Analgesia, sedation, and neuromuscular blocking agents: A standardized protocol of analgosedation in COVID-19.

Abstract

Objectives: Primary: To evaluate the level of sedation, use, daily doses, and duration of analgosedative drugs in COVID-19 patients on mechanical ventilation (MV) using a standardized protocol, comparing survivors and non-survivors. Secondary: To identify independent predictors of hospital mortality.

Design: Retrospective cohort study.

Setting: Medical-surgical ICU.

Patients: Adults with SARS-CoV-2 infection requiring invasive MV and continuous infusion of analgosedation and/or neuromuscular blocking agents (NMBAs) for at least 48 h.

Interventions: None.

Main variables of interest: Level of sedation, use, daily doses, and duration of analgosedative drugs; hospital mortality and associated factors.

Results: Among 198 patients (nurse-to-patient ratio 1:2.4; 65% staff turnover), median global RASS was -4.5. Kaplan-Meier analysis showed lower survival with deeper sedation. Fentanyl (99%) and midazolam (97%) were the most used, followed by NMBAs (81%), propofol and dexmedetomidine (48%). Non-benzodiazepine sedatives were precribed more in survivors (88%) than non-survivors (53%) (p < 0.01). Survivors had more days of fentanyl, midazolam, and dexmedetomidine; no differences in NMBA use or drug doses were observed. Mortality was 63%. Independent predictors of mortality included APACHE II, SOFA₂₄, Charlson score, median RASS, and non-benzodiazepine sedative use.

Conclusions: Standardized protocols emphasizing the ACD components of the ABCDEF bundle, along with appropriate use of analgosedation and NMBAs despite limited staffing, effectively supported the management of sedation without significant dose differences between survivors and non-survivors. Sedation level and the use of non-benzodiazepine sedatives were independently associated with better outcomes, highlighting the importance of the light sedation and the ABCDEF bundle.