Extracorporeal membrane oxygenation and inhaled sedation in coronavirus disease 2019-related acute respiratory distress syndrome

Martin Bellgardt, Dennis Özcelik, Andreas Friedrich Christoph Breuer-Kaiser, Claudia Steinfort, Thomas Georg Karl Breuer, Thomas Peter Weber, Jennifer Herzog-Niescery, Martin Bellgardt, Dennis Özcelik, Andreas Friedrich Christoph Breuer-Kaiser, Claudia Steinfort, Thomas Georg Karl Breuer, Thomas Peter Weber, Jennifer Herzog-Niescery

Abstract

Coronavirus disease 2019 (COVID-19) related acute respiratory distress syndrome (ARDS) is a severe complication of infection with severe acute respiratory syndrome coronavirus 2, and the primary cause of death in the current pandemic. Critically ill patients often undergo extracorporeal membrane oxygenation (ECMO) therapy as the last resort over an extended period. ECMO therapy requires sedation of the patient, which is usually achieved by intravenous administration of sedatives. The shortage of intravenous sedative drugs due to the ongoing pandemic, and attempts to improve treatment outcome for COVID-19 patients, drove the application of inhaled sedation as a promising alternative for sedation during ECMO therapy. Administration of volatile anesthetics requires an appropriate delivery. Commercially available ones are the anesthetic gas reflection systems AnaConDa® and MIRUSTM, and each should be combined with a gas scavenging system. In this review, we describe respiratory management in COVID-19 patients and the procedures for inhaled sedation during ECMO therapy of COVID-19 related ARDS. We focus particularly on the technical details of administration of volatile anesthetics. Furthermore, we describe the advantages of inhaled sedation and volatile anesthetics, and we discuss the limitations as well as the requirements for safe application in the clinical setting.

Keywords: Acute respiratory distress syndrome; COVID-19; Critical care; Extracorporeal membrane oxygenation; Inhaled sedation; Volatile anesthetics.

Conflict of interest statement

Conflict-of-interest statement: There is no conflict of interest associated with any of the authors of this manuscript.

©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.

Figures

Figure 1
Figure 1
Overview of respiratory management of coronavirus disease 2019 related acute respiratory distress syndrome and inhaled sedation. 1AnaConDa®; 2MIRUSTM. RASS: Richmond Agitation-Sedation Scale; PSV: Pressure support ventilation; BIPAP: Bilevel positive airway pressure; FiO2: Fraction of inspired oxygen; PaO2: Partial pressure of oxygen; P/F-ratio: PaO2/FiO2; VV-ECMO: Veno-venous ECMO.
Figure 2
Figure 2
AnaConDa-S® system set up in prone position. 1Closed loop suction system; 2Port to monitor the volatile anesthetic and CO2; 3AnaConDa®-S with anesthesia gas reflector, bacterial and viral filter, and heat and moisture exchanger; 4Evaporator with liquid line from syringe pump and liquid isoflurane or sevoflurane.
Figure 3
Figure 3
MIRUSTM setup in prone position and veno-venous-extracorporeal membrane oxygenation therapy. 1Closed suction system; 2Bacterial and viral filter and heat and moisture exchanger; 3MIRUSTM reflector.
Figure 4
Figure 4
Display of the MIRUSTM sevoflurane controller. The display shows the setting under normal operation.
Figure 5
Figure 5
Display of the MIRUSTM controller. Yellow alarm refers to a low tidal volume. In this case, the wash-in speed “tortoise” should be selected.
Figure 6
Figure 6
Example of a vacuum-based gas scavenging system (CleanAirTM system). 1Expiration port of the ventilator; 2Open reservoir scavenging system; 3Vacuum line.

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