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1.
Korean J Anesthesiol ; 74(4): 285-292, 2021 08.
Article in English | MEDLINE | ID: covidwho-1211980

ABSTRACT

This narrative review evaluates the evidence for using neuromuscular blocking agents (NMBA) in patients being treated for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). While large prospective randomized-controlled trials (RCTs) are lacking at this point in time, smaller observational studies and case series are reviewed to ascertain the indications and utility of NMBAs. Additionally, large RCTs that address similar clinical scenarios are reviewed and the authors translate these findings to patients with COVID-19. Specifically, NMBAs can be helpful during endotracheal intubation to minimize the risk of patient coughing and possibly infecting healthcare personnel. NMBAs can also be used in patients to promote patient-ventilator synchrony while reducing the driving pressure needed with mechanical ventilation (MV), particularly in patients with the severe clinical presentation (Type H phenotype). Prone positioning has also become a cornerstone in managing refractory hypoxemia in patients with SARS-CoV-2 acute respiratory distress syndrome, and NMBAs can be useful in facilitating this maneuver. In the perioperative setting, deep levels of neuromuscular blockade can improve patient outcomes during laparoscopic operations and may theoretically reduce the risk of aerosolization as lower insufflation pressures may be utilized. Regardless of the indication, quantitative neuromuscular monitoring remains the only reliable method to confirm adequate recovery following cessation of neuromuscular blockade. Such monitors may serve a unique purpose in patients with COVID-19 as automation of measurements can reduce healthcare personnel-patient contact that would occur during periodic subjective evaluation with a peripheral nerve stimulator.


Subject(s)
COVID-19/therapy , Intubation, Intratracheal/methods , Neuromuscular Blockade/methods , Neuromuscular Blocking Agents/administration & dosage , Patient Positioning/methods , Respiration, Artificial/methods , Humans , SARS-CoV-2
5.
rev. cuid. (Bucaramanga. 2010) ; 11(3): e1319, ago.2020.
Article in Spanish | WHO COVID, LILACS (Americas) | ID: covidwho-895774

ABSTRACT

Introducción: La inducción de secuencia rápida modificada es la sugerida para la intubación orotraqueal a pacientes COVID-19 que presentan distrés respiratorio en urgencias. El objetivo de esta revisión es plantear el proceso de atención de enfermería durante las fases de planificación, preparación, pretratamiento y sedación con parálisis neuromuscular. Materiales y Métodos: artículo de reflexión acerca de elementos conceptuales en la valoración, diagnóstico, planeación, ejecución y evaluación del cuidado de enfermería, a partir de la revisión de literatura de consensos y protocolos nacionales e internacionales y publicaciones de cuidado de enfermería a pacientes COVID-19. Resultados: los medicamentos recomendados por la literatura en la inducción de secuencia rápida a pacientes COVID-19 son: en la fase de pretratamiento, las benzodiacepinas necesarias para disminuir la ansiedad del paciente, la lidocaína que controla el reflejo de la tos y el fentanilo que contribuye con la analgesia; en la fase de sedación inductores como etomidato y ketamina están indicados en pacientes con inestabilidad hemodinámica y propofol en pacientes estables; en la fase de parálisis neuromuscular el rocuronio es el recomendado como primera opción antes que la succinilcolina y los vasopresores tipo norepinefrina, epinefrina, vasopresina y/o dopamina, son necesarios en todas las fases para el manejo de la inestabilidad hemodinámica. Conclusiones: aplicar el proceso de atención de enfermería durante las fases de inducción de secuencia rápida contribuye con la organización de los medicamentos requeridos para la intubación orotraqueal, lo cual, disminuye la ansiedad del paciente y el riesgo de contaminación del personal de salud.


Introduction: Modified rapid sequence induction is suggested for orotracheal intubation in COVID-19 patients with respiratory distress in the emergency department. The objective of this review is to discuss nursing care during the phases of planning, preparation, pretreatment and sedation with neuromuscular paralysis. Materials and Methods: A reflection article was written on conceptual elements in nursing care assessment, diagnosis, planning, implementation and evaluation based on the literature review of national and international standards and protocols, and publications on nursing care in COVID-19 patients. Results: Drugs recommended by rapid sequence intubation in COVID-19 patients are benzodiazepine for reducing patient's anxiety, lidocaine for cough control and fentanyl for analgesia in the pretreatment phase; inducers such as etomidate and ketamine are suggested in hemodynamic unstable patients and propofol in stable patients in the sedation phase; rocuronium is recommended as the first-choice neuromuscular blocking agent before vasopressors such as succinylcholine and norepinephrine, epinephrine, vasopressin and/or dopamine which are needed in all phases for managing hemodynamic instability. Conclusions: Applying a nursing care plan during rapid sequence induction phases contributes to a more organized medication regimen required for orotracheal intubation, which reduces patient's anxiety and the risk of contamination for healthcare personnel.


Introdução: A indução de sequência rápida modificada é sugerida para intubação orotraqueal em pacientes com COVID-19 com problemas respiratórios no departamento de emergência. O objetivo desta revisão é discutir os cuidados de enfermagem durante as fases de planejamento, preparação, pré-tratamento e sedação com paralisia neuromuscular. Materiais e métodos: Um artigo de reflexão foi elaborado sobre elementos conceituais na avaliação, diagnóstico, planejamento, implementação e avaliação da cuidados de enfermagem com base na revisão da literatura de normas e protocolos nacionais e internacionais, e publicações sobre cuidados de enfermagem em pacientes com COVID-19. Resultados: As drogas recomendadas pela intubação de sequência rápida em pacientes com COVID-19 são benzodiazepinas para reduzir a ansiedade do paciente, lidocaína para controle da tosse e fentanil para analgesia na fase de pré-tratamento; indutores como etomidato e cetamina são sugeridos em pacientes com instabilidade hemodinâmica e propofol em pacientes estáveis na fase de sedação; o rocurônio é recomendado como o bloqueador neuromuscular de primeira opção frente a vasopressores como succinilcolina e norepinefrina, epinefrina, vasopressina e/ou dopamina, que são necessários em todas as fases para o manejo da instabilidade hemodinâmica. Conclusões: A aplicação de um plano de cuidados de enfermagem durante as fases de indução de sequência rápida contribui para a organização dos medicamentos necessários para a intubação orotraqueal, o que reduz a ansiedade do paciente e o risco de contaminação para o pessoal de saúde.


Subject(s)
Humans , Critical Care/methods , Emergencies , Rapid Sequence Induction and Intubation/nursing , COVID-19/nursing , Neuromuscular Blocking Agents/administration & dosage , Neuromuscular Blocking Agents/classification
6.
J Intensive Care Med ; 36(2): 157-174, 2021 Feb.
Article in English | MEDLINE | ID: covidwho-737558

ABSTRACT

The rapid spread of the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has led to a global pandemic. The 2019 coronavirus disease (COVID-19) presents with a spectrum of symptoms ranging from mild to critical illness requiring intensive care unit (ICU) admission. Acute respiratory distress syndrome is a major complication in patients with severe COVID-19 disease. Currently, there are no recognized pharmacological therapies for COVID-19. However, a large number of COVID-19 patients require respiratory support, with a high percentage requiring invasive ventilation. The rapid spread of the infection has led to a surge in the rate of hospitalizations and ICU admissions, which created a challenge to public health, research, and medical communities. The high demand for several therapies, including sedatives, analgesics, and paralytics, that are often utilized in the care of COVID-19 patients requiring mechanical ventilation, has created pressure on the supply chain resulting in shortages in these critical medications. This has led clinicians to develop conservation strategies and explore alternative therapies for sedation, analgesia, and paralysis in COVID-19 patients. Several of these alternative approaches have demonstrated acceptable levels of sedation, analgesia, and paralysis in different settings but they are not commonly used in the ICU. Additionally, they have unique pharmaceutical properties, limitations, and adverse effects. This narrative review summarizes the literature on alternative drug therapies for the management of sedation, analgesia, and paralysis in COVID-19 patients. Also, this document serves as a resource for clinicians in current and future respiratory illness pandemics in the setting of drug shortages.


Subject(s)
Analgesics, Opioid/administration & dosage , COVID-19/complications , Hypnotics and Sedatives/administration & dosage , Neuromuscular Blocking Agents/administration & dosage , Respiration, Artificial , Respiratory Distress Syndrome/therapy , Respiratory Distress Syndrome/virology , Critical Illness , Humans , Intensive Care Units , Pandemics , SARS-CoV-2
7.
Am J Emerg Med ; 38(10): 2194-2202, 2020 Oct.
Article in English | MEDLINE | ID: covidwho-634245

ABSTRACT

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging viral pathogen that causes the novel coronavirus disease of 2019 (COVID-19) and may result in hypoxemic respiratory failure necessitating invasive mechanical ventilation in the most severe cases. OBJECTIVE: This narrative review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation. DISCUSSION: In severe cases, COVID-19 leads to hypoxemic respiratory failure that may meet criteria for acute respiratory distress syndrome (ARDS). The mainstay of treatment for ARDS includes a lung protective ventilation strategy with low tidal volumes (4-8 mL/kg predicted body weight), adequate positive end-expiratory pressure (PEEP), and maintaining a plateau pressure of < 30 cm H2O. While further COVID-19 specific studies are needed, current management should focus on supportive care, preventing further lung injury from mechanical ventilation, and treating the underlying cause. CONCLUSIONS: This review provides evidence-based recommendations for the treatment of COVID-19 related respiratory failure requiring invasive mechanical ventilation.


Subject(s)
COVID-19/therapy , Respiration, Artificial/methods , Respiratory Insufficiency/therapy , Ventilator-Induced Lung Injury/prevention & control , Adrenal Cortex Hormones/administration & dosage , COVID-19/complications , Emergency Service, Hospital/organization & administration , Humans , Neuromuscular Blocking Agents/administration & dosage , Respiration, Artificial/adverse effects , Respiratory Insufficiency/etiology , SARS-CoV-2 , Tidal Volume , Vasodilator Agents/administration & dosage
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