonelli M, Cabrini L, Castelli A, et al. Baseline Characteristics and Outcomes of 1591 Patients Infected with SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. Journal of the American Medical Association. 2020; 323: 1574–1581.
 Sansone P, Giaccari LG, Aurilio C, Coppolino F, Esposito V, Fiore M, et al. Post-Infectious Guillain–Barré Syndrome Related to SARS-CoV-2 Infection: A Systematic Review. Life. 2021; 11: 167.
 Guan WJ, Ni Y, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical characteristics of coronavirus disease 2019 in China. New England Journal of Medicine. 2020; 387: 1708–1720.
 Foti G, Giannini A, Bottino N, Castelli GP, Cecconi M, Grasselli G, et al. Management of critically ill patients with COVID-19: suggestions and instructions from the coordination of intensive care units of Lombardy. Minerva Anestesiologica. 2020; 86: 1234–1245.
 Chanques G, Constantin J, Devlin JW, Ely EW, Fraser GL, Gélinas C, et al. Analgesia and sedation in patients with ARDS. Intensive Care Medicine. 2020; 46: 2342–2356.
 Payen JF, Chanques G, Futier E, Velly L, Jaber S, Constantin JM. Sedation for critically ill patients with COVID-19: which specificities? One size does not fit all. Anaesthesia, Critical Care & Pain Medicine. 2020; 39: 341–343.
 Chanques G, Drouot X, Payen J. 2008-2018: Ten years of gradual changes in the sedation guidelines for critically ill patients. Anaesthesia, Critical Care & Pain Medicine. 2018; 37: 509–511.
 Marini JJ, Gattinoni L. Management of COVID-19 Respiratory Distress. Journal of the American Medical Association. 2020; 323: 2329.
 Mahase E. COVID-19: most patients require mechanical ventilation in first 24 hours of critical care. British Medical Journal. 2020; 368: m1201
 Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine. 2013; 41: 263–306.
 Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: early experience and forecast during an emergency response. Journal of the American Medical Association. 2020; 323: 1545–1546.
 Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB. Pharmacologic treatments for coronavirus disease 2019 (COVID-19): A Review. Journal of the American Medical Association. 2020; 323: 1824–1836.
 Monedero P, Gea A, Castro P, Candela-Toha AM, Hernández-Sanz ML, Arruti E, et al. Early corticosteroids are associated with lower mortality in critically ill patients with COVID-19: a cohort study. Critical Care. 2021; 25: 2.
 Lonardo NW, Mone MC, Nirula R, Kimball EJ, Ludwig K, Zhou X, et al. Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients. American Journal of Respiratory and Critical Care Medicine. 2014; 189: 1383–1394.
 Skrobik Y Duprey Ms, Hill NS, Devlin G. Low-dose nocturnal dexemedetimidine prevents ICU delirium, a randomized, placebo-controlledtrial. American Journal of Respiratory and Critical Care Medicine. 2018; 197: 1147–1156.
 Le Guen M, Liu N, Bourgeois E, Chazot T, Sessler DI, Rouby J, et al. Automated sedation outperforms manual administration of propofol and remifentanil in critically ill patients with deep sedation: a randomized phase II trial. Intensive Care Medicine. 2013; 39: 454–462.
 Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomized controlled trial. Lancet. 2008; 371: 126–134
 Rubulotta F, Rubulotta G, Occhipinti G, Naimo J, Gullo A. Comment on “Effects of neuromuscular block on systemic and cerebral hemodynamics and bispectral index during moderate or deep sedation in critically ill patients” by Inoue et al. Intensive Care Medicine. 2007; 33: 388–389.
 Solverson K, Weatherald J, Parhar KKS. Tolerability and safety of awake prone positioning COVID-19 patients with severe hypoxemic respiratory failure. Canadian Journal of Anesthesia. 2021; 68: 64–70.
 Ferguson ND, Fan E, Camporota L, Antonelli M, Anzueto A, Beale R, et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Medicine. 2012; 38: 1573–1582.
 Armstrong RA, Kane AD, Cook TM. Outcomes from intensive care in patients with COVID‐19: a systematic review and meta‐analysis of observational studies. Anaesthesia. 2020; 75: 1340–1349.
 Immovilli P, Morelli N, Antonucci E, Radaelli G, Barbera M, Guidetti D. COVID-19 mortality and ICU admission: the Italian experience. Critical Care. 2020; 24: 228.
 Soy M, Keser G, Atagündüz P, Tabak F, Atagündüz I, Kayhan S. Cytokine storm in COVID-19: pathogenesis and overview of anti-inflammatory agents used in treatment. Clinical Rheumatology. 2020; 39: 2085–2094.
 Jean S, Lee P, Hsueh P. Treatment options for COVID-19: the reality and challenges. Journal of Microbiology, Immunology and Infection. 2020; 53: 436–443.
 McCreary EK, Angus DC. Efficacy of Remdesivir in COVID-19. Journal of the American Medical Association. 2020; 324: 1041–1042.
 Sinha N, Balayla G. Hydroxychloroquine and COVID-19. Postgraduate Medical Journal. 2020; 96: 550–555.
 Toniati P, Piva S, Cattalini M, Garrafa E, Regola F, Castelli F, et al. Tocilizumab for the treatment of severe COVID-19 pneumonia with hyperinflammatory syndrome and acute respiratory failure: A single center study of 100 patients in Brescia, Italy. Autoimmunity Reviews. 2020; 19: 102568.
 Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. 2020; 135: 2033–2040.
 Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. Journal of Thrombosis and Haemostasis. 2020; 18: 1094–1099.
 Saghazadeh A, Rezaei N. Towards treatment planning of COVID-19: Rationale and hypothesis for the use of multiple immunosuppressive agents: Anti-antibodies, immunoglobulins, and corticosteroids. Interna-tional Immunopharmacology. 2020; 84: 106560.
 Hushmandi K, Bokaie S, Hashemi M, Moghadam ER, Raei M, Hashemi F, et al. A review of medications used to control and improve the signs and symptoms of COVID-19 patients. European Journal of Pharmacology. 2020; 887: 173568.
 Balas MC, Weinhouse GL, Denehy L, Chanques G, Rochwerg B, Misak CJ, et al. Interpreting and implementing the Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption Clinical Practice Guideline. Critical Care Medicine. 2018; 46: 1464–1470.
 Navas-Blanco JR, Dudaryk R. Management of Respiratory Distress Syndrome due to COVID-19 infection. BMC Anesthesiology. 2020; 20: 177.
 Schwarzkopf D, Behrend S, Skupin H, Westermann I, Riedemann NC, Pfeifer R, et al. Family satisfaction in the intensive care unit: a quantitative and qualitative analysis. Intensive Care Medicine. 2013; 39: 1071–1079.
 Devlin JW, Skrobik Y, Gélinas 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. Critical Care Medicine. 2018; 46: e825–e873.
 Mehta S, Spies C, Shehabi Y. Ten tips for ICU sedation. Intensive Care Medicine. 2018; 44: 1141–1143.
 Chanques G, Kress JP, Pohlman A, Patel S, Poston J, Jaber S, et al. Impact of Ventilator Adjustment and Sedation–Analgesia Practices on Severe Asynchrony in Patients Ventilated in Assist-Control Mode. Critical Care Medicine. 2013; 41: 2177–2187.
 Minhas MA, Velasquez AG, Kaul A, Salinas PD, Celi LA. Effect of Protocolized Sedation on Clinical Outcomes in Mechanically Ventilated Intensive Care Unit Patients: a Systematic Review and Meta-analysis of Randomized Controlled Trials. Mayo Clinic Proceedings. 2015; 90: 613–623.
 Stollings J, Szumita P, Devlin J. Choice of analgesia and sedation. In Posa SP, Stollings JL (eds.) ICU liberation. Society of Critical Care Medicine, Mount Prospect. 2020.
 Jabaudon M, Boucher P, Imhoff E, Chabanne R, Faure JS, Roszik L, et al. Sevoflurane for sedation in acute respiratory distress syndrome: a randomized pilot study. American Journal of Respiratory and Critical Care Medicine. 2017; 195: 702–800.
 Alhazzani W, Belley-Cote E, Møller MH, Angus DC, Papazian L, Arabi YM, et al. Neuromuscular blockade in patients with ARDS: a rapid practice guideline. Intensive Care Medicine. 2020; 46: 1977–1986.
 Rose L, Fitzgerald E, Cook D, Kim S, Steinberg M, Devlin JW, et al. Clinician perspectives on protocols designed to minimize sedation. Journal of Critical Care. 2015; 30: 348–352.
 Aitken LM, Bucknall T, Kent B, Mitchell M, Burmeister E, Keogh S. Sedation protocols to reduce duration of mechanical ventilation in the ICU: a Cochrane Systematic Review. Journal of Advanced Nursing. 2016; 72: 261–272.
 Jakob SM. Dexmedetomidine vs Midazolam or Propofol for Sedation during Prolonged Mechanical Ventilation: two randomized controlled trials. Journal of the American Medical Association. 2012; 307: 1151–1160.
 Rijkenberg S, Stilma W, Endeman H, Bosman RJ, Oudemans-van Straaten HM. Pain measurement in mechanically ventilated critically ill patients: Behavioral Pain Scale versus Critical-Care Pain Observation Tool. Journal of Critical Care. 2015; 30: 167–172.
 Chanques G, Viel E, Constantin J, Jung B, de Lattre S, Carr J, et al. The measurement of pain in intensive care unit: comparison of 5 self-report intensity scales. Pain. 2010; 151: 711–721.
 Chanques G, Tarri T, Ride A, Prades A, De Jong A, Carr J, et al. Analgesia nociception index for the assessment of pain in critically ill patients: a diagnostic accuracy study. British Journal of Anaesthesia. 2017; 119: 812–820.
 Pajen JF, Bosson JL, Chanques G, Mantz J, Labarere J. Pain assessment is associated with decreased duration of mechanical ventilation in the intensive care unit: a post Hoc analysis of the Dolore a study. Anesthesiology 2009; 111: 1308–1316.
Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.
Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.
Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.
IndexCopernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.
Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.
Scopus: CiteScore 0.5(2019) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.
Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.