Analgesia and sedation in patients with ARDS
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REVIEW
Analgesia and sedation in patients with ARDS Gerald Chanques1,2* , Jean‑Michel Constantin3, John W. Devlin4,5, E. Wesley Ely6,7,8, Gilles L. Fraser9, Céline Gélinas10, Timothy D. Girard11, Claude Guérin12,13, Matthieu Jabaudon14,15, Samir Jaber1,2, Sangeeta Mehta16, Thomas Langer17,18, Michael J. Murray19, Pratik Pandharipande20, Bhakti Patel21, Jean‑François Payen22, Kathleen Puntillo23, Bram Rochwerg24, Yahya Shehabi25,26, Thomas Strøm27,28, Hanne Tanghus Olsen27 and John P. Kress21 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
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 mechani‑ cally 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 ven‑ tilator 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 symp‑ toms (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 systemati‑ cally 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. Keywords: Sedation, Analgesia, Mechanical ventilation, Intensive care unit, Acute respiratory distress syndrome, Rehabilitation, COVID-19
*Correspondence: g‑chanques@chu‑montpellier.fr 1 Department of Anaesthesia and Critical Care Medicine, Saint Eloi Montpellier University Hospital, Montpellier, France Full author information is available at the end of the article
Introduction Acute respiratory distress syndrome (ARDS) is present in 10% of patients admitted to an intensive care unit (ICU), and is associa
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