Expert Consensus on Management of Analgesia and Sedation for Patients with Severe Coronavirus Disease 2019
The coronavirus disease 2019 (COVID-19) has been declared a global pandemic and is a major public health issue worldwide. COVID-19 is a systemic disease damaging multiple organs, with the lung being the primary target. Approximately 14% of COVID-19 patients develop severe disease, and 5% require admission to the intensive care unit (ICU). Critically ill patients often experience stress, pain, and anxiety due to the pathophysiology of the acute stage of the disease, underlying illnesses, psychological factors, and environmental factors. COVID-19 increases organ function load, resulting in increased tissue oxygen consumption and respiratory dysfunction, which further damage organs and can even be life-threatening. Additionally, various medical procedures, including mechanical ventilation, arterial puncture, central venous catheterization, and hemodialysis, can aggravate discomfort, anxiety, and pain.
Some COVID-19 patients also experience greater mental health problems and sleep disorders, which not only cause emotional fluctuations and delirium but also delay tissue repair and suppress immune function. Therefore, it is necessary to assess pain, anxiety, mental health problems, and sleep quality in COVID-19 patients. Currently, there are no specific antiviral drugs or vaccines against COVID-19. The use of analgesic and sedation agents is appropriate as an initial strategy in critically ill and mechanically ventilated patients with COVID-19, as it can relieve the discomfort of intubation, reduce ventilator-associated lung injury, reduce sympathetic stress, and protect against organ damage. However, no specific data exist on the optimal use of analgesics, sedatives, and agents to control delirium in COVID-19 patients.
This expert consensus aims to standardize the management of pain, agitation, and delirium, formulate appropriate medication plans, and achieve the optimal clinical status for severe COVID-19 patients. The statements were developed by a group of 15 front-line intensive care experts who fought the COVID-19 epidemic in China. The expert group defined clinical questions according to the Population, Intervention, Control, and Outcome (PICO) format. A literature search was performed via PubMed and the Cochrane Library databases. The quality of evidence was assessed using the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology. Due to the sudden outbreak of COVID-19, some recommendations were based on expert opinion due to non-existent or insufficient literature. A total of four rounds of expert seminars and discussions were organized to provide trustworthy recommendations.
The experts developed 30 statements on the management of analgesia and sedation for severe COVID-19 patients. These statements cover pain assessment and analgesia management, agitation assessment and sedation management, delirium management, sleep disturbance management, and palliative care. Of these consensuses, 3 had a high level of evidence (GRADE 1±), 13 had a low level of evidence (GRADE 2±), and 14 were expert opinions. A strong agreement was reached for all statements after two rounds of scoring.
Pain Assessment and Analgesia Management
Analgesia should be considered a high priority in the treatment of severe COVID-19 patients, and the implementation of analgesia-based sedation should be preferred. The Numeric Rating Scale (NRS) is suggested for COVID-19 patients with non-invasive ventilation (communicative patients), and the Critical-Care Pain Observation Tool (CPOT) is suggested for COVID-19 patients with invasive mechanical ventilation (non-communicative patients). Non-pharmacological interventions should be considered as adjuvant pain management therapy in severe COVID-19 patients. Opioid analgesia is recommended as the first choice for critically ill patients with COVID-19. Non-steroidal anti-inflammatory drugs (NSAIDs) and dexmedetomidine should be considered as alternative or adjunctive analgesic drugs for severe COVID-19 patients. Experts suggest formulating appropriate analgesic and sedative strategies during medical procedures based on an individualized evaluation of patients with severe COVID-19.
Agitation Assessment and Sedation Management
Sedation is an important strategy for the treatment of COVID-19 in the ICU. The Richmond Agitation-Sedation Scale (RASS) should be used for sedation assessment in COVID-19 patients. A goal-directed sedation strategy should be used during respiratory support in severe COVID-19 patients. RASS should be maintained at -1 to 0 during high-flow nasal cannula oxygen application in severe COVID-19 patients. During non-invasive ventilation (NIV) in critically ill COVID-19 patients, RASS should be maintained at -1 to 0, and deep sedation (RASS < -2) should be avoided. In general, RASS should be maintained at -2 to 0 when applying invasive mechanical ventilation (IMV) on critically ill COVID-19 patients. It is recommended to maintain RASS at -5 to -4 with a deep sedation strategy if there are obvious discomfort, agitation, patient-ventilator dyssynchrony, and strong respiratory drive during IMV. Deep sedation should be administered for a short duration, but the duration could be adjusted according to the individual condition of patients. Daily interruption should be considered during long periods of deep sedation. RASS should be maintained at -5 when using neuromuscular blocking drugs during the early stage of IMV in severe COVID-19 patients. The degree of sedation during prone position should be based on the respiratory support method and period of the disease. The degree of sedation during extracorporeal membrane oxygenation (ECMO) varies with the different periods of ECMO implementation. "Awake" ECMO is probably reasonable after strict evaluation. Experts suggest a deep sedation strategy (RASS -4 to -5) combined with the neuromuscular blocking agent in severe COVID-19 patients when undergoing high-risk medical procedures such as endotracheal intubation, tracheotomy, and fiber optic bronchoscopy. Sedatives should be used with attention to the effects on hemodynamics and organ functions, as well as the need for depth of sedation.
Delirium Management
Severe COVID-19 patients should be routinely screened for high-risk factors for delirium on admission and during the whole course of the disease. Easy screening tools should be implemented for COVID-19 patients’ delirium assessments. Non-pharmacological interventions should be the first choice of management of delirium. A modified ABCDEF bundle is preferred to meet the need of COVID-19 patients. It is recommended not to use haloperidol or other atypical antipsychotics routinely to prevent or treat delirium in severe COVID-19 patients.
Sleep Disturbance Management
A sleep management strategy should be adopted in severe COVID-19 patients. The Richards-Campbell Sleep Questionnaire (RCSQ) should be an assessment tool among severe COVID-19 patients who can self-report their sleep state. For critically ill patients with IMV, the systematic assessment of deep sedation such as the Bispectral Index (BIS) can be used to evaluate deep sedation instead of polysomnography (PSG) sleep monitoring to provide comprehensive measures to reduce the incidence of sleep fragmentation and delirium. Using a multi-component bundle of interventions for sleep management in critical patients with COVID-19 should be considered. This management strategy is based on human care, control of environmental factors, cognitive behavior therapy for insomnia (CBT-I), and other non-pharmacological interventions, supplemented by pharmaceutical strategies such as melatonin and dexmedetomidine to induce sleep.
Palliative Care
Hospital palliative care is an essential part of COVID-19 therapy. The primary task of palliative care is to relieve the patient’s symptoms. Psychotherapy is another indispensable part of palliative care.
In conclusion, pain, agitation, delirium, and sleep disturbance are commonly manifested in COVID-19 patients and are closely associated with the severity and poor prognosis of the disease. This expert consensus statement should be helpful for clinicians worldwide with limited experience in the management of analgesia and sedation for severe COVID-19 patients by offering specific suggestions in this time of global crisis.
doi.org/10.1097/CM9.0000000000001034
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