Thread by @PulmCrit

new section on the mixology of analgo-sedation for intubated COVID patients. there are lots of approaches analgo-sedation, this is my favorite mix...(1/6)
#COVID19foam
IBCC section: bit.ly/3aTDlyL

if possible, achieving an awake & comfortable patient on the ventilator is enormously beneficial:
- easier to extubate
- can communicate, determine sources of pain
- might help avoid lung-injurious tidal volumes
- less delirium, faster rehab (2/6)

the fundamental principle is multi-modal analgo-sedation. using *low* doses of *several* medications maximizes synergistic efficacy, while avoiding the toxicity of any specific agent (#3/6)

for example, scheduled acetaminophen and pain-dose ketamine infusions can go a long way towards alleviating pain (thereby minimizing opioid requirements). ketamine also has anti-depressant and perhaps anti-IL6 effects. (nope, there's nothing that ketamine can't do.) (#4/6)

as we run out of propofol, sedating atypical antipsychotics may become an important sedative (to reduce the dose of propofol needed). olanzapine may be ideal due to lack of QTc prolongation. minimizing propofol dose may also help avoid hypertriglyceridemia from HLH. (#5/6)

some patients with COVID seem to be unusually difficult to sedate (not sure why?), so other adjuncts like phenobarbital are likely to come into play as well. careful dosing is essential, because the half-life is long! (#6/6)