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Available online 2 June 2025
Analgesia, sedation, and neuromuscular blocking agents: A standardized protocol of analgosedation in COVID-19
Analgesia, sedación y agentes bloqueantes neuromusculares: un protocolo estandarizado de analgosedación en COVID-19
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Cecilia Inés Loudeta,b,
Corresponding author
, Marisol García Sarubbioc, María Julia Meschinic, Jacqueline Vilca Becerrab, María Agustina Mazzolenic, Vanesa Aramendic, Agustina Barbieric, Carolina Colavitac, Gustavo Cerria, Sofía Pachoa, Eliseo Hernán Ferraria, Rosa Reinad
a Applied Pharmacology Department, Faculty of Medical Sciences, National University of La Plata, Argentina
b Intensive Care Unit, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
c Pharmacy Service, Hospital Interzonal General de Agudos General San Martín, La Plata, Argentina
d Sociedad Argentina de Terapia Intensiva, Cnel. Niceto Vega 4617- 1414 Ciudad Autónoma de Buenos Aires, Argentina
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Table 1. Epidemiological and outcome variables in invasively ventilated patients with COVID-19.
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Table 2. Sedative, analgesic and neuromuscular blocking agents, use and days of use.
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Table 3. Doses of sedative, analgesic and neuromuscular blocking agents in invasively ventilated patients with COVID-19.
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Abstract
Objectives

Primary: To evaluate the level of sedation, use, daily doses, and duration of analgosedative drugs in COVID-19 patients on mechanical ventilation (MV) using a standardized protocol, comparing survivors and non-survivors. Secondary: To identify independent predictors of hospital mortality.

Design

Retrospective cohort study.

Setting

Medical-surgical ICU.

Patients

Adults with SARS-CoV-2 infection requiring invasive MV and continuous infusion of analgosedation and/or neuromuscular blocking agents (NMBAs) for at least 48 h.

Interventions

None.

Main variables of interest

Level of sedation, use, daily doses, and duration of analgosedative drugs; hospital mortality and associated factors.

Results

Among 198 patients (nurse-to-patient ratio 1:2.4; 65% staff turnover), median global RASS was –4.5. Kaplan–Meier analysis showed lower survival with deeper sedation. Fentanyl (99%) and midazolam (97%) were the most used, followed by NMBAs (81%), propofol and dexmedetomidine (48%). Non-benzodiazepine sedatives were precribed more in survivors (88%) than non-survivors (53%) (p < 0.01). Survivors had more days of fentanyl, midazolam, and dexmedetomidine; no differences in NMBA use or drug doses were observed. Mortality was 63%. Independent predictors of mortality included APACHE II, SOFA24, Charlson score, median RASS, and non-benzodiazepine sedative use.

Conclusions

Standardized protocols emphasizing the ACD components of the ABCDEF bundle, along with appropriate use of analgosedation and NMBAs despite limited staffing, effectively supported the management of sedation without significant dose differences between survivors and non-survivors. Sedation level and the use of non-benzodiazepine sedatives were independently associated with better outcomes, highlighting the importance of the light sedation and the ABCDEF bundle.

Keywords:
COVID-19 pandemic
ARDS
Critical care
Analgesic drugs
Sedatives
Neuromuscular blocking agents
Guidelines
Protocols
Resumen
Objetivos

Primario: Evaluar nivel de sedación, uso, dosis diarias y duración de fármacos analgosedantes en pacientes con COVID-19 en ventilación mecánica (VM) utilizando protocolos estandarizados, comparando sobrevivientes y no sobrevivientes. Secundario: Identificar predictores independientes de mortalidad hospitalaria.

Diseño

Cohorte retrospectiva

Ámbito

UCI médico-quirúrgica.

Pacientes

Adultos con SARS-CoV-2, VM invasiva e infusión continua de analgosedación y/o bloqueantes neuromusculares (BNMs) ≥48 horas.

Intervenciones

Ninguna.

Variables de interés principales

Nivel de sedación, uso, dosis diarias y duración de analgosedantes; mortalidad hospitalaria y factores asociados.

Resultados

Se incluyeron 198 pacientes. Relación enfermero-paciente 1:2,4; recambio de enfermería 65%. El RASS global fue −4.5. La sedación profunda se asoció con menor supervivencia (Kaplan–Meier). Fentanilo (99%) y midazolam (97%) fueron los más utilizados; seguidos por BNMs (81%), propofol y dexmedetomidina (48%). Los sedantes no benzodiacepínicos se usaron en 88% de los sobrevivientes versus 53% de los no sobrevivientes (p < 0,01). Los sobrevivientes tuvieron significativamente más días con fentanilo, midazolam y dexmedetomidina, sin diferencias con BNMs ni en las dosis de todos los fármacos. Mortalidad 63%. Los predictores independientes de mortalidad incluyeron APACHE II, SOFA24, Charlson, RASS mediana y uso de sedantes no benzodiacepínicos.

Conclusiones

Protocolos estandarizados que enfatizan los componentes ACD del paquete ABCDEF y el uso adecuado de la analgosedación y BNMs, incluso con personal limitado, permitieron una gestión efectiva de la sedación sin diferencias significativas en dosis entre sobrevivientes y no sobrevivientes. El nivel de sedación y los sedantes no benzodiacepínicos se asociaron independientemente con mejores resultados, destacando la importancia de sedación ligera paquetes ABCDEF.

Palabras clave:
Pandemia de COVID-19
SDRA
Cuidados críticos
Fármacos analgésicos
Sedantes
Agentes bloqueantes neuromusculares
Guías
Protocolos

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