Clinical Practice: Should we Radically Alter our Sedation of Critical Care Patients, Especially Given the COVID-19 Pandemics?
Critical care
alpha-2 adrenergic agonists
alpha-2 agonists
clonidine
conventional sedation
cooperative sedation
dexmedetomidine
general anaesthesia
guanfacine
sedation
Journal
Romanian journal of anaesthesia and intensive care
ISSN: 2392-7518
Titre abrégé: Rom J Anaesth Intensive Care
Pays: Romania
ID NLM: 101681752
Informations de publication
Date de publication:
Dec 2020
Dec 2020
Historique:
entrez:
31
5
2021
pubmed:
1
6
2021
medline:
1
6
2021
Statut:
ppublish
Résumé
The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of sedation has evolved over the last 40 years (no-sedation, deep sedation, daily emergence, minimal sedation, etc.). Most guidelines now recommend determining the depth of sedation and minimizing the use of benzodiazepines and opioids. The broader use of alpha-2 adrenergic agonists ('alpha-2 agonists') led to sedation regimens beginning at admission to the CCU that contrast with hypnotics+opioids ("conventional" sedation), with major consequences for cognition, ventilation and circulatory performance. The same doses of alpha-2 agonists used for 'cooperative' sedation (ataraxia, analgognosia) elicit no respiratory depression but modify the autonomic nervous system (cardiac parasympathetic activation, attenuation of excessive cardiac and vasomotor sympathetic activity). Alpha-2 agonists should be selected only in patients who benefit from their effects ('personalized' indications, as opposed to a 'one size fits all' approach). Then, titration to effect is required, especially in the setting of systemic hypotension and/or hypovolemia. Since no general guidelines exist for the use of alpha-2 agonists for CCU sedation, our clinical experience is summarized for the benefit of physicians in clinical situations in which a recommendation might never exist (refractory delirium tremens; unstable, hypovolemic, hypotensive patients, etc.). Because the physiology of alpha-2 receptors and the pharmacology of alpha-2 agonists lead to personalized indications, some details are offered. Since interactions between conventional sedatives and alpha-2 agonists have received little attention, these interactions are addressed. Within the existing guidelines for CCU sedation, this article could facilitate the use of alpha-2 agonists as effective and safe sedation while awaiting large, multicentre trials and more evidence-based medicine.
Identifiants
pubmed: 34056133
doi: 10.2478/rjaic-2020-0018
pii: rjaic-2020-0018
pmc: PMC8158317
doi:
Types de publication
Journal Article
Langues
eng
Pagination
43-76Informations de copyright
© 2020 Stelian L Quintin et al. published by Sciendo.
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