Brian Fuller, MD, MSCI,FCCM
Associate Professor of Anesthesiology and Emergency Medicine
Washington University/Barnes-Jewish Hospital
Saint Louis, MO
Disclosure information not submitted.
Hawnwan Moy, MD
Assistant Professor of Emergency Medicine
Washington University School of Medicine, United States
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David Olvera, BA,FP-C, NRP, CMTE
Director of Clinical Research
Air Methods Corporation, United States
Disclosure information not submitted.
B Daniel Nayman, MBA, NRP, FP-C
Clinical Patient Care Consultant
ZOLL Data Systems, United States
Disclosure information not submitted.
Ryan Pappal, n/a
Medical Student
Washington University School of Medicine, 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.
Marin Kollef, MD
Professor
Washington Univ. School of Medicine, United States
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Christopher Palmer, MD, FCCM
Washington University in Saint Louis School of Medicine
Saint Louis, MO
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Enyo Ablordeppey, MD, MPH, FACEP
Washington University School of Medicine
Saint Louis, MO, United States
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Brett Faine, PharmD, MS
Clinical Assistant Professor of Pharmacy Practice and Science
University of Iowa College of Pharmacy, United States
Disclosure information not submitted.
Title: Sedatives, Deep Sedation, and Coma in Mechanically Ventilated Air Transport Patients: A Cohort Study
Introduction: Analgesia and sedation are germane therapies for mechanically ventilated patients. Early deep sedation in the intensive care unit (ICU) and emergency department (ED) is associated with worse outcome. Despite the fact that >550,000 patients require air medical transport annually, there is a lack of data on sedation practices and deep sedation for mechanically ventilated patients in this clinical setting. Our objectives were to describe sedation practices in mechanically ventilated patients transported by air ambulance, and examine the incidence of deep sedation and coma.
Methods: This was a retrospective cohort study (January 2015 - December 2020) of consecutive, adult mechanically ventilated air medical transport patients (n=72,148) treated in the pre-hospital environment. All patients were transported by Air Methods, an air medical transport provider with > 300 bases in 48 states. Sedation depth was assessed with Richmond Agitation-Sedation Scale (RASS; deep sedation defined as -3 to -5, and coma as -5), Ramsay Sedation Scale (deep sedation defined as 5 or 6, and coma as 6). In patients without sedation depth documented via a validated scale, a documented Glasgow Coma Scale (GCS) was used as a surrogate (deep sedation defined as ≤ 9, and coma as 3).
Results: Median duration of care was 1.2 hours (0.9–1.5). The most common medications [%; median dose (interquartile range)] and doses for analgesia and sedation were: fentanyl [50.8%; 100mcg (50-150)], midazolam [38.8%; 5mg (2.5-6)], ketamine [38.6%; 225mg (100-400), and propofol [13.0%; 139mg (72-237). Deep sedation was observed in 63,478 (88.0%) patients, and coma in 42,483 (58.9%) patients. Sedation depth was significantly different between deep sedation patients versus light sedation patients: RASS -4 (-5 to -3) vs. -1 (-2 to 0), Ramsay 6 (5 to 6) vs. 1 (1 to 4), and GCS 3 (3 – 5) vs. 7 (4 – 11), p < 0.01 for all.
Conclusions: Considering the brief duration of care, comparatively high doses of analgesics and sedatives are administered in the air medical transport environment. Deep sedation appears to be very common, the majority of whom are comatose in this clinical setting. Given the known impact that deep sedation and coma have on outcome, this study identifies potential areas for quality improvement in order to improve patient-centered outcomes.