<abstract xmlns="http://www.w3.org/1999/xhtml"><p>The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of sedation has evolved over the last 40 years (no-sedation, deep sedation, daily emergence, minimal sedation, etc.). Most guidelines now recommend determining the depth of sedation and minimizing the use of benzodiazepines and opioids. The broader use of alpha-2 adrenergic agonists (‘alpha-2 agonists’) led to sedation regimens beginning at admission to the CCU that contrast with hypnotics+opioids (“conventional“ sedation), with major consequences for cognition, ventilation and circulatory performance. The same doses of alpha-2 agonists used for ‘cooperative’ sedation (ataraxia, analgognosia) elicit no respiratory depression but modify the autonomic nervous system (cardiac parasympathetic activation, attenuation of excessive cardiac and vasomotor sympathetic activity). Alpha-2 agonists should be selected only in patients who benefit from their effects (‘personalized’ indications, as opposed to a ‘one size fits all’ approach). Then, titration to effect is required, especially in the setting of systemic hypotension and/or hypovolemia. Since no general guidelines exist for the use of alpha-2 agonists for CCU sedation, our clinical experience is summarized for the benefit of physicians in clinical situations in which a recommendation might never exist (refractory delirium tremens; unstable, hypovolemic, hypotensive patients, etc.). Because the physiology of alpha-2 receptors and the pharmacology of alpha-2 agonists lead to personalized indications, some details are offered. Since interactions between conventional sedatives and alpha-2 agonists have received little attention, these interactions are addressed. Within the existing guidelines for CCU sedation, this article could facilitate the use of alpha-2 agonists as effective and safe sedation while awaiting large, multicentre trials and more evidence-based medicine.</p></abstract>

The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of sedation has evolved over the last 40 years (no-sedation, deep sedation, daily emergence, minimal sedation, etc.). Most guidelines now recommend determining the depth of sedation and minimizing the use of benzodiazepines and opioids. The broader use of alpha-2 adrenergic agonists (‘alpha-2 agonists’) led to sedation regimens beginning at admission to the CCU that contrast with hypnotics+opioids (“conventional“ sedation), with major consequences for cognition, ventilation and circulatory performance. The same doses of alpha-2 agonists used for ‘cooperative’ sedation (ataraxia, analgognosia) elicit no respiratory depression but modify the autonomic nervous system (cardiac parasympathetic activation, attenuation of excessive cardiac and vasomotor sympathetic activity). Alpha-2 agonists should be selected only in patients who benefit from their effects (‘personalized’ indications, as opposed to a ‘one size fits all’ approach). Then, titration to effect is required, especially in the setting of systemic hypotension and/or hypovolemia. Since no general guidelines exist for the use of alpha-2 agonists for CCU sedation, our clinical experience is summarized for the benefit of physicians in clinical situations in which a recommendation might never exist (refractory delirium tremens; unstable, hypovolemic, hypotensive patients, etc.). Because the physiology of alpha-2 receptors and the pharmacology of alpha-2 agonists lead to personalized indications, some details are offered. Since interactions between conventional sedatives and alpha-2 agonists have received little attention, these interactions are addressed. Within the existing guidelines for CCU sedation, this article could facilitate the use of alpha-2 agonists as effective and safe sedation while awaiting large, multicentre trials and more evidence-based medicine.

Clinical Practice: Should we radically alter our sedation of critical care patients, Especially given the COVID-19 pandemics?

Romanian Journal of Anaesthesia and Intensive Care

This work is licensed under the Creative Commons Attribution 4.0 International License.

The high number of patients infected with the SARS-CoV-2 virus requiring care for ARDS puts sedation in the critical care unit (CCU) to the edge. Depth of...

Clinical Practice: Should we radically alter our sedation of critical care patients, Especially given the COVID-19 pandemics?

Article Category: Original Paper

Published Online: Jan 04, 2021

Page range: 43 - 76

DOI: https://doi.org/10.2478/rjaic-2020-0018

Keywords
Critical care, sedation, general anaesthesia, conventional sedation, cooperative sedation, alpha-2 adrenergic agonists, alpha-2 agonists, clonidine, dexmedetomidine, guanfacine

© 2020 Stelian L Quintin et al. published by Sciendo

This work is licensed under the Creative Commons Attribution 4.0 International License.

Clinical Practice: Should we radically alter our sedation of critical care patients, Especially given the COVID-19 pandemics?

Article Category: Original Paper

Published Online: Jan 04, 2021

Page range: 43 - 76

DOI: https://doi.org/10.2478/rjaic-2020-0018

KeywordsCritical care, sedation, general anaesthesia, conventional sedation, cooperative sedation, alpha-2 adrenergic agonists, alpha-2 agonists, clonidine, dexmedetomidine, guanfacine

© 2020 Stelian L Quintin et al. published by Sciendo

This work is licensed under the Creative Commons Attribution 4.0 International License.

Keywords
Critical care, sedation, general anaesthesia, conventional sedation, cooperative sedation, alpha-2 adrenergic agonists, alpha-2 agonists, clonidine, dexmedetomidine, guanfacine