Chapter 8: Analgesia, Sedation, and Mechanical Ventilation

INTRODUCTION

Mass casualty events (MCEs) are defined as “act[s] of bioterrorism or other public health or medical emergenc[ies]” and constitute national disasters, pandemics or acts of terrorism.¹ The response to these disasters is rapidly becoming a new reality as they continue to overwhelm health care systems. Over the last several decades, the United States has witnessed an increase in these events and as a consequence, hospital and intensive care units (ICUs) around the nation have been urged to develop emergency preparedness protocols. However, there are many challenges that may hinder delivery of standard of care to patients during MCEs, including lack of equipment and supplies and increased demand for resources. Currently, the coronavirus disease 2019 (COVID-19) is the mass casualty event. In this chapter, we aim to summarize potential strategies when mechanical ventilation and pharmaceutical services are limited.

THERAPEUTIC OPTIONS FOR ANALGESIA, SEDATION, AND PARALYSIS IN MECHANICALLY VENTILATED PATIENTS IN THE SETTING OF DRUG SHORTAGES

Pandemics and global sedative shortages have led to a significant increase in demand for analgesics and sedative medications that are essential for the care of critically ill patients.^2–4 This may be attributed to interruption in supply chain, production delays, or increased demand due to higher patient census and acuity.² In the case of the COVID-19 pandemic, dramatic increase in patients requiring mechanical ventilation along with analgesics/sedatives to maintain ventilator synchrony and impending exhaustion of these vital agents necessitated exploring safe clinical alternatives.⁵ While creating a document providing information on therapeutic alternatives is vital, it is also necessary to develop drug conservation strategies.^2,6 This may be accomplished by performing vigilant inventory tracking, prioritizing supply to the patients who are most likely to benefit and conducting prospective monitoring to limit inappropriate utilization. This is crucial to minimize depletion of the supply on hand.^2,6 The purpose of this section is to provide recommendations for standard and non-standard therapeutic options when faced with medication shortages or limited availability.

General Principles

When faced with shortage situations, it is important to remain mindful of general principles and overarching themes of pharmacotherapy management, as recommended by the Society of Critical Care Medicine’s PADIS guidelines.⁷ For example, current guidelines recommend analgesia-first or analgosedation (the administration of an analgesic agent before sedative administration) due to the premise that pain is commonly experienced in critically ill patients and is a major reason for agitation.⁷ If the absence of pain or discomfort or if analgosedation is inadequate, sedative agents may be required.⁷ Non–benzodiazepine-based sedation (e.g., dexmedetomidine or propofol) may be preferred over benzodiazepine-based sedation due to a decrease in duration of mechanical ventilation, ICU length of stay, and frequency of delirium observed in clinical trials.⁷ These agents are titrated to the desired clinical effect, guided by validated sedation/analgesia scoring tools (e.g., Richmond Agitation Sedation Scale, Riker Sedation-Agitation Scale, Critical Care Pain Observation ...