Pharmaceutical Agents of Choice for sedation in Covid19 patients

[Sparda29]

Pharmacist here. One of the main concerns happening at my hospital is that we are running very low on drugs. We have ran out of Midazolam, we have ran out of Fentanyl, we have about 500 vials of Propofol (100 ml each) left, which should be enough for 4-5 days, and we have maybe enough Morphine left to make 40-50 bags. For some reason, the anesthesiologists at our hospital do not want to use Precedex (dexmedetomidine), what possible reasoning do they have to avoid it?

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[MoMoGesiologist]

I don’t like using it if pts need heavy sedation (like in COVID ARDS vent asynchrony) because it’s not strong enough. Also don’t like using it if expecting pts to need long term sedation (like in COVID ARDS) as weaning off dexmedetomidine after someone has been on it for ten days may cause rebound issues.

Maybe encourage ketamine or volatile anesthesia for sedation!?

 

[Sparda29]

I don’t like using it if pts need heavy sedation (like in COVID ARDS vent asynchrony) because it’s not strong enough. Also don’t like using it if expecting pts to need long term sedation (like in COVID ARDS) as weaning off dexmedetomidine after someone has been on it for ten days may cause rebound issues.

Maybe encourage ketamine or volatile anesthesia for sedation!?

I'm hoping our purchaser can find the drugs because they were very late on the ball about this. This is what happens when you keep a low inventory and then only purchase during high demand times.

 

[vector2]

Pharmacist here. One of the main concerns happening at my hospital is that we are running very low on drugs. We have ran out of Midazolam, we have ran out of Fentanyl, we have about 500 vials of Propofol (100 ml each) left, which should be enough for 4-5 days, and we have maybe enough Morphine left to make 40-50 bags. For some reason, the anesthesiologists at our hospital do not want to use Precedex (dexmedetomidine), what possible reasoning do they have to avoid it?

All your icu pts need intense triaging during during sedation holidays to see who really, really, really needs a propofol gtt. It’s difficult when the nurses are so busy, but there are likely some supine pts who would be fine with prn dilaudid pushes +- Ativan push prn. There’s probably another cohort who would do fine with precedex although it is a weak sedative imo. Remember, analgesia first should be the paradigm for icu sedation. Low dose ketamine gtt with prn ativan is also an option. Save your propofol for prone pts or those with severe ventilator dyssynchrony.

 

[MoMoGesiologist]

All your icu pts need intense triaging during during sedation holidays to see who really, really, really needs a propofol gtt. It’s difficult when the nurses are so busy, but there are likely some supine pts who would be fine with prn dilaudid pushes +- Ativan push prn. There’s probably another cohort who would do fine with precedex although it is a weak sedative imo. Remember, analgesia first should be the paradigm for icu sedation. Low dose ketamine gtt with prn ativan is also an option. Save your propofol for prone pts or those with severe ventilator dyssynchrony.

Y does it have to be analgesia first? I get it’s the SCCM PADIS guideline. But these aren’t surgical post op pts and they shouldn’t have pain. Should we really be loading all these ppl up on narcs for two weeks while they’re intubated? A lot do fine on low dose propofol. Just curious and asking

 

[Ronin786]

Y does it have to be analgesia first? I get it’s the SCCM PADIS guideline. But these aren’t surgical post op pts and they shouldn’t have pain. Should we really be loading all these ppl up on narcs for two weeks while they’re intubated? A lot do fine on low dose propofol. Just curious and asking

Most patients dont need sedation at all. They need an RT to adjust their vent and a nurse to reassure them everything will be fine. There's obvious discomfort to having an ETT in your throat and sitting in a bed all day long, so opioids help from that.

My approach to it has been this, you either need deep sedation and paralysis to assist with vent dyssynchrony and oxygenation or you need to be awake. You're easily going to run out of drugs if everybody that's intubated is kept at propofol @ 100mcg/kg. Give the combative ones a dose of haloperidol or a narcotic here and there to keep them chill. But this is a perfect time to implement these practices in your ICU because people are less willing to complain when they know there's nothing you can do for them.

The more ICUs that I work in where patients are awake with an ETT or riding it out @5 of propofol makes me see how ridiculous some of these ICU practices are.

 

[deleted697535]

Well theres absolutely no evidence for anything right now with this virus so go nuts, do whatever you need to keep the tube in. Haldol drip, 4 point restraint, precedex, whatever.
Whatever person thinks they have a secret recipe that covids need to be on, or not on is really just making it up.
We dont even know what vent mode to use, how could we know what sedation is better than another?

 

[Sparda29]

Most patients dont need sedation at all. They need an RT to adjust their vent and a nurse to reassure them everything will be fine. There's obvious discomfort to having an ETT in your throat and sitting in a bed all day long, so opioids help from that.

My approach to it has been this, you either need deep sedation and paralysis to assist with vent dyssynchrony and oxygenation or you need to be awake. You're easily going to run out of drugs if everybody that's intubated is kept at propofol @ 100mcg/kg. Give the combative ones a dose of haloperidol or a narcotic here and there to keep them chill. But this is a perfect time to implement these practices in your ICU because people are less willing to complain when they know there's nothing you can do for them.

The more ICUs that I work in where patients are awake with an ETT or riding it out @5 of propofol makes me see how ridiculous some of these ICU practices are.

Yikes. We have about 70 people currently sedated, intubated, and on vents. We have another 70 awake and on the med/surg floors who they are trying to discharge as soon as they start feeling better.

 

[vector2]

Y does it have to be analgesia first? I get it’s the SCCM PADIS guideline. But these aren’t surgical post op pts and they shouldn’t have pain. Should we really be loading all these ppl up on narcs for two weeks while they’re intubated? A lot do fine on low dose propofol. Just curious and asking

I’ve never had a big pvc pipe banging against my cords and trachea while awake but my impression is that at best it’s uncomfortable ranging to quite painful. Secondly, most COVID pts have RRs of 30-40 so a bit of opioid helps with potential air hunger. Finally, I wouldn’t characterize my recommendation of prn dilaudid pushes as “loading these ppl up on narcs”

 

[Hoya11]

Pharmacist here. One of the main concerns happening at my hospital is that we are running very low on drugs. We have ran out of Midazolam, we have ran out of Fentanyl, we have about 500 vials of Propofol (100 ml each) left, which should be enough for 4-5 days, and we have maybe enough Morphine left to make 40-50 bags. For some reason, the anesthesiologists at our hospital do not want to use Precedex (dexmedetomidine), what possible reasoning do they have to avoid it?

precedex is weak but if you have it laying around, and you combine it with propfol and ketamine mixed together it should be nice
precedex and remifentanil is also nice

 

[chessknt]

Most patients dont need sedation at all. They need an RT to adjust their vent and a nurse to reassure them everything will be fine. There's obvious discomfort to having an ETT in your throat and sitting in a bed all day long, so opioids help from that.

My approach to it has been this, you either need deep sedation and paralysis to assist with vent dyssynchrony and oxygenation or you need to be awake. You're easily going to run out of drugs if everybody that's intubated is kept at propofol @ 100mcg/kg. Give the combative ones a dose of haloperidol or a narcotic here and there to keep them chill. But this is a perfect time to implement these practices in your ICU because people are less willing to complain when they know there's nothing you can do for them.

The more ICUs that I work in where patients are awake with an ETT or riding it out @5 of propofol makes me see how ridiculous some of these ICU practices are.

Problem is PPE is scarce and icu rns are being spread thin and can't camp out the room. We are at 5:1 icu rn (supplemented by floor rns) and 1 rt for 20 vents right now before going into what we expect to be a very ****ty week. Even if they can park in the room we want to minimize exposure to providers right? So the ideal scenario of Q10 minute or even hourly reassurance and vent tweaking is not going to happen so lots of these patients end up heavily sedated as a result of the logistics of the pandemic.

My alternatives to prop and versed are going to be ketamine, phenobarb, Ativan, and possibly oral benzos if we start getting desperate. Antipsychotics are going to be a hard pass if we end up going heavy on hcq (we aren't right now) if qtc gets above 500. Precedex might help cut down dosage but as a lone anxiolytic isn't very useful in this population. I think volatile anesthetic gasses could be considered but I'm not sure we fully understand what the effects of long term exposure (ie weeks) to these agents could be especially given the degree of lung damage these individuals have.

 

[deleted875186]

I would second ketamine. Or hydromorphone/morphine boluses or drip, with as needed Ativan if still dysnychronous.

if someone is still dysnychronous after this you can still paralyze for 24 hrs with some Ativan on board instead of doing deep sedation alone.

 

[Hork Bajir]

Not an intensivist, just an OR dude thinking out loud: does anyone use a laryngotracheal atomizer to spray the posterior oropharynx and cords with lido Q3-4h? Treat it like we do and awake intubation with good topicalization (as best as you can) might decrease the sedation required just to tolerate the tube.

Any systemic absorption of the lido would just help with sedation and be an added benefit lol

Major downside that I can see would be the work involved in doing it every few hours, potentially exposing the person doing it to aerosols

 

[chocomorsel]

I’ve never had a big pvc pipe banging against my cords and trachea while awake but my impression is that at best it’s uncomfortable ranging to quite painful. Secondly, most COVID pts have RRs of 30-40 so a bit of opioid helps with potential air hunger. Finally, I wouldn’t characterize my recommendation of prn dilaudid pushes as “loading these ppl up on narcs”

What if we let them ride the vent at 30-40 an hour if that's what they are trying to naturally do? Assist them but adjust their rate to their breathing if they are semiawake? Maybe they will feel less anxious and require less sedation? SIMV may be good for these patients if people are running low on sedation.
I mean we are learning as we go and there's all this talk that we aren't actually treating ARDS due to very good compliance. What's your experience been? And what do you think of all this talk about High Altitude Pulmonary Edema since you are in the front lines?

 

[deleted875186]

What if we let them ride the vent at 30-40 an hour if that's what they are trying to naturally do? Assist them but adjust their rate to their breathing if they are semiawake? Maybe they will feel less anxious and require less sedation? SIMV may be good for these patients if people are running low on sedation.
I mean we are learning as we go and there's all this talk that we aren't actually treating ARDS due to very good compliance. What's your experience been? And what do you think of all this talk about High Altitude Pulmonary Edema since you are in the front lines?

I’m not sure letting them set their own RR that high is going to help them rest and eventually wean from the ventilator.

 

[deleted875186]

Not an intensivist, just an OR dude thinking out loud: does anyone use a laryngotracheal atomizer to spray the posterior oropharynx and cords with lido Q3-4h? Treat it like we do and awake intubation with good topicalization (as best as you can) might decrease the sedation required just to tolerate the tube.

Any systemic absorption of the lido would just help with sedation and be an added benefit lol

Major downside that I can see would be the work involved in doing it every few hours, potentially exposing the person doing it to aerosols

How on earth are you going to do laryngoscopy of these people q4h? Sounds worse than no sedation.

 

[deleted875186]

How about we try APRV for these people? Might require less sedation if your running low on propofol and fentanyl.

 

[Hork Bajir]

No laryngoscopes needed, just bend the flexible stylet into a U-shape and pass it as far back as it’ll go. Works surprisingly well (try it on yourself next time you’re bored )

 

[chocomorsel]

I’m not sure letting them set their own RR that high is going to help them rest and eventually wean from the ventilator.

Well, I am reading on this and the way they are behaving like they have HAPE. Question is, how fast or deep are these patients breathing when they aren't intubated? When they are hypoxic on Nasal cannula. Do we know? Do the people on the front lines know?
My theory based on what I am reading is they are breathing fast possibly because it it's a HAPE type illness, when at high altitude these patients hyperventilate because of the hypoxic stimulation?
It's all theory, but wondering, if they are in distress when they are breathing this fast? As Dr. Sidell asked, are they tachycardic? I mean when they are tubed it's hard to tell because the tube is a stimulant, but before they buy the tube?

 

[deleted697535]

Snorkel em, flip em, norepi, crrt if k problems. That's it. That's all we got. Anything else is voodoo til about 2021 & reasonable trials come back.

How many times has theory and first principles been really wrong?

Steroids parlaysis hypothermia etc?

Hell I remember 2011 pre prosecco when proning was considered to not work for ards. Then it became the panacea

 

[deleted697535]

*pre prosevo. Sorry autocorrect knows me too well.

Its been dropping off the A's everywhere I type again these days

 

[chocomorsel]

Snorkel em, flip em, norepi, crrt if k problems. That's it. That's all we got. Anything else is voodoo til about 2021 & reasonable trials come back.

How many times has theory and first principles been really wrong?

Steroids parlaysis hypothermia etc?

Hell I remember 2011 pre prosecco when proning was considered to not work for ARDS. Then it became the panacea

You may be right. Snorkel them? That's tube them right?
CRRT? By this point what is their mortality rate? Is it even worth it? Are they going into acute Hyperkalemia as soon as they get AKI? Or does it take a while line non Covid sepsis/SIRS?

 

[deleted697535]

Yeah I'd say mortality is huge if on crrt and tubed. But then you have these people that say vv works. So who knows? I haven't had to go that far yet. We're limited by perfusionists recently so we've not gone to vv so quick yet.

 

[kmurp]

Pharmacist here. One of the main concerns happening at my hospital is that we are running very low on drugs. We have ran out of Midazolam, we have ran out of Fentanyl, we have about 500 vials of Propofol (100 ml each) left, which should be enough for 4-5 days, and we have maybe enough Morphine left to make 40-50 bags. For some reason, the anesthesiologists at our hospital do not want to use Precedex (dexmedetomidine), what possible reasoning do they have to avoid it?

One idea: If you have any surgery centers in your area that are shut down, you may be able to purchase their stock of propofol and versed.

 

[jwk]

Not an intensivist, just an OR dude thinking out loud: does anyone use a laryngotracheal atomizer to spray the posterior oropharynx and cords with lido Q3-4h? Treat it like we do and awake intubation with good topicalization (as best as you can) might decrease the sedation required just to tolerate the tube.

Any systemic absorption of the lido would just help with sedation and be an added benefit lol

Major downside that I can see would be the work involved in doing it every few hours, potentially exposing the person doing it to aerosols

What about a lidocaine infusion? I have no idea about long term use, but it's being used as part of some ERAS protocols for a day or two postop.

 

[deleted171991]

What about a lidocaine infusion? I have no idea about long term use, but it's being used as part of some ERAS protocols for a day or two postop.

Lidocaine could be dangerous in a disease that can affect the heart and the liver.

 

[Ronin786]

Lidocaine could be dangerous in a disease that can affect the heart and the liver.

But...if you give them HCQ you can add on lidocaine to help with the VT you'll give them.