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Blondonnet R, Balde A, Zhai R, Pereira B, Futier E, Bazin JE, Godet T, Constantin JM, Lambert C, Jabaudon M. Use of volatile anesthetics for sedation in the ICU during the COVID-19 pandemic: A national survey in France (VOL'ICU 2 study). PLoS One 2022; 17:e0278090. [PMID: 36580451 PMCID: PMC9799316 DOI: 10.1371/journal.pone.0278090] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 11/09/2022] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- * E-mail:
| | - Aissatou Balde
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Ruoyang Zhai
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Jean-Etienne Bazin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Godet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Jean-Michel Constantin
- Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, GRC 29, AP-HP, DMU DREAM, Sorbonne University, Paris, France
| | - Céline Lambert
- Biostatistics Unit, DRCI, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
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Inhaled Sedation in Patients with COVID-19-Related Acute Respiratory Distress Syndrome: An International Retrospective Study. J Clin Med 2022; 12:jcm12010012. [PMID: 36614813 PMCID: PMC9821008 DOI: 10.3390/jcm12010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/09/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The coronavirus disease 2019 (COVID-19) pandemic and the shortage of intravenous sedatives has led to renewed interest in inhaled sedation for patients with acute respiratory distress syndrome (ARDS). We hypothesized that inhaled sedation would be associated with improved clinical outcomes in COVID-19 ARDS patients. METHODS Retrospective international study including mechanically ventilated patients with COVID-19 ARDS who required sedation and were admitted to 10 European and US intensive care units. The primary endpoint of ventilator-free days through day 28 was analyzed using zero-inflated negative binomial regression, before and after adjustment for site, clinically relevant covariates determined according to the univariate results, and propensity score matching. RESULTS A total of 196 patients were enrolled, 78 of whom died within 28 days. The number of ventilator-free days through day 28 did not differ significantly between the patients who received inhaled sedation for at least 24 h (n = 111) and those who received intravenous sedation only (n = 85), with medians of 0 (interquartile range [IQR] 0-8) and 0 (IQR 0-17), respectively (odds ratio for having zero ventilator-free days through day 28, 1.63, 95% confidence interval [CI], 0.91-2.92, p = 0.10). The incidence rate ratio for the number of ventilator-free days through day 28 if not 0 was 1.13 (95% CI, 0.84-1.52, p = 0.40). Similar results were found after multivariable adjustment and propensity matching. CONCLUSION The use of inhaled sedation in COVID-19 ARDS was not associated with the number of ventilator-free days through day 28.
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Kanapeckaitė A, Mažeikienė A, Geris L, Burokienė N, Cottrell GS, Widera D. Computational pharmacology: New avenues for COVID-19 therapeutics search and better preparedness for future pandemic crises. Biophys Chem 2022; 290:106891. [PMID: 36137310 PMCID: PMC9464258 DOI: 10.1016/j.bpc.2022.106891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/03/2022] [Accepted: 09/04/2022] [Indexed: 01/07/2023]
Abstract
The COVID-19 pandemic created an unprecedented global healthcare emergency prompting the exploration of new therapeutic avenues, including drug repurposing. A large number of ongoing studies revealed pervasive issues in clinical research, such as the lack of accessible and organised data. Moreover, current shortcomings in clinical studies highlighted the need for a multi-faceted approach to tackle this health crisis. Thus, we set out to explore and develop new strategies for drug repositioning by employing computational pharmacology, data mining, systems biology, and computational chemistry to advance shared efforts in identifying key targets, affected networks, and potential pharmaceutical intervention options. Our study revealed that formulating pharmacological strategies should rely on both therapeutic targets and their networks. We showed how data mining can reveal regulatory patterns, capture novel targets, alert about side-effects, and help identify new therapeutic avenues. We also highlighted the importance of the miRNA regulatory layer and how this information could be used to monitor disease progression or devise treatment strategies. Importantly, our work bridged the interactome with the chemical compound space to better understand the complex landscape of COVID-19 drugs. Machine and deep learning allowed us to showcase limitations in current chemical libraries for COVID-19 suggesting that both in silico and experimental analyses should be combined to retrieve therapeutically valuable compounds. Based on the gathered data, we strongly advocate for taking this opportunity to establish robust practices for treating today's and future infectious diseases by preparing solid analytical frameworks.
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Affiliation(s)
- Austė Kanapeckaitė
- AK Consulting, Laisvės g. 7, LT 12007 Vilnius, Lithuania,Corresponding author
| | - Asta Mažeikienė
- Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, M. K. Čiurlionio g. 21, LT-03101 Vilnius, Lithuania
| | - Liesbet Geris
- Biomechanics Research Unit, GIGA In Silico Medicine, University of Liège, Quartier Hôpital, Avenue de l'Hôpital 11 (B34), Liège 4000, Belgium,Biomechanics Section, Department of Mechanical Engineering, KU Leuven, Celestijnenlaan 300C (2419), Leuven 3001, Belgium,Skeletel Biology and Engineering Research Center, Department of Development and Regeneration, KU Leuven, Herestraat 49 (813), Leuven 3000, Belgium
| | - Neringa Burokienė
- Clinics of Internal Diseases, Family Medicine and Oncology, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Čiurlionio str. 21/27, LT-03101 Vilnius, Lithuania
| | - Graeme S. Cottrell
- University of Reading, School of Pharmacy, Hopkins Building, Reading RG6 6UB, United Kingdom
| | - Darius Widera
- University of Reading, School of Pharmacy, Hopkins Building, Reading RG6 6UB, United Kingdom
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Peng L, Liu S, Xu J, Xie W, Fang X, Xia T, Gu X. Metformin alleviates prolonged isoflurane inhalation induced cognitive decline via reducing neuroinflammation in adult mice. Int Immunopharmacol 2022; 109:108903. [PMID: 35709590 PMCID: PMC9190296 DOI: 10.1016/j.intimp.2022.108903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/15/2022] [Accepted: 05/24/2022] [Indexed: 12/12/2022]
Abstract
With the widespread use of volatile anesthetic agents in the prolonged sedation for COVID-19 pneumonia and ARDS, there is an urgent need to investigate the effects and treatments of lengthy low-concentration inhaled anesthetics exposure on cognitive function in adults. Previous studies showed that general anesthetics dose- and exposure length-dependently induced neuroinflammatory response and cognitive decline in neonatal and aging animals. The anti-diabetes drug metformin has anti-neuroinflammation effects by modulating microglial polarization and inhibiting astrocyte activation. In this study, we demonstrated that the inhalation of 1.3% isoflurane (a sub-minimal alveolar concentration, sub-MAC) for 6 h impaired recognition of novel objects from Day 1 to Day3 in adult mice. Prolonged sub-MAC isoflurane exposure also triggered typically reactive microglia and A1-like astrocytes in the hippocampus of adult mice on Day 3 after anesthesia. In addition, prolonged isoflurane inhalation switched microglia into a proinflammatory M1 phenotype characterized by elevated CD68 and iNOS as well as decreased arginase-1 and IL-10. Metformin pretreatment before anesthesia enhanced cognitive performance in the novel object test. The positive cellular modifications promoted by metformin pretreatment included the inhibition of reactive microglia and A1-like astrocytes and the polarization of microglia into M2 phenotype in the hippocampus of adult mice. In conclusion, prolonged sub-MAC isoflurane exposure triggered significant hippocampal neuroinflammation and cognitive decline in adult mice which can be alleviated by metformin pretreatment via inhibiting reactive microglia and A1-like astrocytes and promoting microglia polarization toward anti-inflammatory phenotype in the hippocampus.
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Affiliation(s)
- Liangyu Peng
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Shuai Liu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Jiyan Xu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Wenjia Xie
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
| | - Xin Fang
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China
| | - Tianjiao Xia
- Medical School of Nanjing University, Nanjing 210093, Jiangsu, China; Jiangsu Key Laboratory of Molecular Medicine, Nanjing University, Nanjing 210093, Jiangsu, China.
| | - Xiaoping Gu
- Department of Anesthesiology, Affiliated Drum Tower Hospital of Medical Department of Nanjing University, Nanjing 210008, Jiangsu, China.
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Jabaudon M, Zhai R, Blondonnet R, Bonda WLM. Inhaled sedation in the intensive care unit. Anaesth Crit Care Pain Med 2022; 41:101133. [PMID: 35907598 DOI: 10.1016/j.accpm.2022.101133] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 11/19/2022]
Abstract
Inhaled sedation with halogenated agents, such as isoflurane or sevoflurane, is now feasible in intensive care unit (ICU) patients through dedicated vaporisers and scavenging systems. Such a sedation strategy requires specific equipment and adequate training of ICU teams. Isoflurane and sevoflurane have ideal pharmacological properties that allow efficient, well-tolerated, and titratable light-to-deep sedation. In addition to their function as sedative agents, these molecules may have clinical benefits that could be especially relevant to ICU patients. Our goal was to summarise the pharmacological basis and practical aspects of inhaled ICU sedation, review the available evidence supporting inhaled sedation as a viable alternative to intravenous sedation, and discuss the remaining areas of uncertainty and future perspectives of development.
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Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France.
| | - Ruoyang Zhai
- GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, Clermont-Ferrand, France; GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
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Hanidziar D, Westover MB. Monitoring of sedation in mechanically ventilated patients using remote technology. Curr Opin Crit Care 2022; 28:360-366. [PMID: 35653256 PMCID: PMC9434805 DOI: 10.1097/mcc.0000000000000940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Two years of coronavirus disease 2019 (COVID-19) pandemic highlighted that excessive sedation in the ICU leading to coma and other adverse outcomes remains pervasive. There is a need to improve monitoring and management of sedation in mechanically ventilated patients. Remote technologies that are based on automated analysis of electroencephalogram (EEG) could enhance standard care and alert clinicians real-time when severe EEG suppression or other abnormal brain states are detected. RECENT FINDINGS High rates of drug-induced coma as well as delirium were found in several large cohorts of mechanically ventilated patients with COVID-19 pneumonia. In patients with acute respiratory distress syndrome, high doses of sedatives comparable to general anesthesia have been commonly administered without defined EEG endpoints. Continuous limited-channel EEG can reveal pathologic brain states such as burst suppression, that cannot be diagnosed by neurological examination alone. Recent studies documented that machine learning-based analysis of continuous EEG signal is feasible and that this approach can identify burst suppression as well as delirium with high specificity. SUMMARY Preventing oversedation in the ICU remains a challenge. Continuous monitoring of EEG activity, automated EEG analysis, and generation of alerts to clinicians may reduce drug-induced coma and potentially improve patient outcomes.
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Affiliation(s)
- Dusan Hanidziar
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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Landoni G, Belloni O, Russo G, Bonaccorso A, Carà G, Jabaudon M. Inhaled Sedation for Invasively Ventilated COVID-19 Patients: A Systematic Review. J Clin Med 2022; 11:jcm11092500. [PMID: 35566625 PMCID: PMC9105857 DOI: 10.3390/jcm11092500] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/20/2022] [Accepted: 04/26/2022] [Indexed: 01/22/2023] Open
Abstract
Background: Volatile anesthetics were used as sedative agents in COVID-19 (Coronavirus Disease 2019) invasively ventilated patients for their potentially beneficial pharmacological effects and due to the temporary shortages of intravenous agents during the pandemic crisis. Methods: Online databases (PubMed, EMBASE, The Cochrane Central Register of Controlled Trial) and the “clinicaltrials.gov” website were searched for studies reporting the use of isoflurane, sevoflurane or desflurane. Results: We identified three manuscripts describing the beneficial effects of isoflurane on 41 COVID-19 patients with acute respiratory distress syndrome (ARDS) in Germany (n = 2) and in the USA (n = 1), in terms of reduction in the use of opioids and other sedatives. We also found a case report of two patients with transient nephrogenic diabetes insipidus, which started after 6 and 8 days of sevoflurane sedation. We identified two randomized controlled trials (RCTs; 92 patients overall), two observational studies (238 patients) on the use of volatile anesthetics in COVID-19 patients that were completed but not yet published, and one RCT interrupted for a low recruitment ratio (19 patients) and thus not published. We also identified five ongoing RCTs on the use of inhaled sedation in ARDS, which are also likely to be recruiting COVID-19 patients and which have currently enrolled a total of >1643 patients. Conclusion: Isoflurane was the most frequently used volatile agent in COVID-19 patients and allowed a reduction in the use of other sedative and analgesic drugs. Randomized evidence is building up and will be useful to confirm or challenge these findings.
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Affiliation(s)
- Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
- School of Medicine, Vita-Salute San Raffaele University, 20132 Milan, Italy
- Correspondence:
| | - Olivia Belloni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Giada Russo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Alessandra Bonaccorso
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Gianmarco Carà
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (O.B.); (G.R.); (A.B.); (G.C.)
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, F-63000 Clermont-Ferrand, France;
- GReD, Université Clermont Auvergne, CNRS, INSERM, F-63000 Clermont-Ferrand, France
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Associated Factors of High Sedative Requirements within Patients with Moderate to Severe COVID-19 ARDS. J Clin Med 2022; 11:jcm11030588. [PMID: 35160040 PMCID: PMC8837042 DOI: 10.3390/jcm11030588] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
The coronavirus pandemic continues to challenge global healthcare. Severely affected patients are often in need of high doses of analgesics and sedatives. The latter was studied in critically ill coronavirus disease 2019 (COVID-19) patients in this prospective monocentric analysis. COVID-19 acute respiratory distress syndrome (ARDS) patients admitted between 1 April and 1 December 2020 were enrolled in the study. A statistical analysis of impeded sedation using mixed-effect linear regression models was performed. Overall, 114 patients were enrolled, requiring unusual high levels of sedatives. During 67.9% of the observation period, a combination of sedatives was required in addition to continuous analgesia. During ARDS therapy, 85.1% (n = 97) underwent prone positioning. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) was required in 20.2% (n = 23) of all patients. vv-ECMO patients showed significantly higher sedation needs (p < 0.001). Patients with hepatic (p = 0.01) or renal (p = 0.01) dysfunction showed significantly lower sedation requirements. Except for patient age (p = 0.01), we could not find any significant influence of pre-existing conditions. Age, vv-ECMO therapy and additional organ failure could be demonstrated as factors influencing sedation needs. Young patients and those receiving vv-ECMO usually require increased sedation for intensive care therapy. However, further studies are needed to elucidate the causes and mechanisms of impeded sedation.
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Hanidziar D. Use of anaesthesia machines for mechanical ventilation and sedation in patients with COVID-19 ARDS. Br J Anaesth 2021; 127:e72-e73. [PMID: 34045065 PMCID: PMC8108387 DOI: 10.1016/j.bja.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 12/02/2022] Open
Affiliation(s)
- Dusan Hanidziar
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
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