Shortage of sedatives and neuromuscular blockers during COVID-19 pandemic: The result of an overstocking procedure in French hospitals?

Trends and Patterns of ICU E-Referrals in Saudi Arabia during 2020-2021: Results from the National Saudi Medical Appointments and Referrals Centre

Background/Objectives: Intensive care unit (ICU) e-referrals are an important indicator for exploring potential deficiencies in critical care resources. This study aimed to examine the epidemiology and patterns of ICU e-referrals across all regions of Saudi Arabia during the COVID-19 pandemic using routinely collected data from April 2020 to December 2021. Methods: This descriptive epidemiological study analyzed data from the Saudi Medical Appointments and Referrals Centre (SMARC). This study reveals novel regional ICU e-referral patterns for critical cases using national unique digital health data, adding insights beyond the existing literature. Variables included age, sex, referral timing, reason, specialty, and region of origin. Descriptive statistics and mapping of administrative areas were performed based on e-referral request rates per 10,000 population. Results: During the study period, 36,619 patients had ICU e-referral requests. The mean age was 54.28 years, with males constituting 64.81% of requests. Out-of-scope e-referrals comprised 71.44% of requests. Referrals related to medical specialties, such as cardiology and pulmonology, were the most common (62.48%). Referral patterns showed peaks in July-August 2020 and May 2021. The Northern Border and Albaha areas had the highest request rates per population, potentially reflecting a higher proportion of severe cases requiring ICU-level care compared to other regions. Conclusions: The temporal pattern and geographic distribution of ICU e-referrals mirrored previously reported critical COVID-19 cases in Saudi Arabia. Preventive measures and vaccination programs contributed to a significant decline in ICU e-referral requests, suggesting a positive impact on controlling severe COVID-19 cases. Population-adjusted analysis revealed regional disparities, highlighting the importance of considering population size in healthcare resource management and policy.

Rapid production of the anaesthetic mepivacaine through continuous, portable technology

Local anaesthetics such as mepivacaine are key molecules in the medical sector, so ensuring their supply chain is crucial for every health care system. Rapid production of mepivacaine from readily available commercial reagents and (non-dry) solvents under safe conditions using portable, continuous apparatus could make an impactful difference in underdeveloped countries. In this work, we report a continuous platform for synthesising mepivacaine, one of the most widely used anaesthetics for minor surgeries. With a focus on sustainability, reaction efficiency and seamless implementation, this platform afforded the drug in 44% isolated yield following a concomitant distillation-crystallisation on a gram scale after N-functionalisation and amide coupling, with full recovery of the solvents and excess reagents. The use of flow chemistry as an enabling tool allowed the use of "forbidden" chemistry which is typically challenging for preparative and large scale reactions in batch mode. Overall, this continuous platform presents a promising and sustainable approach that has the potential to meet the demands of the healthcare industry.

Contamination of the central medical air supply with water leading to mass ventilator failure

Here, we present a case of mass ventilator failure due to contaminated medical air. Multiple ventilators failed routine tests, including almost all of the ventilators in our intensive care unit. A faulty air compressor had led to water contamination of our centre's supply of medical air. Water entered the pipeline supply of air and, hence the ventilators and anaesthetic machines. The disruption of the machines' proportional mixer valve resulted in unreliable delivery of fresh gas flow. This malfunction was discovered during routine pre-use checks, and backup ventilators were available to replace the faulty ventilators. A shortage of equipment was averted due to a serendipitous availability of ventilator stockpiles prepared for the COVID-19 pandemic. Ventilator shortages are commonly described in mass casualty and pandemic scenarios. While there are multiple strategies described in literature to augment and maximise equipment available for mechanical ventilation, stockpiling equipment remains an expensive but necessary component of disaster contingency planning.

Sedation with Sevoflurane versus Propofol in COVID-19 Patients with Acute Respiratory Distress Syndrome: Results from a Randomized Clinical Trial

BACKGROUND

Acute respiratory distress syndrome (ARDS) related to COVID-19 (coronavirus disease 2019) led to intensive care units (ICUs) collapse. Amalgams of sedative agents (including volatile anesthetics) were used due to the clinical shortage of intravenous drugs (mainly propofol and midazolam).

METHODS

A multicenter, randomized 1:1, controlled clinical trial was designed to compare sedation using propofol and sevoflurane in patients with ARDS associated with COVID-19 infection in terms of oxygenation and mortality.

RESULTS

Data from a total of 17 patients (10 in the propofol arm and 7 in the sevoflurane arm) showed a trend toward PaO₂/FiO₂ improvement and the sevoflurane arm's superiority in decreasing the likelihood of death (no statistical significance was found).

CONCLUSIONS

Intravenous agents are the most-used sedative agents in Spain, even though volatile anesthetics, such as sevoflurane and isoflurane, have shown beneficial effects in many clinical conditions. Growing evidence demonstrates the safety and potential benefits of using volatile anesthetics in critical situations.

Molecular mechanisms of muscular and non-muscular actions of neuromuscular blocking agents in critical illness: a narrative review

Despite frequent use of neuromuscular blocking agents in critical illness, changes in neuromuscular transmission with critical illness are not well appreciated. Recent studies have provided greater insights into the molecular mechanisms for beneficial muscular effects and non-muscular anti-inflammatory properties of neuromuscular blocking agents. This narrative review summarises the normal structure and function of the neuromuscular junction and its transformation to a 'denervation-like' state in critical illness, the underlying cause of aberrant neuromuscular blocking agent pharmacology. We also address the important favourable and adverse consequences and molecular bases for these consequences during neuromuscular blocking agent use in critical illness. This review, therefore, provides an enhanced understanding of clinical therapeutic effects and novel pathways for the salutary and aberrant effects of neuromuscular blocking agents when used during acquired pathologic states of critical illness.

Trends in the Use of Sedative-Hypnotics, Opioids, and Neuromuscular Blockers in Hospitalized Patients During the COVID-19 Pandemic: Observational Retrospective Study

Background

The coronavirus disease 2019 (COVID-19) pandemic has increased the use of drugs administered for mechanical ventilation, leading to shortages in some countries.

Objective

The aim was to identify trends in the consumption of sedatives, hypnotics, neuromuscular blockers, and opioids used for anesthetic induction and deep sedation in hospitals in Colombia.

Method

This was a descriptive, longitudinal, and retrospective study with monthly follow-up of sedative, hypnotic, opioid, and neuromuscular blocker dispensing in 20 clinics and hospitals from January to November 2020. The frequencies of use of each drug and variations in the institutions and intensive care units (ICUs) were identified.

Results

A total of 1,252,576 units of the analyzed drugs were delivered to 79,094 treated patients, 55.0% of whom were women (n = 43,521). The drugs with the greatest increase in consumption were rocuronium (1058% variation in March–November) and propofol (511%). The consumption of midazolam and vecuronium initially increased, but by the end of the study period, it decreased. Among drugs dispensed only in ICUs, 920,170 units were delivered (73.5% of the drugs dispensed during the study), and the most often dispensed drugs were fentanyl (n = 251,519; 27.3% of the drugs used in the ICU) and midazolam (5 mg/5 mL) solution (n = 188,568; 20.5%). Specifically in the ICU, the drugs with the greatest increase in use were rocuronium (19,709%), propofol (2622%), and ketamine (2591%).

Conclusion

Rapid changes in the use of drugs were evident, which demonstrates the need for closer cooperation among treating physicians, service providers, pharmaceutical managers, and state institutions to maintain a sufficient and timely supply of critical drugs in this type of contingency.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-022-00337-z.

Sevoflurane administration from extracorporeal membrane oxygenation via the AnaConDa device for a patient with COVID-19: a breakthrough solution for the shortage of intravenous anesthetics

One of the major issues encountered during the coronavirus disease 2019 (COVID-19) pandemic has been the shortage of intravenous anesthetics. Moreover, patients undergoing extracorporeal membrane oxygenation (ECMO) need large quantities of intravenous anesthetics for sedation. We report the case of a 52-year-old man who was admitted to our hospital due to acute respiratory distress syndrome by COVID-19 and treated with ECMO. As controlling sedation with intravenous anesthetics was challenging, we attempted to administer inhaled anesthetics via the gas flow of ECMO. We decreased the quantity of intravenous anesthetics and opioids. This method might help overcome the shortage of intravenous anesthetics.

Does Unprecedented ICU Capacity Strain, As Experienced During the COVID-19 Pandemic, Impact Patient Outcome?

OBJECTIVES

To determine whether patients admitted to an ICU during times of unprecedented ICU capacity strain, during the COVID-19 pandemic in the United Kingdom, experienced a higher risk of death.

DESIGN

Multicenter, observational cohort study using routine clinical audit data.

SETTING

Adult general ICUs participating the Intensive Care National Audit & Research Centre Case Mix Programme in England, Wales, and Northern Ireland.

PATIENTS

One-hundred thirty-thousand six-hundred eighty-nine patients admitted to 210 adult general ICUs in 207 hospitals.

INTERVENTIONS

Multilevel, mixed effects, logistic regression models were used to examine the relationship between levels of ICU capacity strain on the day of admission (typical low, typical, typical high, pandemic high, and pandemic extreme) and risk-adjusted hospital mortality.

MEASUREMENTS AND MAIN RESULTS

In adjusted analyses, compared with patients admitted during periods of typical ICU capacity strain, we found that COVID-19 patients admitted during periods of pandemic high or pandemic extreme ICU capacity strain during the first wave had no difference in hospital mortality, whereas those admitted during the pandemic high or pandemic extreme ICU capacity strain in the second wave had a 17% (odds ratio [OR], 1.17; 95% CI, 1.05-1.30) and 15% (OR, 1.15; 95% CI, 1.00-1.31) higher odds of hospital mortality, respectively. For non-COVID-19 patients, there was little difference in trend between waves, with those admitted during periods of pandemic high and pandemic extreme ICU capacity strain having 16% (OR, 1.16; 95% CI, 1.08-1.25) and 30% (OR, 1.30; 95% CI, 1.14-1.48) higher overall odds of acute hospital mortality, respectively.

CONCLUSIONS

For patients admitted to ICU during the pandemic, unprecedented levels of ICU capacity strain were significantly associated with higher acute hospital mortality, after accounting for differences in baseline characteristics. Further study into possible differences in the provision of care and outcome for COVID-19 and non-COVID-19 patients is needed.

[Contribution of a hospital pharmacy team to critical care of patients infected with SARS-CoV-2]

Le circuit du médicament hospitalier le plus sûr est la dispensation journalière individuelle nominative automatisée assurée par la pharmacie. Depuis plusieurs années nous essayons de convaincre les décideurs hospitaliers de l’implanter dans notre établissement. En attendant, pour pallier les risques d’erreurs médicamenteuses encourus par les patients et les soignants, nous avons constitué plusieurs équipes de travail au sein des unités de soins. Ces équipes sont constituées d’un pharmacien et d’un ou deux préparateurs en pharmacie hospitalière qui assurent notamment la gestion des armoires à pharmacie des unités de soins. La collaboration étroite avec médecins et personnel infirmier développée au fil des années a été un élément favorable déterminant lorsqu’il a fallu doter en médicaments et en dispositifs médicaux stériles (DMS) les nouvelles unités de soins critiques face à l’afflux de patients contaminés par le SARS-CoV2. Le suivi quotidien des médicaments consommés par patient, particulièrement les curares, et des DMS en rupture d’approvisionnement a été un élément clé de la gestion des stocks et des changements de principes actifs, de conditionnements et/ou de références de matériel. Les faits relatés donnent du poids au rapport Claris qui souligne les effets positifs en termes de qualité et de sécurité de prise en charge des patients du travail des PPH et pharmaciens dans les unités de soins. Ils soulignent par ailleurs les dangers auxquels sont exposés patients et soignants samedi, dimanche et jours fériés quand la pharmacie est fermée. Ils légitiment la question de l’extension de l’ouverture de la pharmacie en équipe complète 365 jours par an.

Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome

OBJECTIVE

To propose agile strategies for a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for patients with COVID-19-associated acute respiratory distress syndrome, considering the high risk of infection among health workers, the humanitarian treatment that we must provide to patients and the inclusion of patients' families, in a context lacking specific therapeutic strategies against the virus globally available to date and a potential lack of health resources.

METHODS

A nonsystematic review of the scientific evidence in the main bibliographic databases was carried out, together with national and international clinical experience and judgment. Finally, a consensus of recommendations was made among the members of the Committee for Analgesia, Sedation and Delirium of the Sociedad Argentina de Terapia Intensiva.

RESULTS

Recommendations were agreed upon, and tools were developed to ensure a comprehensive approach to analgesia, sedation, delirium, early mobility and family engagement for adult patients with acute respiratory distress syndrome due to COVID-19.

DISCUSSION

Given the new order generated in intensive therapies due to the advancing COVID-19 pandemic, we propose to not leave aside the usual good practices but to adapt them to the particular context generated. Our consensus is supported by scientific evidence and national and international experience and will be an attractive consultation tool in intensive therapies.