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1.
JAMA Netw Open ; 4(10): e2131012, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1482078

ABSTRACT

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.


Subject(s)
Benzodiazepines/therapeutic use , COVID-19/psychology , Hypnotics and Sedatives/therapeutic use , Serotonin Uptake Inhibitors/therapeutic use , Serotonin and Noradrenaline Reuptake Inhibitors/therapeutic use , Adult , Aged , COVID-19/epidemiology , Databases, Factual , Female , Humans , Longitudinal Studies , Male , Middle Aged , Pandemics , SARS-CoV-2 , Sex Distribution
2.
Crit Care Med ; 49(10): 1684-1693, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1452742

ABSTRACT

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.


Subject(s)
Hypnotics and Sedatives/pharmacokinetics , Hypnotics and Sedatives/therapeutic use , Congresses as Topic , Consensus , Delphi Technique , District of Columbia , Humans , Hypnotics and Sedatives/pharmacology , Respiration, Artificial/instrumentation , Respiration, Artificial/methods , Time Factors
3.
Int J Obstet Anesth ; 48: 103212, 2021 11.
Article in English | MEDLINE | ID: covidwho-1401518

ABSTRACT

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.


Subject(s)
COVID-19/therapy , Live Birth , Positive-Pressure Respiration/methods , Pregnancy Complications, Infectious/therapy , Adult , Analgesics/therapeutic use , Anti-Bacterial Agents/therapeutic use , Anticoagulants/therapeutic use , COVID-19/physiopathology , Female , Humans , Hypnotics and Sedatives/therapeutic use , Neuromuscular Nondepolarizing Agents/therapeutic use , Pregnancy , Pregnancy Complications, Infectious/physiopathology , Pregnancy Outcome , SARS-CoV-2 , Treatment Outcome , Young Adult
5.
Medicina (Kaunas) ; 57(9)2021 Aug 26.
Article in English | MEDLINE | ID: covidwho-1374457

ABSTRACT

Background and Objectives: Descriptions of end-of-life in COVID-19 are limited to small cross-sectional studies. We aimed to assess end-of-life care in inpatients with COVID-19 at Alicante General University Hospital (ALC) and compare differences according to palliative and non-palliative sedation. Material and Methods: This was a retrospective cohort study in inpatients included in the ALC COVID-19 Registry (PCR-RT or antigen-confirmed cases) who died during conventional admission from 1 March to 15 December 2020. We evaluated differences among deceased cases according to administration of palliative sedation. Results: Of 747 patients evaluated, 101 died (13.5%). Sixty-eight (67.3%) died in acute medical wards, and 30 (44.1%) received palliative sedation. The median age of patients with palliative sedation was 85 years; 44% were women, and 30% of cases were nosocomial. Patients with nosocomial acquisition received more palliative sedation than those infected in the community (81.8% [9/11] vs 36.8% [21/57], p = 0.006), and patients admitted with an altered mental state received it less (20% [6/23] vs. 53.3% [24/45], p = 0.032). The median time from admission to starting palliative sedation was 8.5 days (interquartile range [IQR] 3.0-14.5). The main symptoms leading to palliative sedation were dyspnea at rest (90%), pain (60%), and delirium/agitation (36.7%). The median time from palliative sedation to death was 21.8 h (IQR 10.4-41.1). Morphine was used in all palliative sedation perfusions: the main regimen was morphine + hyoscine butyl bromide + midazolam (43.3%). Conclusions: End-of-life palliative sedation in patients with COVID-19 was initiated quite late. Clinicians should anticipate the need for palliative sedation in these patients and recognize the breathlessness, pain, and agitation/delirium that foreshadow death.


Subject(s)
COVID-19 , Terminal Care , Aged, 80 and over , Cross-Sectional Studies , Female , Humans , Hypnotics and Sedatives/therapeutic use , Retrospective Studies , SARS-CoV-2
6.
J ECT ; 37(1): 71-73, 2021 03 01.
Article in English | MEDLINE | ID: covidwho-1352357

ABSTRACT

ABSTRACT: We describe the case of a patient, hospitalized in a California community medical ICU for over a month, with severe neuroleptic malignant syndrome (NMS), unresponsive to medical management, but responsive to electroconvulsive therapy (ECT). We discuss the medical, logistical, and legal challenges in providing ECT in this setting. We also describe a previously unpublished use of dexmedetomidine, which aided in the safe and rapid reduction of benzodiazepines and permitted a successful ECT course. The rapid delivery and efficacy of ECT were essential because of the burgeoning coronavirus pandemic. The patient's treatment required exemplary efforts by providers across multiple disciplines, ongoing medicolegal consultation with the county mental health medical director, as well as consultation with expert members of the International Society for ECT and Neurostimulation. We conclude with a discussion of the unique challenges of providing emergency ECT to patients in California, including during a serious pandemic, when courts are closed. This case illustrates the importance of cultivating and maintaining high-quality ECT expertise in community hospitals and keeping ECT services available even during pandemics. Also, this case demonstrates that ECT is not "merely an elective procedure" but a vital, life-saving treatment, even during the era of COVID-19. To our knowledge, this is the first such published case of emergency ECT performed in California.


Subject(s)
COVID-19/epidemiology , Dexmedetomidine/therapeutic use , Electroconvulsive Therapy , Hypnotics and Sedatives/therapeutic use , Neuroleptic Malignant Syndrome/therapy , California/epidemiology , Combined Modality Therapy , Female , Humans , Middle Aged , Pandemics , SARS-CoV-2
7.
Pediatr Blood Cancer ; 68(11): e29272, 2021 11.
Article in English | MEDLINE | ID: covidwho-1333028

ABSTRACT

BACKGROUND: Sedation for lumbar punctures (LPs) in pediatric acute lymphoblastic leukemia (ALL) patients has been the standard for decades to reduce pain and anxiety. Recent studies on the potential long-term neurocognitive effects of cumulative propofol exposure have raised concerns about this practice. The recent pandemic introduced additional burdens to patients, with the requirement of a negative COVID-19 test prior to each sedated procedure. PROCEDURE: These factors prompted a quality improvement intervention at our institution where we aimed to reduce postinduction sedated LPs by 50%. Our intervention included patient and family education, followed by a simulation of the procedure for selected patients. Those converted to unsedated LPs were queried for their preference. Comparative cost, clinical time, and LP success rates were collected for sedated and unsedated LPs. RESULTS: Following the intervention, the percentage of LPs performed with sedation dropped from 100% to 48%. All LPs were successful using both techniques. Most patients who experienced the unsedated LP technique, and their guardians, strongly preferred this approach. Unsedated LPs significantly reduced clinical time (169 vs. 83 minutes) for families, decreased expenditures ($5736 reduction per procedure), and improved institutional opportunity cost due to a decrease in last-minute cancelations. CONCLUSION: We have shown that it is feasible to significantly reduce the use of sedation for LPs in patients with ALL, which has the potential to improve health and patient experience at a lower cost.


Subject(s)
Hypnotics and Sedatives/therapeutic use , Pain Management , Precursor Cell Lymphoblastic Leukemia-Lymphoma/diagnosis , Spinal Puncture , Adolescent , Adult , COVID-19/diagnosis , Child , Female , Humans , Hypnotics and Sedatives/adverse effects , Male , Pain Management/adverse effects , Pain Management/methods , Propofol/adverse effects , Propofol/therapeutic use , SARS-CoV-2/isolation & purification , Spinal Puncture/methods , Young Adult
8.
PLoS One ; 16(7): e0253778, 2021.
Article in English | MEDLINE | ID: covidwho-1327974

ABSTRACT

BACKGROUND: Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). METHODS: We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used. RESULTS: In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature. CONCLUSION: The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.


Subject(s)
COVID-19/complications , Critical Illness , Hypnotics and Sedatives/pharmacology , Respiratory Distress Syndrome/complications , Respiratory Distress Syndrome/drug therapy , Adult , Aged , Dose-Response Relationship, Drug , Female , Humans , Hypnotics and Sedatives/therapeutic use , Male , Middle Aged , Respiration, Artificial , Retrospective Studies , Time Factors
9.
Emerg Med Clin North Am ; 39(3): 493-508, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1262904

ABSTRACT

Anatomically, the airway is ever changing in size, anteroposterior alignment, and point of most narrow dimension. Special considerations regarding obesity, chronic and acute illness, underlying developmental abnormalities, and age can all affect preparation and intervention toward securing a definitive airway. Mechanical ventilation strategies should focus on limiting peak inspiratory pressures and optimizing lung protective tidal volumes. Emergency physicians should work toward minimizing risk of peri-intubation hypoxemia and arrest. With review of anatomic and physiologic principles in the setting of a practical approach toward evaluating and managing distress and failure, emergency physicians can successfully manage critical pediatric airway encounters.


Subject(s)
Respiratory Distress Syndrome/therapy , Respiratory Insufficiency/therapy , Airway Management , COVID-19/therapy , Child , Craniofacial Abnormalities/complications , Critical Care , Equipment Design , Functional Residual Capacity , Heart Arrest/therapy , Humans , Hypnotics and Sedatives/therapeutic use , Intubation, Intratracheal/methods , Laryngoscopes , Laryngoscopy/methods , Larynx/anatomy & histology , Neuromuscular Diseases/therapy , Noninvasive Ventilation , Oxygen Inhalation Therapy , Pediatric Emergency Medicine , Pediatric Obesity/complications , Positive-Pressure Respiration , Video Recording
10.
Clin Infect Dis ; 71(16): 2089-2098, 2020 11 19.
Article in English | MEDLINE | ID: covidwho-1153157

ABSTRACT

BACKGROUND: With evidence of sustained transmission in more than 190 countries, coronavirus disease 2019 (COVID-19) has been declared a global pandemic. Data are urgently needed about risk factors associated with clinical outcomes. METHODS: A retrospective review of 323 hospitalized patients with COVID-19 in Wuhan was conducted. Patients were classified into 3 disease severity groups (nonsevere, severe, and critical), based on initial clinical presentation. Clinical outcomes were designated as favorable and unfavorable, based on disease progression and response to treatments. Logistic regression models were performed to identify risk factors associated with clinical outcomes, and log-rank test was conducted for the association with clinical progression. RESULTS: Current standard treatments did not show significant improvement in patient outcomes. By univariate logistic regression analysis, 27 risk factors were significantly associated with clinical outcomes. Multivariate regression indicated age >65 years (P < .001), smoking (P = .001), critical disease status (P = .002), diabetes (P = .025), high hypersensitive troponin I (>0.04 pg/mL, P = .02), leukocytosis (>10 × 109/L, P < .001), and neutrophilia (>75 × 109/L, P < .001) predicted unfavorable clinical outcomes. In contrast, the administration of hypnotics was significantly associated with favorable outcomes (P < .001), which was confirmed by survival analysis. CONCLUSIONS: Hypnotics may be an effective ancillary treatment for COVID-19. We also found novel risk factors, such as higher hypersensitive troponin I, predicted poor clinical outcomes. Overall, our study provides useful data to guide early clinical decision making to reduce mortality and improve clinical outcomes of COVID-19.


Subject(s)
COVID-19/epidemiology , Coronavirus/pathogenicity , Hospitalization/statistics & numerical data , Adult , Aged , Aged, 80 and over , Chi-Square Distribution , China/epidemiology , Female , Humans , Hypnotics and Sedatives/therapeutic use , Male , Middle Aged , Obesity/complications , Obesity/epidemiology , Retrospective Studies , Risk Factors , Young Adult
11.
Encephale ; 46(3S): S116-S118, 2020 Jun.
Article in French | MEDLINE | ID: covidwho-1065050

ABSTRACT

French recommendations have been proposed for psychotropics use and possible adaptations during the SARS-CoV-2 epidemic. Between uncertainties linked to the lack of data and speculations about possible benefits of psychotropics against the coronavirus, we propose here elements allowing to base the pharmacotherapeutic decisions potentially useful in Covid+ patients with psychiatric disorders.


Subject(s)
Antiviral Agents/therapeutic use , Betacoronavirus , Coronavirus Infections/drug therapy , Drug Repositioning , Pandemics , Pneumonia, Viral/drug therapy , Psychotropic Drugs/therapeutic use , Anti-Anxiety Agents/adverse effects , Anti-Anxiety Agents/therapeutic use , Antiviral Agents/adverse effects , Antiviral Agents/pharmacology , Betacoronavirus/drug effects , COVID-19 , Comorbidity , Coronavirus Infections/epidemiology , Dyspnea/chemically induced , Dyspnea/etiology , Humans , Hypnotics and Sedatives/adverse effects , Hypnotics and Sedatives/therapeutic use , Mental Disorders/drug therapy , Mental Disorders/epidemiology , Pneumonia, Viral/epidemiology , Psychotropic Drugs/adverse effects , Psychotropic Drugs/pharmacology , Respiration/drug effects , Risk Assessment , SARS-CoV-2
12.
Lancet Respir Med ; 9(3): 239-250, 2021 03.
Article in English | MEDLINE | ID: covidwho-1053892

ABSTRACT

BACKGROUND: To date, 750 000 patients with COVID-19 worldwide have required mechanical ventilation and thus are at high risk of acute brain dysfunction (coma and delirium). We aimed to investigate the prevalence of delirium and coma, and risk factors for delirium in critically ill patients with COVID-19, to aid the development of strategies to mitigate delirium and associated sequelae. METHODS: This multicentre cohort study included 69 adult intensive care units (ICUs), across 14 countries. We included all patients (aged ≥18 years) admitted to participating ICUs with severe acute respiratory syndrome coronavirus 2 infection before April 28, 2020. Patients who were moribund or had life-support measures withdrawn within 24 h of ICU admission, prisoners, patients with pre-existing mental illness, neurodegenerative disorders, congenital or acquired brain damage, hepatic coma, drug overdose, suicide attempt, or those who were blind or deaf were excluded. We collected de-identified data from electronic health records on patient demographics, delirium and coma assessments, and management strategies for a 21-day period. Additional data on ventilator support, ICU length of stay, and vital status was collected for a 28-day period. The primary outcome was to determine the prevalence of delirium and coma and to investigate any associated risk factors associated with development of delirium the next day. We also investigated predictors of number of days alive without delirium or coma. These outcomes were investigated using multivariable regression. FINDINGS: Between Jan 20 and April 28, 2020, 4530 patients with COVID-19 were admitted to 69 ICUs, of whom 2088 patients were included in the study cohort. The median age of patients was 64 years (IQR 54 to 71) with a median Simplified Acute Physiology Score (SAPS) II of 40·0 (30·0 to 53·0). 1397 (66·9%) of 2088 patients were invasively mechanically ventilated on the day of ICU admission and 1827 (87·5%) were invasively mechanical ventilated at some point during hospitalisation. Infusion with sedatives while on mechanical ventilation was common: 1337 (64·0%) of 2088 patients were given benzodiazepines for a median of 7·0 days (4·0 to 12·0) and 1481 (70·9%) were given propofol for a median of 7·0 days (4·0 to 11·0). Median Richmond Agitation-Sedation Scale score while on invasive mechanical ventilation was -4 (-5 to -3). 1704 (81·6%) of 2088 patients were comatose for a median of 10·0 days (6·0 to 15·0) and 1147 (54·9%) were delirious for a median of 3·0 days (2·0 to 6·0). Mechanical ventilation, use of restraints, and benzodiazepine, opioid, and vasopressor infusions, and antipsychotics were each associated with a higher risk of delirium the next day (all p≤0·04), whereas family visitation (in person or virtual) was associated with a lower risk of delirium (p<0·0001). During the 21-day study period, patients were alive without delirium or coma for a median of 5·0 days (0·0 to 14·0). At baseline, older age, higher SAPS II scores, male sex, smoking or alcohol abuse, use of vasopressors on day 1, and invasive mechanical ventilation on day 1 were independently associated with fewer days alive and free of delirium and coma (all p<0·01). 601 (28·8%) of 2088 patients died within 28 days of admission, with most of those deaths occurring in the ICU. INTERPRETATION: Acute brain dysfunction was highly prevalent and prolonged in critically ill patients with COVID-19. Benzodiazepine use and lack of family visitation were identified as modifiable risk factors for delirium, and thus these data present an opportunity to reduce acute brain dysfunction in patients with COVID-19. FUNDING: None. TRANSLATIONS: For the French and Spanish translations of the abstract see Supplementary Materials section.


Subject(s)
COVID-19/psychology , Coma/epidemiology , Delirium/epidemiology , SARS-CoV-2 , Aged , Coma/virology , Critical Illness/psychology , Delirium/virology , Female , Humans , Hypnotics and Sedatives/therapeutic use , Intensive Care Units/statistics & numerical data , Male , Middle Aged , Prevalence , Respiration, Artificial/psychology , Respiration, Artificial/statistics & numerical data , Retrospective Studies , Risk Factors
13.
Riv Psichiatr ; 55(6): 337-341, 2020.
Article in Italian | MEDLINE | ID: covidwho-992941

ABSTRACT

Insomnia symptoms might affect about 60% of the Italian population. Insomnia is a "24 hours syndrome" and a risk factor for medical and mental disorders. It should always be assessed and treated in the clinical practice. Cognitive Behavioral Therapy for Insomnia is the first line treatment but its availability in Italy is scarce. Pharmacological options in Italy are: melatonin 2 mg prolonged release that should be the first choice in subjects ≥55 years old and used until 13 weeks; and for a short term use (≤4 weeks) Z-drugs or short-acting benzodiazepines (in subjects <65 years old) or a sedating antidepressant.


Subject(s)
COVID-19/epidemiology , Consensus , Epidemics , SARS-CoV-2 , Sleep Aids, Pharmaceutical/therapeutic use , Sleep Initiation and Maintenance Disorders/drug therapy , Aged , Antidepressive Agents/therapeutic use , COVID-19/complications , Cognitive Behavioral Therapy , GABA Agonists/therapeutic use , Humans , Hypnotics and Sedatives/therapeutic use , Italy/epidemiology , Middle Aged , Receptors, Melatonin/agonists , Sleep Initiation and Maintenance Disorders/etiology , Sleep Initiation and Maintenance Disorders/therapy , Societies, Scientific
14.
Intensive Care Med ; 46(12): 2342-2356, 2020 12.
Article in English | MEDLINE | ID: covidwho-917111

ABSTRACT

Acute Respiratory Distress Syndrome (ARDS) is one of the most demanding conditions in an Intensive Care Unit (ICU). Management of analgesia and sedation in ARDS is particularly challenging. An expert panel was convened to produce a "state-of-the-art" article to support clinicians in the optimal management of analgesia/sedation in mechanically ventilated adults with ARDS, including those with COVID-19. Current ICU analgesia/sedation guidelines promote analgesia first and minimization of sedation, wakefulness, delirium prevention and early rehabilitation to facilitate ventilator and ICU liberation. However, these strategies cannot always be applied to patients with ARDS who sometimes require deep sedation and/or paralysis. Patients with severe ARDS may be under-represented in analgesia/sedation studies and currently recommended strategies may not be feasible. With lightened sedation, distress-related symptoms (e.g., pain and discomfort, anxiety, dyspnea) and patient-ventilator asynchrony should be systematically assessed and managed through interprofessional collaboration, prioritizing analgesia and anxiolysis. Adaptation of ventilator settings (e.g., use of a pressure-set mode, spontaneous breathing, sensitive inspiratory trigger) should be systematically considered before additional medications are administered. Managing the mechanical ventilator is of paramount importance to avoid the unnecessary use of deep sedation and/or paralysis. Therefore, applying an "ABCDEF-R" bundle (R = Respiratory-drive-control) may be beneficial in ARDS patients. Further studies are needed, especially regarding the use and long-term effects of fast-offset drugs (e.g., remifentanil, volatile anesthetics) and the electrophysiological assessment of analgesia/sedation (e.g., electroencephalogram devices, heart-rate variability, and video pupillometry). This review is particularly relevant during the COVID-19 pandemic given drug shortages and limited ICU-bed capacity.


Subject(s)
Analgesia/standards , Hypnotics and Sedatives/therapeutic use , Respiratory Distress Syndrome/drug therapy , Analgesia/methods , Guidelines as Topic , Humans , Pain Management/methods
15.
J Emerg Med ; 60(3): 359-364, 2021 03.
Article in English | MEDLINE | ID: covidwho-894016

ABSTRACT

BACKGROUND: Hydroxychloroquine (HCQ) poisoning is a life-threatening but treatable toxic ingestion. The scale of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19) and the controversial suggestion that HCQ is a treatment option have led to a significant increase in HCQ use. HCQ poisoning should be at the top-of-mind for emergency providers in cases of toxic ingestion. Treatment for HCQ poisoning includes sodium bicarbonate, epinephrine, and aggressive electrolyte repletion. We highlight the use of hypertonic saline and diazepam. CASE REPORT: We describe the case of a 37-year-old man who presented to the emergency department after the ingestion of approximately 16 g of HCQ tablets (initial serum concentration 4270 ng/mL). He was treated with an epinephrine infusion, hypertonic sodium chloride, high-dose diazepam, sodium bicarbonate, and aggressive potassium repletion. Persistent altered mental status necessitated intubation, and he was managed in the medical intensive care unit until his QRS widening and QTc prolongation resolved. After his mental status improved and it was confirmed that his ingestion was not with the intent to self-harm, he was discharged home with outpatient follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: For patients presenting with HCQ overdose and an unknown initial serum potassium level, high-dose diazepam and hypertonic sodium chloride should be started immediately for the patient with widened QRS. The choice of hypertonic sodium chloride instead of sodium bicarbonate is to avoid exacerbating underlying hypokalemia which may in turn potentiate unstable dysrhythmia. In addition, early intubation should be a priority in vomiting patients because both HCQ toxicity and high-dose diazepam cause profound sedation.


Subject(s)
COVID-19/drug therapy , Diazepam/therapeutic use , Heart Block/chemically induced , Hydroxychloroquine/poisoning , Hypnotics and Sedatives/therapeutic use , Long QT Syndrome/chemically induced , Poisoning/therapy , Saline Solution, Hypertonic/therapeutic use , Adult , Electrocardiography , Emergency Service, Hospital , Heart Block/therapy , Humans , Long QT Syndrome/therapy , Male , SARS-CoV-2
16.
Pharmacotherapy ; 40(12): 1180-1191, 2020 12.
Article in English | MEDLINE | ID: covidwho-866159

ABSTRACT

Evidence-based management of analgesia and sedation in COVID-19-associated acute respiratory distress syndrome remains limited. Non-guideline recommended analgesic and sedative medication regimens and deeper sedation targets have been employed for patients with COVID-19 due to exaggerated analgesia and sedation requirements with extended durations of mechanical ventilation. This, coupled with a desire to minimize nurse entry into COVID-19 patient rooms, marked obesity, altered end-organ function, and evolving medication shortages, presents numerous short- and long-term challenges. Alternative analgesic and sedative agents and regimens may pose safety risks and require judicious bedside management for appropriate use. The purpose of this commentary is to provide considerations and solutions for designing safe and effective analgesia and sedation strategies for adult patients with considerable ventilator dyssynchrony and sedation requirements, such as COVID-19.


Subject(s)
Analgesics/therapeutic use , COVID-19/complications , COVID-19/drug therapy , Evidence-Based Medicine/methods , Hypnotics and Sedatives/therapeutic use , Respiration, Artificial/methods , Humans , SARS-CoV-2
17.
Prim Care Companion CNS Disord ; 22(4)2020 Jul 16.
Article in English | MEDLINE | ID: covidwho-654929

ABSTRACT

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.


Subject(s)
Coronavirus Infections/therapy , Deprescriptions , Dexmedetomidine/therapeutic use , Emergence Delirium/diagnosis , Hypnotics and Sedatives/therapeutic use , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Substance Withdrawal Syndrome/diagnosis , Adult , Analgesics, Opioid/therapeutic use , Benzodiazepines/therapeutic use , Betacoronavirus , COVID-19 , Emergence Delirium/therapy , Humans , Male , Neurologic Examination , Pandemics , Practice Guidelines as Topic , Propofol/therapeutic use , SARS-CoV-2 , Substance Withdrawal Syndrome/therapy
20.
Palliat Med ; 34(9): 1249-1255, 2020 10.
Article in English | MEDLINE | ID: covidwho-690192

ABSTRACT

BACKGROUND: The literature contains limited information on the problems faced by dying patients with COVID-19 and the effectiveness of interventions to manage these. AIM: The aim of this audit was to assess the utility of our end-of-life care plan, and specifically the effectiveness of our standardised end-of-life care treatment algorithms, in dying patients with COVID-19. DESIGN: The audit primarily involved data extraction from the end-of-life care plan, which includes four hourly nursing (ward nurses) assessments of specific problems: patients with problems were managed according to standardised treatment algorithms, and the intervention was deemed to be effective if the problem was not present at subsequent assessments. SETTING/PARTICIPANTS: This audit was undertaken at a general hospital in England, covered the 8 weeks from 16 March to 11 May 2020 and included all inpatients with COVID-19 who had an end-of-life care plan (and died). RESULTS: Sixty-one patients met the audit criteria: the commonest problem was shortness of breath (57.5%), which was generally controlled with conservative doses of morphine (10-20 mg/24 h via a syringe pump). Cough and audible respiratory secretions were relatively uncommon. The second most common problem was agitation/delirium (55.5%), which was generally controlled with standard pharmacological interventions. The cumulative number of patients with shortness of breath, agitation and audible respiratory secretions increased over the last 72 h of life, but most patients were symptom controlled at the point of death. CONCLUSION: Patients dying of COVID-19 experience similar end-of-life problems to other groups of patients. Moreover, they generally respond to standard interventions for these end-of-life problems.


Subject(s)
Coronavirus Infections/mortality , Delirium/drug therapy , Drug Therapy/standards , Dyspnea/drug therapy , Hospice Care/standards , Palliative Care/standards , Pneumonia, Viral/mortality , Terminal Care/standards , Aged , Aged, 80 and over , Analgesics, Opioid/therapeutic use , Betacoronavirus , COVID-19 , Coronavirus Infections/epidemiology , Coronavirus Infections/nursing , Drug Therapy/statistics & numerical data , Female , Hospice Care/statistics & numerical data , Humans , Hypnotics and Sedatives/therapeutic use , Male , Middle Aged , Morphine/therapeutic use , Palliative Care/statistics & numerical data , Pandemics , Pneumonia, Viral/epidemiology , Pneumonia, Viral/nursing , Practice Guidelines as Topic , SARS-CoV-2 , Terminal Care/statistics & numerical data , United Kingdom/epidemiology
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