Critical care
Sedation practices in the ICU: Moving past the COVID-19 pandemic
The COVID-19 pandemic brought unprecedented change to critical care practice patterns, and sedation practices in the intensive care unit are no exception. In a large cohort analysis of over 2,000 adults with COVID-19 (Pun BT, et al. Lancet Respir Med. 2021;9[3]:239-50), 64% of patients received benzodiazepines (median of 7 days), and patients were deeply sedated. More than half of the patients were delirious, with benzodiazepine use associated with increased incidence of delirium. These observations represent a significant departure from well-established pre-COVID best-practices in sedation: light targets, daily sedation interruption, and avoiding continuous benzodiazepine infusions whenever possible (Girard TD, et al. Lancet; 2008;371[9607]:126-34; Fraser GL, et al. Crit Care Med;2013 Sep;41[9 Suppl 1]:S30-8; Riker RR, et al. JAMA;2009;301[5]:489-99).
Dr. Casey Cable
As COVID-19 case counts begin to improve in many of our communities, we have the opportunity to refocus on best sedation practices and build on a growing body of recent evidence. The MENDS2 trial, completed pre-COVID-19, assigned mechanically ventilated patients with sepsis to either propofol or dexmedetomidine and showed no difference in delirium or coma in this cohort of lightly sedated patients (Hughes CG, et al. N Engl J Med. 2021;384[15]:1424-36). Furthering this point, Olsen et al. found no difference in outcomes when mechanically ventilated patients were randomized to no sedation vs light sedation (Olsen HT, et al. N Engl J Med; 2020;382[12]:1103-11).
While the evidence surrounding sedation strategies in the critically ill continues to grow, one thing is certain: promoting lighter sedation targets and reengaging in sedation-related best practices following the COVID-19 pandemic will continue to play a vital role in improving both short and long-term outcomes for our critically ill patients.
Casey Cable, MD, MSc
Steering Committee Member
Kyle Stinehart, MD
Steering Committee Member
Home mechanical ventilation
How to initiate a chronic respiratory failure clinic
Noninvasive ventilation (NIV) is an established treatment for chronic hypercapnic respiratory failure from neuromuscular disorders, COPD, obesity hypoventilation syndrome (OHS), and restrictive thoracic disorders. Previously, hospital admission was considered essential for setup of chronic NIV but with advances in the modes of ventilation and remote monitoring, hospital admission has become less justifiable, especially in countries with centralized medical systems and presence of centers of excellence for home ventilation (Van Den Biggelaar RJM, et al. Chest. 2020;158[6]:2493-2501); Duiverman ML, et al. Thorax. 2020;75:244-52). In the United States, where centralized health care is atypical, management of NIV has been disparate with no clear consensus on practice patterns. Thus, we hope to provide some guidance toward the establishment of such clinics in the U.S.
Dr. Ashima S. Sahni
Prior to developing an NIV clinic, establishing a referral source from neuromuscular, rehabilitation/spinal cord injury, bariatric surgery, and COPD programs is important. After this, collaboration with a respiratory therapist through durable medical equipment is essential to building a robust care team. These companies are also important for assisting in remote monitoring, providing overnight pulse oximetry/CO2 monitoring, mask fitting, and airway clearance. Clinicians are encouraged to develop protocols for initiation and titration of NIV and mouthpiece ventilation. Clinics should provide spirometry, maximal inspiratory pressure, transcutaneous CO2, and/or blood gas testing. Additionally, in this patient population, wheelchair scales are necessary. Clinical workflow should include a review of NIV downloads, identify asynchronies and troubleshoot it in timely and reliable manner (Blouet S, et al. Int J Chron Obstruct Pulmon Dis. 2018;13:2577-86). Lastly, effort should be made for an adequate assessment of the home situation including layout of home along with family support utilizing social worker and palliative care team. Due to patient mobility, we encourage continued availability of telehealth for these patients.
In summary, strong clinical infrastructure, a robust care team, and an efficient, secure, reliable telemonitoring system are key to provide better care to this vulnerable patient population.
Ashima S. Sahni, MD, MBBS, FCCP
NetWork Member
Amen Sergew, MD
Steering Committee Member