Department of Emergency Medicine, Washington University School of Medicine in St. Louis, Campus Box 8054, St. Louis, MO, 63110, USA.
Division of Critical Care, Departments of Emergency Medicine and Anesthesia, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Drive, 1008 RCP, Iowa City, IA, 52242, USA.
Crit Care. 2022 Jun 15;26(1):179. doi: 10.1186/s13054-022-04042-9.
Mechanically ventilated patients have experienced greater periods of prolonged deep sedation during the coronavirus disease (COVID-19) pandemic. Multiple studies from the pre-COVID era demonstrate that early deep sedation is associated with worse outcome. Despite this, there is a lack of data on sedation depth and its impact on outcome for mechanically ventilated patients during the COVID-19 pandemic. We sought to characterize the emergency department (ED) and intensive care unit (ICU) sedation practices during the COVID-19 pandemic, and to determine if early deep sedation was associated with worse clinical outcomes.
Dual-center, retrospective cohort study conducted over 6 months (March-August, 2020), involving consecutive, mechanically ventilated adults. All sedation-related data during the first 48 h were collected. Deep sedation was defined as Richmond Agitation-Sedation Scale of - 3 to - 5 or Riker Sedation-Agitation Scale of 1-3. To examine impact of early sedation depth on hospital mortality (primary outcome), we used a multivariable logistic regression model. Secondary outcomes included ventilator-, ICU-, and hospital-free days.
391 patients were studied, and 283 (72.4%) experienced early deep sedation. Deeply sedated patients received higher cumulative doses of fentanyl, propofol, midazolam, and ketamine when compared to light sedation. Deep sedation patients experienced fewer ventilator-, ICU-, and hospital-free days, and greater mortality (30.4% versus 11.1%) when compared to light sedation (p < 0.01 for all). After adjusting for confounders, early deep sedation remained significantly associated with higher mortality (adjusted OR 3.44; 95% CI 1.65-7.17; p < 0.01). These results were stable in the subgroup of patients with COVID-19.
The management of sedation for mechanically ventilated patients in the ICU has changed during the COVID pandemic. Early deep sedation is common and independently associated with worse clinical outcomes. A protocol-driven approach to sedation, targeting light sedation as early as possible, should continue to remain the default approach.
在冠状病毒病（COVID-19）大流行期间，接受机械通气的患者经历了更长时间的深度镇静。COVID-19 之前的多项研究表明，早期深度镇静与较差的预后相关。尽管如此，关于 COVID-19 大流行期间机械通气患者的镇静深度及其对预后的影响的数据仍然缺乏。我们旨在描述 COVID-19 大流行期间急诊科（ED）和重症监护病房（ICU）的镇静实践，并确定早期深度镇静是否与更差的临床结局相关。
这是一项为期 6 个月（2020 年 3 月至 8 月）的双中心回顾性队列研究，涉及连续接受机械通气的成年患者。收集了前 48 小时内所有与镇静相关的数据。深度镇静定义为 Richmond 躁动-镇静量表为-3 至-5 或 Riker 镇静-躁动量表为 1-3。为了研究早期镇静深度对住院死亡率（主要结局）的影响，我们使用了多变量逻辑回归模型。次要结局包括呼吸机、ICU 和住院无天数。
共纳入 391 例患者，其中 283 例（72.4%）患者出现早期深度镇静。与轻度镇静相比，深度镇静患者接受了更高剂量的芬太尼、丙泊酚、咪达唑仑和氯胺酮。与轻度镇静相比，深度镇静患者的呼吸机、ICU 和住院无天数更少，死亡率更高（30.4%对 11.1%）（所有比较均为 p<0.01）。调整混杂因素后，早期深度镇静仍与更高的死亡率显著相关（调整后的 OR 3.44；95%CI 1.65-7.17；p<0.01）。这些结果在 COVID-19 患者亚组中是稳定的。
COVID-19 大流行期间，ICU 中机械通气患者的镇静管理发生了变化。早期深度镇静很常见，且与更差的临床结局独立相关。应继续采用以目标导向的镇静方案，尽早实现轻度镇静。
