Use of Levomepromazine for the Treatment of Emergence Agitation in Patients Receiving Mechanical Ventilation for SARS-CoV-2 Related Acute Respiratory Distress Syndrome

Abstract

Purpose: To report our experience with the use of Levomepromazine (LMZ) for the treatment of delirium in patients treated for Acute Respiratory Distress Syndrome (ARDS) due to COVID-19. Methods: Retrospective series of patients admitted to the Intensive Care Unit (ICU) of a non-academic hospital and who requiring invasive mechanical ventilation for the treatment of ARDS due to SARS-CoV-2. Infection was confirmed by Reverse Transcriptase Polymerase Chain Reaction (RT-PCR) testing, and patients presented delirium after withdrawal of neuromuscular blockade or sedation lightening treated with LMZ on top of other treatment. Results: Out of 34 ARDS patients admitted from 22 March 2020 to 23 January 2021, 11 (32.3%) died before neuromuscular blockade withdrawal, and of the remaining 23, 16 were treated with LMZ. The median time to initiation of LMZ was 6 days (interquartile, 5 to 8) from the start of sedation, and median duration of LMZ treatment was 5 (1 to 28) days. Median sedation score (as assessed by the Sedation Agitation Scale (SAS)) was 2 (1-4) at initiation and 3 (2-4) at discontinuation of LMZ, while median analgesia scores (Behavioral Pain Scale (BPS)) were respectively 3 (3-5) and 4 (3-5). Of the 16 patients treated with LMZ, 12 were weaned from mechanical ventilation immediately following discontinuation, without recurrence of delirium. No adverse effects related to LMZ use were observed. The 4 patients who could not be weaned from mechanical ventilation following LMZ required new neuromuscular blockade. Conclusions: Based on this retrospective series, LMZ seems to be useful for the management of delirium occurring after withdrawal of neuromuscular blockade or lightening of sedation in patients with ARDS due to SARS-CoV-2.