Expert consensus on management of analgesia and sedation for patients with severe coronavirus disease 2019.

Abstract

The coronavirus disease 2019 (COVID-19) has been declared a global pandemic and is a major public health issue worldwide. COVID-19 is a systemic disease damaging multiple organs, including the lung as the main target organ. Approximately 14% COVID-19 patients develop a severe disease and 5% require admission to ICU. Those critically ill patients are often in a state of stress, pain, and anxiety due to the pathophysiology of the acute stage of the disease, underlying illness, psychological factors, and environmental factors. COVID-19 increases organ function load, resulting in increased tissue oxygen consumption and respiratory dysfunction, which further damage organs and can even be life-threatening. In addition, various medical procedures including mechanical ventilation, arterial puncture, central venous catheterization, and hemodialysis could aggravate discomfort, anxiety, and pain. Meanwhile, some patients with COVID-19 have greater mental health problems and sleep disorders, which not only cause emotional fluctuations and delirium but also delay tissue repair and suppress immune function. Thus, it is necessary to assess pain, anxiety, mental health problems and sleep quality of the patients with COVID-19. At present, there are no specific antiviral drugs or vaccines against COVID-19. The use of analgesic and sedation agents is appropriate as an initial strategy in critically ill and mechanically ventilated patients with COVID-19, as it can not only relieve the discomfort of intubation and reduce ventilator-associated lung injury but also reduce sympathetic stress and protect against organ damage. No specific data exist on the optimal use of analgesics, sedatives, and agents to control delirium in patients with COVID-19. Our consensuses are mainly aimed at standardizing the management of pain, agitation, and delirium, formulating the appropriate medication plan, and achieving the optimal clinical status for severe patients with COVID-19. The statements were drawn up by a group of 15 front-line intensive care experts who fought the COVID-19 epidemic in China. The expert group defined clinical questions according to the Population, Intervention, Control, and Outcome format. A literature search was performed via PubMed and the Cochrane Library databases. The quality of evidence was assessed using the methodology described in Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). Because of the sudden outbreak of COVID-19, the proposed question could be the subject of a recommendation as an expert opinion due to non-existent or insufficient literature. A total of four rounds of expert seminars and discussions were organized to provide trustworthy recommendations. Totally experts draw up 30 statements on the management of analgesia and sedation for severe COVID-19 patients [Table 1 ]. Of these consensuses, 3 had a high level of evidence (GRADE 1±), 13 had a low level of evidence (GRADE 2±), and 14 were expert opinions. A strong agreement was reached for all statements after two rounds of scoring [Supplementary Material Manuscript-gls.pdf, https://links.lww.com/CM9/A282].Table 1: The main consensus statement on the management of analgesia and sedation for severe COVID-19 patientsTable 1 (Continued): The main consensus statement on the management of analgesia and sedation for severe COVID-19 patientsPain, agitation, delirium, and sleep disturbance are commonly manifested in COVID-19 patients and are closely associated with the severity and poor prognosis of the disease. This expert consensus statement should be helpful for clinicians worldwide with limited experience in the management of analgesia and sedation for severe COVID-19 patients by offering specific suggestions in this time of global crisis. Acknowledgements The authors thank all of the health care workers and other hospital staff as well as the local authorities for their efforts to combat the outbreak of COVID-19. Funding The work was supported by a grant from the China Health Information and Health Care Big Data Society: Special Research Fund for Analgesia and Sedation of Severe Infection (No. Z-2019-1-001). Conflicts of interest None.