Medicine, University of Michigan Hospitals. I'm here today to talk about strategies for approaching spontaneous awakening trial in patients with COVID-19. It's important to manage pain, agitation, delirium in the COVID-19 population. And critically ill patients with COVID-19 infection often require the use of sedatives and allergies and medications to manage, and medications to manage delirium. And this is to achieve patient comfort, drain mechanical ventilation, to optimize ventilatory synchrony and gas exchange in the setting of severe hypoxic respiratory failure. Also, it's for prevention of unplanned device removal, including unplanned excavations, and for the management of agitated delirium. The COVID-19 patient population presents with challenges to managing their pain, agitation, and delirium. And they include, we see an increased incidence of encephalopathy that often requires the increased use of analgesia and sedative agents. This population has an increased incidence of ARDS, requiring the use of our evidence-based practices, including botidivines, high PEEP, and prone positioning, which often require increased use of analgesia and sedative medications. This population is in special precautions isolation, and there's an increased risk of viral transmission to healthcare workers. And these result in decreased time in the room that minimizes the assessments we can make and the ability for frequent titration of medications. It can also affect the choice of sedatives, which we select and can result in the potential increased use of sedatives because we fear we can't get in the room in time and we wanna prevent that patient from self-extubating. We wanna achieve the best outcome for these patients, and that's by applying the evidence. And the best evidence we have shows that we can get, by using lower levels of sedation and non-benzodiazepine regimes, we can decrease duration of mechanical ventilation, decrease ICU days, and increase days free of delirium and coma. Utilizing the ICU liberation bundle, that's the ABCDEF to optimize the patient outcomes. And that begins with the choice of sedation. Based on the goals we wanna achieve with sedation, we want the patient to be calm, we want the patient to be calm, comfortable, cooperative, reduce anxiety and agitation, facilitate mechanical ventilation, and decrease traumatic memory of ICU stay in procedures. So let's talk about some sedation strategies. First and foremost, we need to treat pain first, because unrecognized pain is a frequent cause of agitation. Consider the use of Anglo sedation, and also consider the use of enteral opioid agents, and that might decrease the consumption of intravenous opiates. During the pandemic, we often have seen drug shortages, and so using different routes for these medications might be helpful. Our sedation strategy should include targeting light sedation, a RAS of a minus one to a minus two up to zero, using intermittent sedation prior to moving to a continuous strategy, whenever possible. Propofol is our first line agent for sedation, but in this, the COVID-19 population, we have to worry and monitor for high triglyceride levels, and if present, we might need to use an alternative sedative. Dexmethomidine infusion can be used for light sedation, and should be used if you need a continuous IV sedative in a patient that is delirious. Often in this population, we do need to use deep sedation, RAS of minus four to minus five, and this is often when there is significant ventilator dyssynchrony that we've not been able to correct by altering the ventilator, and it exists with the evidence of impaired gas exchange, despite the use of anglo-sedation strategies. We need to remember that deep sedation can reduce six months survival, it causes an increase in hospital mortality, longer duration on mechanical ventilation, longer ICU length of stays, and increased physiologic stress. So we need to use it only when we need to use it. So we should be discussing sedation goals each day on rounds, we need to titrate our sedatives throughout the day to achieve that targeted RAS, and we need to perform spontaneous awakening trials when the safety screen is daily, when the safety screen is passed. What's that spontaneous awakening trial? It is where once a day, at a minimum of once a day, we completely turn off the sedative, continuous sedative infusions. First step in the spontaneous awakening trial is to perform a safety screen. You can see up on the box on the right, you can continue with a spontaneous awakening trial, the patient is safe to have one if you have no active seizures, no alcohol withdrawal, no agitation, you're not on paralytics, you don't have myocardial ischemia, and you have normal intracranial pressure. If I've passed the safety screen, then I perform that spontaneous awakening trial by turning off all my continuous sedative meds, and then I watch to see how the patient tolerates it. It would be considered a failure if you saw a significant increase in anxiety, agitation, or pain, a respiratory rate of greater than 35 a minute, oxygen saturations less than 88%, respiratory distress, or acute cardiac dysrhythmias. If you see any of those, then that would be considered a failure and you would want to restart sedative medication. You can trial giving a bolus dose of a sedative to see if that works. If not, you can restart the sedative dose, but we want to restart it at half the dose they were on when you turned it off, and then titrate up to your target RAS. If the patient successfully completes a spontaneous awakening trial, you want to coordinate then with a respiratory therapist to see if an SBT is to be completed for that patient. So this concludes talking about strategies for approaching an SAT in patients with COVID-19. Again, remember, we want to target light sedation when possible, that's targeting a RAS of minus one, minus two to zero. We will adjust sedation targets based on ventilatory needs. Assess the sedation level, the RAS regularly, discuss sedation target each day on rounds, treat pain first, consider anglo-sedation, and perform an SAT daily when a safety screen is passed. Thank you for your time and attention.

managing pain

agitation

delirium

COVID-19 patients

sedation strategies