Prescription of anxiolytics, sedatives, hypnotics and antidepressants in outpatient, universal care during the COVID-19 pandemic in Portugal: a nationwide, interrupted time-series approach.

BACKGROUND: The COVID-19 pandemic has had a significant impact on the population's mental health. However, its impact on the consumption of anxiolytics, sedatives, hypnotics and antidepressants remains to be evaluated. Hence, this article aims to assess the prescription trends of these drugs in Portugal, from January 2018 to March 2021, while critically examining whether the COVID-19 pandemic had an impact on these prescription trends or not. METHODS: A nationwide interrupted time-series analysis of the prescription data of anxiolytics, sedatives, hypnotics and antidepressants in outpatient setting of the public health sector was conducted. The data encompassed the defined daily dose per month, age range and sex and were analysed following a segmented regression approach. RESULTS: The pandemic preceded an immediate reduction in the prescription of anxiolytics, sedatives and hypnotics for children and adolescents. However, an increasing trend throughout the pandemic has been noted in the prescription of these drugs, especially among adults aged 65 years or above. A drop in antidepressant prescription was observed as an immediate effect of the pandemic among male and female adolescents and elderly women. From March 2020 to March 2021, a decreasing prescription trend has been noted among men. CONCLUSIONS: When analysing specific genders and age ranges, differences can be noted, in terms of both immediate impact and prescribing trends throughout 1 year of the COVID-19 pandemic. The impact of the pandemic on mental health and its association with the consumption trends of psychoactive drugs, and with the access to mental health treatments, should be further assessed.

Case report on intervention of sedative drug dependence with "simple and quick reconstruction method" in psychological crisis assistance.

INTRODUCTION: In the past, the problem of sedation drug dependence has been reported in psychological counseling cases, but it is rare to use the rapid reconstruction method for psychological emergency intervention. This article reports the applying of rapid reconstruction method in the intervention of sedation drug dependence during psychological emergency in the context of the Corona Virus Disease-2019 public health events. THE MAIN THERAPEUTIC INTERVENTIONS: Firstly present the problem including presenting experiences related to psychological stress, troubles of events, core problems and self-assessment based on a score of 0 to 10, secondly transfer information including normalizing relevant reactions and providing useful knowledge, thirdly cope with strategies of seeking internal and external resources, reassessing and making improvement plans, at last improve the summary which includes reviewing the process to summarize gains, initiate actions and commit. OUTCOMES: The author discussed the current psychological crisis with the patient, scored the tense and anxious situation, normalized the response to the patient and passed on the knowledge about controlling Corona Virus Disease-2019 prevention and sedative drugs, helped him find the method to adjust himself and the social resources he confided to his friends during the similar period, scored again, put forward the plan, reviewed the conversation process and made a commitment to not use sedative drugs. CONCLUSIONS: Through the "simple and quick reconstruction method," the patient was able to solve the problem of dependence on sedative drugs, relieve tension and anxiety, find resources, and keep living.

The clinical practice of palliative sedation in patients dying from COVID-19: a retrospective chart review.

BACKGROUND: Clinical experts experienced challenges in the practice of palliative sedation (PS) during the COVID-19 pandemic. Rapid deterioration in patients' situation was observed while the indications for starting PS seemed to differ compared to other terminal patients. It is unclear to which extent clinical trajectories of PS differ for these COVID patients compared to regular clinical practice of PS. OBJECTIVES: To describe the clinical practice of PS in patients with COVID versus non-COVID patients. METHODS: A retrospective analysis of data from a Dutch tertiary medical centre was performed. Charts of adult patients who died with PS during hospitalisation between March '20 and January '21 were included. RESULTS: During the study period, 73 patients received PS and of those 25 (34%) had a COVID infection. Refractory dyspnoea was reported as primary indication for starting PS in 84% of patients with COVID compared to 33% in the other group (p < 0.001). Median duration of PS was significantly shorter in the COVID group (5.8 vs. 17.1 h, p < 0.01). No differences were found for starting dosages, but median hourly dose of midazolam was higher in the COVID group (4.2 mg/hr vs. 2.4 mg/hr, p < 0.001). Time interval between start PS and first medication adjustments seemed to be shorter in COVID patients (1.5 vs. 2.9 h, p = 0.08). CONCLUSION: PS in COVID patients is characterized by rapid clinical deterioration in all phases of the trajectory. What is manifested by earlier dose adjustments and higher hourly doses of midazolam. Timely evaluation of efficacy is recommended in those patients.

Use of volatile anesthetics for sedation in the ICU during the COVID-19 pandemic: A national survey in France (VOL'ICU 2 study).

BACKGROUND: The COVID-19 pandemic has increased the number of patients in ICUs leading to a worldwide shortage of the intravenous sedative agents obligating physicians to find alternatives including inhaled sedation. Inhaled sedation in French ICU has been previously explored in 2019 (VOL'ICU study). This survey was designed to explore the use of inhaled sedation two years after our first survey and to evaluate how the COVID-19 pandemic has impacted the use of inhaled sedation. METHODS: We designed a national survey, contacting medical directors of French ICUs between June and October 2021. Over a 50-item questionnaire, the survey covered the characteristics of the ICU, data on inhaled sedation, and practical aspects of inhaled ICU sedation for both COVID-19 and non-COVID-19 patients. Answers were compared with the previous survey, VOL'ICU. RESULTS: Among the 405 ICUs contacted, 25% of the questionnaires were recorded. Most ICU directors (87%) knew about the use of inhaled ICU sedation and 63% of them have an inhaled sedation's device in their unit. The COVID-19 pandemic increased the use of inhaled sedation in French ICUs. The main reasons said by the respondent were "need for additional sedative" (62%), "shortage of intravenous sedatives" (38%) and "involved in a clinical trial" (30%). The main reasons for not using inhaled ICU sedation were "device not available" (76%), "lack of familiarity" (60%) and "no training for the teams" (58%). More than 70% of respondents were overall satisfied with the use of inhaled sedation. Almost 80% of respondents stated that inhaled sedation was a seducing alternative to intravenous sedation for management of COVID-19 patients. CONCLUSION: The use of inhaled sedation in ICU has increased fastly in the last 2 years, and is frequently associated with a good satisfaction among the users. Even if the COVID-19 pandemic could have impacted the widespread use of inhaled sedation, it represents an alternative to intravenous sedation for more and more physicians.

The impact of the coronavirus pandemic on sedation in critical care: volatile anesthetics in the ICU.

PURPOSE OF REVIEW: To reflect on the impact of the coronavirus pandemic on sedation for mechanically ventilated patients. RECENT FINDINGS: Shortages of intravenous sedatives during coronavirus pandemic renewed interest in using widely available inhaled anaesthetics for sedation of critically ill patients. Universally used for surgical anaesthesia, inhaled anaesthetics may offer therapeutic advantages in patients with acute lung injury with good sedation profiles, rapid clearance and lower lung inflammation in pilot trials. However, enabling ICU sedation with inhaled anaesthetics required technological and human resource innovation during the chaos of the global pandemic. The disruption of standard sedation practices is challenging during normal operations, yet pandemic facilitated innovation in this field by fostering cross-discipline collaboration supported by healthcare professionals, hospitals, research institutes and regulators. SUMMARY: Although further research is needed to establish the role of inhaled anaesthetics in critical care sedation toolkit, maintaining the spirit of innovation ignited during the recent coronavirus pandemic would require ongoing collaboration and streamlining of processes among healthcare, research and regulatory institutions.

Tracheotomy in ventilator-dependent patients with COVID-19: a cross-sectional study of analgesia and sedative requirements.

OBJECTIVE: During March 2020 in the United States, demand for sedatives increased by 91%, that for analgesics rose by 79%, and demand for neuromuscular blockers increased by 105%, all owing to the number of COVID-19 cases requiring invasive mechanical ventilation (MV). We hypothesize that analgesic and sedative requirements decrease following tracheotomy in this patient population. METHODS: In this cross-sectional study, we conducted a retrospective chart review to identify patients with COVID-19 who underwent tracheotomy (T) at an academic medical center between March 2020 and January 2021. We used a paired Student t-test to compare total oral morphine equivalents (OMEs), total lorazepam equivalents, 24-hour average dexmedetomidine dosage in µg/kg/hour, and 24-hour average propofol dosage in µg/kg/minute on days T-1 and T+2 for each patient. RESULTS: Of 50 patients, 46 required opioids before and after tracheotomy (mean decrease of 49.4 mg OMEs). Eight patients required benzodiazepine infusion (mean decrease of 45.1 mg lorazepam equivalents. Fifteen patients required dexmedetomidine infusion (mean decrease 0.34 µg/kg/hour). Seventeen patients required propofol (mean decrease 20.5 µg/kg/minute). CONCLUSIONS: When appropriate personal protective equipment is available, use of tracheotomy in patients with COVID-19 who require MV may help to conserve medication supplies in times of extreme shortages.

Use of Alcohol, Cannabinoids, Psychostimulants, and Sedatives before and during the COVID-19 Pandemic among Students in 40 European Countries.

In March 2020, the WHO announced the COVID-19 pandemic, which has been ongoing for over 2 years. To stop the spread of the virus, the governments of many countries decided to introduce reasonable social restrictions that were suitable for pandemic waves. This led to radical changes in people's lives, especially among students, who are very active in society. Before COVID-19, being of student age was associated with the highest frequency of stimulants use. It is important to note that drugs are taken disparately in various areas. Therefore, using the Computer-Assisted Web Interview type of study, the impact of the pandemic on the use of alcohol, cannabinoids, psychostimulants (e.g., amphetamine, methamphetamine, ecstasy) and sedatives (e.g., zolpidem, zopiclone, alprazolam, lorazepam, etc.) was assessed among students from European countries. The questionnaire included single- and multiple-answer questions. The first part concerned sociodemographic questions, while the second included questions about the use of stimulants in the last 3 months prior to participation in the study. Distribution of the survey covered the period from 31 January 2016 to 30 April 2021. A total of 17,594 European students participated in the study. The vast majority of participants were women (80.4%) and students of non-medical universities (77.2%) living in Eastern European countries (86.1%). Of all students, 15,613 (89.6%) reported alcohol drinking, 2538 (14.1%) the use of cannabinoids, 650 (3.6%) psychostimulants, and 2252 (12.5%) sedatives in the past three months. It has been shown that women are far less likely to use alcohol (OR 0.81), psychostimulants (OR 0.44) and cannabinoids (OR 0.49), while they are more likely to use sedatives (OR 1.41). During the COVID-19 pandemic, the consumption of alcohol (OR 0.55) and psychostimulants (OR 0.72) decreased and that of sleep medications increased (OR 1.17). To conclude, the COVID-19 pandemic influenced the pattern of stimulants used by students in European countries. The restriction of social interactions contributed to the decrease in the consumption of alcohol and psychostimulants but increased the use of sedatives and the frequency of their use. Women were found to use sedatives more often, while men preferred to drink alcohol and use cannabinoids or psychostimulants. It has also been shown that students of Central and Eastern Europe more often use alcohol and sedatives, while in Southern European countries psychostimulants and cannabinoids are preferred.

Bundled Bispectral Index Monitoring and Sedation During Paralysis in Acute Respiratory Distress Syndrome.

BACKGROUND: Clinical assessments of depth of sedation are insufficient for patients undergoing neuromuscular blockade during treatment of acute respiratory distress syndrome (ARDS). This quality initiative was aimed to augment objective assessment and improve sedation during therapeutic paralysis using the bispectral index (BIS). METHODS: This quality improvement intervention provided education and subsequent implementation of a BIS monitoring and sedation/analgesia bundle in a large, urban, safety-net intensive care unit. After the intervention, a retrospective review of the first 70 admissions with ARDS assessed use and documented sedation changes in response to BIS. RESULTS: Therapeutic neuromuscular blockade was initiated for 58 of 70 patients (82.8%) with ARDS, of whom 43 (74%) had BIS monitoring and 29.3% had bundled BIS sedation-titration orders. Explicit documentation of sedation titration in response to BIS values occurred in 27 (62.8%) of those with BIS recordings. CONCLUSIONS: BIS sedation/analgesia bundled order sets are underused, but education and access to BIS monitoring led to high use of monitoring alone and subsequent sedation changes.

Sedative polypharmacy mediates the effect of mechanical ventilation on delirium in critically ill COVID-19 patients: A retrospective cohort study.

BACKGROUND: Polypharmacy of sedatives (PP) is a potentially modifiable, iatrogenic risk factor for ICU delirium. The extent to which sedative PP influenced development of high rates of delirium among critically ill COVID-19 patients is unknown. We tested the hypothesis that PP, defined as the use of four or more classes of intravenous agents, is a mediator in the causal pathway of mechanical ventilation and delirium. METHODS: Retrospective cohort study of adults admitted with a primary diagnosis of RT-PCR+ for SARS-CoV2 to ICUs of a tertiary-level academic medical center between February 2020 and April 2021. Mediation analysis was conducted with bootstrap estimation to assess whether an association between mechanical ventilation and delirium was mediated by PP. Analyses were adjusted for potential confounders related to mechanical ventilation, mediator, and outcome, including age, gender, vasopressor use, median RASS scores, SOFA score within 24 h of admission, and maximum CRP levels. RESULTS: A total of 212 patients were included in the analysis. Of total patients, 72.6%(154/212) of patients had delirium (CAM-ICU+) during ICU stay. 54.7%(116/212) patients received PP. Mechanical ventilation (OR 3.81 [1.16-12.52]) and PP (OR 7.38 [2.4-22.68]) were identified as risk factors for development of ICU delirium after adjusting for prespecified confounders. PP acts as a mediator in the causal pathway between mechanical ventilation and delirium. 39% (95% CI: 17%-94%) of the effect of mechanical ventilation on delirium was mediated through PP. CONCLUSION: PP mediates approximately 39% of the effect of mechanical ventilation on delirium, which is clinically and statistically significant. Studies should assess whether mitigating PP could lead to reduction in ICU delirium. IMPLICATION STATEMENT: PP of sedatives (defined as use of four or more intravenous agents) mediates approximately 39% of the effect of mechanical ventilation on development of ICU delirium. Avoidance of sedative PP may represent a viable strategy for reduction of ICU delirium.

A dual-center cohort study on the association between early deep sedation and clinical outcomes in mechanically ventilated patients during the COVID-19 pandemic: The COVID-SED study.

BACKGROUND: Mechanically ventilated patients have experienced greater periods of prolonged deep sedation during the coronavirus disease (COVID-19) pandemic. Multiple studies from the pre-COVID era demonstrate that early deep sedation is associated with worse outcome. Despite this, there is a lack of data on sedation depth and its impact on outcome for mechanically ventilated patients during the COVID-19 pandemic. We sought to characterize the emergency department (ED) and intensive care unit (ICU) sedation practices during the COVID-19 pandemic, and to determine if early deep sedation was associated with worse clinical outcomes. STUDY DESIGN AND METHODS: Dual-center, retrospective cohort study conducted over 6 months (March-August, 2020), involving consecutive, mechanically ventilated adults. All sedation-related data during the first 48 h were collected. Deep sedation was defined as Richmond Agitation-Sedation Scale of - 3 to - 5 or Riker Sedation-Agitation Scale of 1-3. To examine impact of early sedation depth on hospital mortality (primary outcome), we used a multivariable logistic regression model. Secondary outcomes included ventilator-, ICU-, and hospital-free days. RESULTS: 391 patients were studied, and 283 (72.4%) experienced early deep sedation. Deeply sedated patients received higher cumulative doses of fentanyl, propofol, midazolam, and ketamine when compared to light sedation. Deep sedation patients experienced fewer ventilator-, ICU-, and hospital-free days, and greater mortality (30.4% versus 11.1%) when compared to light sedation (p < 0.01 for all). After adjusting for confounders, early deep sedation remained significantly associated with higher mortality (adjusted OR 3.44; 95% CI 1.65-7.17; p < 0.01). These results were stable in the subgroup of patients with COVID-19. CONCLUSIONS: The management of sedation for mechanically ventilated patients in the ICU has changed during the COVID pandemic. Early deep sedation is common and independently associated with worse clinical outcomes. A protocol-driven approach to sedation, targeting light sedation as early as possible, should continue to remain the default approach.

Consumption of Psychiatric Drugs in Primary Care during the COVID-19 Pandemic.

BACKGROUND: The main objective of this research was to analyze whether there were changes in the use of antidepressants, anxiolytics, and hypnotic-sedative drugs, in the context of primary health care, during the COVID-19 pandemic compared to the pre-pandemic period. We further sought to study consumption in vulnerable population groups. METHODS: A cross-sectional observational study was performed in a primary health district of Spain. The data were obtained from the Andalusian Public Health System database, for the pre-COVID-19 period, from March 2019 to February 2020, and for the COVID-19 period, from March 2020 to February 2021. Univariant and bivariant analyses were performed. The effect size was measured using the Rosenthal test. RESULTS: While the total number of medical prescriptions decreased by 2.5% in the COVID-19 period, the prescriptions of psychiatric drugs increased by 6.1%. The increase in the dose consumption per 1000 inhabitants (DHD) was highest for anxiolytics (7.2%), followed by hypnotic-sedatives (5.6%) and antidepressants (3.7%). The consumption of antidepressants, anxiolytics, and sedative-hypnotic drugs was higher in women, older people, and rural areas and lower in areas with social transformation needs, with these differences being statistically significant. CONCLUSIONS: The consumption of psychiatric drugs has increased over the COVID-19 pandemic, especially in women, older people, and rural areas. Thus, we should reflect on the adequate use of these drugs.

Variations in COVID-19 vaccination uptake among people in receipt of psychotropic drugs: cross-sectional analysis of a national population-based prospective cohort.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has disproportionately affected people with mental health conditions. AIMS: We investigated the association between receiving psychotropic drugs, as an indicator of mental health conditions, and COVID-19 vaccine uptake. METHOD: We conducted a cross-sectional analysis of a prospective cohort of the Northern Ireland adult population using national linked primary care registration, vaccination, secondary care and pharmacy dispensing data. Univariable and multivariable logistic regression analyses investigated the association between anxiolytic, antidepressant, antipsychotic, and hypnotic use and COVID-19 vaccination status, accounting for age, gender, deprivation and comorbidities. Receiving any COVID-19 vaccine was the primary outcome. RESULTS: There were 1 433 814 individuals, of whom 1 166 917 received a COVID-19 vaccination. Psychotropic medications were dispensed to 267 049 people. In univariable analysis, people who received any psychotropic medication had greater odds of receiving COVID-19 vaccination: odds ratio (OR) = 1.42 (95% CI 1.41-1.44). However, after adjustment, psychotropic medication use was associated with reduced odds of vaccination (ORadj = 0.90, 95% CI 0.89-0.91). People who received anxiolytics (ORadj = 0.63, 95% CI 0.61-0.65), antipsychotics (ORadj = 0.75, 95% CI 0.73-0.78) and hypnotics (ORadj = 0.90, 95% CI 0.87-0.93) had reduced odds of being vaccinated. Antidepressant use was not associated with vaccination (ORadj = 1.02, 95% CI 1.00-1.03). CONCLUSIONS: We found significantly lower odds of vaccination in people who were receiving treatment with anxiolytic and antipsychotic medications. There is an urgent need for evidence-based, tailored vaccine support for people with mental health conditions.

Positive Stimulation for Medically Sedated Patients: A Music Therapy Intervention to Treat Sedation-Related Delirium in Critical Care.

Sedation is an essential component of treatment for some patients admitted to the ICU, but it carries a risk of sedation-related delirium. Sedation-related delirium is associated with higher mortality and increased length of stay, but pharmacologic treatments for delirium can lead to oversedation or other adverse effects. Therefore, nonpharmacologic treatments are recommended in the literature; however, these recommendations are quite general and do not provide structured interventions. To establish a structured nonpharmacologic intervention that could improve indications of delirium after sedation, we combined evidence-based interventions including recordings of sensory-rich stories told by the patient's family and patient-specific music into our novel positive stimulation for medically sedated patients (PSMSP) protocol. The positive listening stimulation playlist organized by a board-certified music therapist (MT-BC) within the PSMSP protocol can be used in carefully monitored sessions with the MT-BC potentially to decrease agitation and stabilize arousal, as well as being played by nursing staff throughout the patient's recovery from sedation. Further controlled studies will be necessary, but the PSMSP protocol has the potential to reduce agitation and increase arousal during listening, as highlighted by the case of a patient recovering from sedation during treatment for COVID-19 pneumonia. It is important for the entire critical care team to be aware of nonpharmacologic treatments like PSMSP that are available for delirium mitigation so that, where applicable, these therapies can be incorporated into the patient's treatment regimen.

Trends in the Use of Benzodiazepines, Z-Hypnotics, and Serotonergic Drugs Among US Women and Men Before and During the COVID-19 Pandemic.

Importance: The ongoing COVID-19 pandemic and associated mitigation measures have disrupted access to psychiatric medications, particularly for women. Objective: To assess the sex differences in trends in the prescribing of benzodiazepines, Z-hypnotics and serotonergic (selective serotonin reuptake inhibitors [SSRIs] and serotonin and norepinephrine reuptake inhibitors [SNRIs]), which are commonly prescribed for anxiety, insomnia, and depression. Design, Setting, and Participants: This cohort study used data from Clinformatics Data Mart, one of the largest commercial health insurance databases in the US. Enrollees 18 years or older were required to have complete enrollment in a given month during our study period, January 1, 2018, to March 31, 2021, to be included for that month. Main Outcomes and Measures: Prescription of a benzodiazepine, Z-hypnotic, or SSRI or SNRI. For each month, the percentage of patients with benzodiazepine, Z-hypnotic, or SSRI or SNRI prescriptions by sex was calculated. Results: The records of 17 255 033 adults (mean [SD] age, 51.7 [19.5] years; 51.3% female) were examined in 2018, 17 340 731 adults (mean [SD] age, 52.5 [19.7] years; 51.6% female) in 2019, 16 916 910 adults (mean [SD] age, 53.7 [19.8] years; 51.9% female) in 2020, and 15 135 998 adults (mean [SD] age, 56.2 [19.8] years; 52.5% female) in 2021. Compared with men, women had a higher rate of prescriptions for all 3 drugs classes and had larger changes in prescription rates over time. Benzodiazepine prescribing decreased from January 2018 (women: 5.61%; 95% CI, 5.60%-5.63%; men: 3.03%; 95% CI, 3.02%-3.04%) to March 2021 (women: 4.91%; 95% CI, 4.90%-4.93%; men: 2.66%; 95% CI, 2.65%-2.67%), except for a slight increase in April 2020 among women. Z-hypnotic prescribing increased from January 2020 for women (1.39%; 95% CI, 1.38%-1.40%) and February 2020 for men (0.97%; 95% CI, 0.96%-0.98%) to October 2020 (women: 1.46%; 95% CI, 1.46%-1.47%; men: 1.00%; 95% CI, 0.99%-1.01%). Prescribing of SSRIs and SNRIs increased from January 2018 (women: 12.77%; 95% CI; 12.75%-12.80%; men: 5.56%; 95% CI, 5.44%-5.58%) to April 2020 for men (6.73%; 95% CI, 6.71%-6.75%) and October 2020 for women (15.18%; 95% CI, 15.16%-15.21%). Conclusions and Relevance: In this cohort study, coinciding with the COVID-19 pandemic onset was an increase in Z-hypnotic as well as SSRI and SNRI prescriptions in both men and women along with an increase in benzodiazepine prescriptions in women, findings that suggest a substantial mental health impact of COVID-19-associated mitigation measures.

Design of Clinical Trials Evaluating Sedation in Critically Ill Adults Undergoing Mechanical Ventilation: Recommendations From Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research (SCEPTER) Recommendation III.

OBJECTIVES: Clinical trials evaluating the safety and effectiveness of sedative medication use in critically ill adults undergoing mechanical ventilation differ considerably in their methodological approach. This heterogeneity impedes the ability to compare results across studies. The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations convened a meeting of multidisciplinary experts to develop recommendations for key methodologic elements of sedation trials in the ICU to help guide academic and industry clinical investigators. DESIGN: A 2-day in-person meeting was held in Washington, DC, on March 28-29, 2019, followed by a three-round, online modified Delphi consensus process. PARTICIPANTS: Thirty-six participants from academia, industry, and the Food and Drug Administration with expertise in relevant content areas, including two former ICU patients attended the in-person meeting, and the majority completed an online follow-up survey and participated in the modified Delphi process. MEASUREMENTS AND MAIN RESULTS: The final recommendations were iteratively refined based on the survey results, participants' reactions to those results, summaries written by panel moderators, and a review of the meeting transcripts made from audio recordings. Fifteen recommendations were developed for study design and conduct, subject enrollment, outcomes, and measurement instruments. Consensus recommendations included obtaining input from ICU survivors and/or their families, ensuring adequate training for personnel using validated instruments for assessments of sedation, pain, and delirium in the ICU environment, and the need for methodological standardization. CONCLUSIONS: These recommendations are intended to assist researchers in the design, conduct, selection of endpoints, and reporting of clinical trials involving sedative medications and/or sedation protocols for adult ICU patients who require mechanical ventilation. These recommendations should be viewed as a starting point to improve clinical trials and help reduce methodological heterogeneity in future clinical trials.

Two cases of severe COVID-19 in gestational week 27 and 28 respectively, after which both pregnancies proceeded to term.

COVID-19 in pregnancy increases the risk of caesarean section. We present two cases of late gestation pregnant women with severe COVID-19. Both were successfully treated with mechanical ventilation without termination of pregnancy and, following recovery from COVID-19, had vaginal deliveries at term. These two cases demonstrate the possibility of treating pregnant women with severe COVID-19 with mechanical ventilation in the late second and early third trimesters without them having a pre-term delivery. With a multidisciplinary approach, such management could avoid the maternal risks of surgery during a severe infection and, at the same time, enable term birth with a lower risk of neonatal complications.