Analgesic medication administration in COVID-19 positive ARDS patients undergoing tracheostomy

ABSTRACT

Rationale Observational studies describe high sedative and analgesic medication (SA) requirements in patients with COVID-19 ARDS. High levels of SA have been shown to increase ICU length-of-stay, incidence of delirium, and mortality;all of which increase health system utilization. The aim of this study is to evaluate SA parameters in patients with COVID-19 ARDS undergoing tracheostomy. Methods: We enrolled 55 COVID-19 positive adult patients undergoing tracheostomy between 4/16/20 and 8/26/20. Cumulative dosage and sedation parameters, Richmond Agitation-Sedation Scale (RASS) scores, Glasgow Coma Scale (GCS) were collected in the 48-hour periods pre-and post-tracheostomy via chart review. Data analysis was performed with Microsoft Excel Analysis ToolPak. Results: Baseline characteristics include a mean age of 60.2, mean BMI of 30.2 kg/m2, 28 (51%) were male, and 39 (70.9%) of the tracheostomies were placed percutaneously. Fentanyl was used in 38 (69.1%), dexmedetomidine in 28 (50.9%), midazolam in 13 (23.6%), hydromorphone in 13 (23.6%), and propofol in 12 (21.8%) patients. •Total fentanyl dose (6940.3 mcg to 5382.2 mcg p=0.02) and total propofol dose (67066 mcg/kg to 24098 mcg/kg, p=0.02) were significantly lower post-tracheostomy compared to pre-tracheostomy (Figure 1). •There was a trend toward lower dexmedetomidine (27.7 mcg/kg to 27.4 mcg/kg, p=0.91), midazolam (183.4 mg to 133.8 mg, p=0.27), and hydromorphone (216.0 mg to 206.2 mg, p=0.72) total doses in the post-tracheostomy period. •Mean ordered RASS goals were similar in both groups (-1.1 to-0.9, p=0.12). Mean RASS deviations from goal were also similar in both groups (-0.3 vs-0.2, p=0.64). •Mean GCS values (8.4 to 9.1, p=0.007) were significantly higher in the post-tracheostomy group. Conclusions: In this retrospective cohort of COVID-19 ARDS patients undergoing tracheostomy, SA requirements were decreased in the post-tracheostomy period. Both fentanyl (22.4% reduction) and propofol (64.1% reduction) total doses were significantly lower post-tracheostomy. All other recorded SA trended toward reduction in the post-tracheostomy period but without statistical significance (Figure 1). Assessment of sedation scores showed that reduction in SA use were not associated with changes in ordered RASS goals or worse adherence to RASS goals, as these were similar in both groups. These findings suggest that the same RASS goal, and an increased GCS, may be equally obtained with less sedation in the post-tracheostomy period. We recognize the limitations of a retrospective, single-enter, cohort study. Early tracheostomy should be considered in appropriate patients to reduce SA administration and reduce health care utilization, particularly with ICU beds at a premium.