Robert Stephens, MD
Resident Physician
Barnes Jewish Hospital
Saint Louis, MO
Disclosure information not submitted.
Erin Evans, MD
Critical Care Medicine Fellow
University of Iowa, United States
Disclosure information not submitted.
Michael Pajor, MD
Emergency Medicine Resident
Washington University School of Medicine, United States
Disclosure information not submitted.
Ryan Pappal, n/a
Medical Student
Washington University School of Medicine, United States
Disclosure information not submitted.
Marin Kollef, MD
Professor
Washington Univ. School of Medicine, United States
Disclosure information not submitted.
Brian Roberts, MD, MSc
Associate Professor of Emergency Medicine
Cooper University Hospital, United States
Disclosure information not submitted.
Nicholas Mohr, MD, MS, FCCM
Professor
University of Iowa Hospital and Clinics
Iowa City, IA
Disclosure information not submitted.
Brian Fuller, MD, MSCI,FCCM
Associate Professor of Anesthesiology and Emergency Medicine
Washington University/Barnes-Jewish Hospital
Saint Louis, MO
Disclosure information not submitted.
Title: The impact of early deep sedation in mechanically ventilated patients during the COVID-19 pandemic
Introduction: Data demonstrate that early deep sedation in the emergency department (ED) and intensive care unit (ICU) is common and harmful. However, the impact of COVID19 on deep sedation and outcomes is unclear. This study’s objective was to assess the impact of early deep sedation on mechanically ventilated patients during the first six months of the COVID19 pandemic.
Methods: This was a retrospective cohort study (March – September, 2020) of consecutive mechanically ventilated adults (n=271) in the ED or ICU of a single center. Deep sedation was defined as Richmond Agitation-Sedation Scale of -3 to -5. Early sedation depth was defined as that from the ED, or from first sedation depth recorded in the ICU (for patients not intubated in the ED). Hospital mortality was the primary outcome and ventilator-, ICU-, and hospital-free days were secondary outcomes. Backward, stepwise multivariable logistic regression was used to evaluate the primary outcome as a function of early sedation depth.
Results: 271 patients were studied (156 + for COVID-19). Early deep sedation was seen in 126 (46.5%) patients, and was associated with higher frequency of deep sedation in the ICU on day 1 (65.9% vs 31.0%; p < 0.01), day 2 (55.0% vs 30.5%; p< 0.01), and days 3-7 (50.5% vs 36.4%). Mean (SD) ventilator-free days were 12.6 (11.6) in the early deep sedation group, compared to 16.9 (10.7) in the light sedation group (mean difference, 4.2; 95% CI, 1.5-6.9). Similar results existed for ICU-free days (mean difference, 3.9; 95% CI, 1.3-6.4) and hospital-free days (mean difference, 3.9; 95% CI 1.6-6.2). Mortality was 38.1% in the deep sedation group and 20.0% in the light sedation group (between-group difference, 18.1%; odds ratio, 2.46; 1.43-4.24). After adjusting for age, illness severity, hypoxia, and COVID status, early deep sedation was not associated with mortality (adjusted OR, 1.85; 0.97-3.53).
Conclusions: Early deep sedation is common in mechanically ventilated patients in the COVID19 era, and leads to increased deep sedation up to one week in the ICU. In the current analysis, outcome was driven more by COVID status than sedation depth. Given the significant amount of data regarding the negative impact of deep sedation on outcome, evidence-based approaches should continue to be applied, studied, and reported in COVID19 patients.