Treatments

Medications and treatments in ICU

Analgosedation Options

Intermittent IV Bolus

 

Medication

Dosing/

Administration

Pros

Cons

Onset/Duration

Analgesia

Fentanyl

0.5 – 1 mcg/kg (up to 3mcg/kg IV)

Typically: 25-100 mcg IV 

 

Q 0.5 – 1 hr

 

  • Ok to use in renal impairment
  • Minimal effect on BP
  • Rapid onset of action
  • Can accumulate in hepatic impairment
  • Short duration of action (requires frequent redosing of boluses if not on continuous infusion)
  • Onset: less than 1 to 2 minutes
  • Duration: 0.5 – 1 hr
Hydromorphone

0.2 – 1 mg IV

 

Q 1 – 2 hrs

  • Lower accumulation in renal impairment vs morphine

 

  • Onset: 5 – 15 min
  • Duration:  3 – 4 hrs

 

Morphine 

0.1 mg/kg IV 

Typically: 4-8mg IV

 

Q 1 – 4 hrs

  • Longer acting compared with other opioid options
  • Not safe in renal impairment
  • May cause hypotension
  • May cause itching
  • Onset: 5 – 10 min
  • Duration: 3 – 5 hrs

Sedation

Midazolam 

0.1 - 0.3 mg/kg IV

Typically: 2-10mg IV

 

Q 5 - 15 minutes

  • Can be given IM if needed
  • Minimal hemodynamic effects
  • Shorter acting compared to lorazepam, diazepam
  • Caution with use in renal, hepatic failure due to accumulation
  • Clearance decreases with increasing age
  • Benzodiazepines are associated with increased delirium vs non benzodiazepine sedatives
  • Onset: 60 – 90 seconds
  • Duration: 15 – 30 min
Lorazepam 

0.05 - 0.1 mg/kg IV

Typically: 2-4mg IV

 

Q 2 – 6 hrs

  • Ok to use in hepatic dysfunction vs other benzodiazepines
  • Minimal hemodynamic effects
  • Caution with use in renal failure due to accumulation
  • Clearance decreases with increasing age
  • Benzodiazepines are associated with increased delirium vs non benzodiazepine sedatives
  • Onset: 2 - 3 min
  • Duration: 6 – 8 hrs
Diazepam 

0.05 – 0.2 mg/kg IV

Typically: 5-20mg IV 

 

Q 3 – 6 hrs

  • Minimal hemodynamic effects
  • Longer acting vs midazolam or lorazepam due to active metabolites
  • Can accumulate in renal dysfunction
  • Active long acting metabolite which may accumulate over time
  • Benzodiazepines are associated with increased delirium vs non benzodiazepine sedatives
  • Do not give IM
  • Onset: 2 – 3 min
  • Duration: 1 – 2 hrs
  • Duration will increase with repeated dosing due to active metabolite accumulation

Analgesic and Sedative Properties

Ketamine

0.5 – 2 mg/kg IV 

 

 

Q 15 – 30 minutes 

  • Good choice in hemodynamic instability
  • Provides bronchodilatory effects, beneficial in asthma patients
  • Provides both sedative and analgesic effects
  • May cause increased secretions
  • Do not use in ischemic heart disease
  • Causes tachycardia and hypertension
  • Onset: 30 - 90 seconds
  • Duration: 10 – 20 min

 

 

 

 

Continuous Infusions

Medication

Dosing/Administration

Pros

Cons

Analgesia

Fentanyl

0.5 – 2 mcg/kg/hr 

Typically: 25-300mcg/hr

  • Easy titration (short half-life)
  • Ok to use in renal impairment
  • Minimal effect on BP
  • Available as both PCA syringe for infusion or IVPB
  • Can accumulate in hepatic impairment

 

Hydromorphone
  1. – 0.02 mg/kg/hr

Typically: 0.5 – 3mg/hr

  • Lower accumulation in renal impairment vs morphine
  • Available in concentrated formulation for fluid restricted patients on high opioid doses
  • Difficult titration (long half-life)
  • Can accumulate in renal and hepatic impairment
Morphine 

0.025 – 0.05 mg/kg/hr

Typically: 2 - 6 mg/hr

  • Available in concentrated formulation for fluid restricted patients on high opioid doses
  • Difficult titration (long half-life)
  • Not safe in renal impairment
  • May cause hypotension
  • May cause itching

Sedation

Midazolam 

20 – 50 mcg/kg/hr

Typically: 0.5 - 10 mg/hr

  • Shorter acting compared to lorazepam (less accumulation, shorter awakening times)
  • Available as both PCA syringe for infusion or IVPB

 

 

  • Accumulation with prolonged administration
  • Tolerance may develop
  • Caution with use in renal, hepatic failure
  • Clearance decreases with increasing age
  • Benzodiazepines are associated with increased delirium vs non benzodiazepine sedatives
Lorazepam 

0.05 – 0.1 mg/kg/hr

Typically: 1 – 6 mg/hr

  • Ok to use in hepatic dysfunction vs other benzodiazepines

 

  • May cause propylene glycol toxicity (AKI, high lactic acid, metabolic acidosis, hypotension)
  • Associated with longer time to awaken compared to midazolam
  • Tolerance may develop
  • Caution with use in renal failure
  • Clearance decreases with increasing age
  • Benzodiazepines are associated with increased delirium vs non benzodiazepine sedatives
Propofol

5 – 75 mcg/kg/min

 

  • Easy to titrate (short half-life)
  • Rapid onset and offset
  • Has anticonvulsant properties
  • Good option for patients who need frequent awakenings
  • Causes hypotension
  • May cause propofol infusion syndrome or hypertriglyceridemia with higher doses and prolonged use
  • Requires changing out IV lines/bottles q12h
  • Contraindicated with egg or soybean allergy
Dexmedetomidine 

0.1– 1 mcg/kg/hr

(Do not give a bolus dose due to bradycardia)

 

 

  • May not be ideal for COVID patients due to lighter level of sedation compared to other agents
  • No significant respiratory drive reduction, may not help with ventilator synchrony
  • May cause hypotension and bradycardia

Analgesic and Sedative Properties

Ketamine

0.15 – 2.5 mg/kg/hr

 

  • Good choice in hemodynamic instability
  • Provides bronchodilatory effects, beneficial in asthma patients
  • Provides both sedative and analgesic effects
  • Large volume administered (low concentration 1-2mg/mL)
  • May cause increased secretions
  • Do not use in ischemic heart disease
  • Causes tachycardia and hypertension
  • Potential of neurotoxicity with prolonged use

 

 

Other things to consider:

Fentanyl patches

Oral immediate release tab formulations (oxy, morphine, hydromorphone) down OG/NG tube 

Oral liquid formulations (oxy, morphine, hydromorphone) down OG/NG tube

Pooling small propofol vials (20ml) into empty IV bags when 100ml propofol vials run short

Using small propofol vials (20ml) to prime lines vs using the large bottles (lines changed q12H) to save content in 100ml bottles

Phenobarbital

  • Bolus dose: 15 – 20 mg/kg IV
  • Infusion: 0.5 – 1 mg/kg/hr
  • Pros: provides deep level of sedation, provides anticonvulsant effects
  • Cons: Some dosage forms contain propylene glycol and may cause propylene glycol toxicity, increased LFT’s, rare incidence of SJS, long acting (difficult to titrate, may accumulate with prolonged use and increase time to awakening)

Remifentanil 

  • Continuous infusion: 0.1 to 1 mcg/kg/h
  • Pros: easy to titrate (short half-life)
  • Cons: May cause hypotension and bradycardia
Last Updated 4 months ago

Hemodynamic Support in Adults with Shock

Fluids

  • Use a conservative fluid administration strategy.
  • Use crystalloids over colloids.
  • Balanced crystalloids are preferred over unbalanced crystalloids.

Pressor Support

  • Norepinephrine as  first-line.
  • Vasopressin or epinephrine as the first line if norepinephrine is not available.
  • Dopamine is not recommended if norepinephrine is not available.
  • Vasopressin as second-line agent if the target 60-65 mm Hg MAP cannot be achieved by norepinephrine alone

 Pharmacological Therapy 

  • In adults receiving mechanical ventilation without ARDS routine use of systemic corticosteroids is suggested against
  • In those with ARDS, use of corticosteroids is suggested

Sources:

 Poston JT, Patel BK, Davis AM. Management of Critically Ill Adults With COVID-19. JAMA. 2020 Mar 26.

https://jamanetwork.com/journals/jama/fullarticle/2763879

Last Updated 5 months ago

COVID Clinical Trials Database

 

Convalescent Plasma

NCT04338360
  • Age at least 18 years
  • Laboratory confirmed diagnosis of SARS-CoV-2
  • Admitted to an acute care facility for the treatment of COVID-19
  • Severe or life threatening COVID-19
  • Informed consent
  • Severe COVID-19 is defined by >/= 1 of the following:
  • dyspnea
  • RR >/= 30/min
  • SatO2 </= 93%
  • PaO2/FiO2 < 300
  • lung infiltrates > 50% within 24 to 48 hours
  • Life-threatening COVID-19 is defined as one or more of the following:
  • respiratory failure
  • septic shock
  • multiple organ failure
None

Recruiting: Patients

Michael Joyne, MD

505-255-4288

USCOVIDplasma@mayo.edu

 

NCT04344977
  • Written informed consent
  • Age ? 18yo and ? 70yo
  • Females must have both of the following:
    • Negative serum or urine pregnancy test
    • Negative anti-HLA screening test (to reduce risk of TRALI)
  • Subjects must not be symptomatic, must be afebrile for ?14 days, beyond 28 days of the resolution of their acute illness, and enroll within 18 months of onset of illness, and meet at least 1 of the following:
    • History suggestive of resolved COVID-19 like illness OR
    • History of + SARS-CoV-2 (either serologic or RT-PCR) OR
    • Current participation in a protocol for plasmapheresis and an anti-SARS-CoV-2 neutralizing antibody titer of at least 1:80
  • Anti-SARS-CoV-2 neutralizing antibody titer of at least 1:80
  • Weight ? 110lbs (50 kg)
  • Meets FDA-approved criteria for plasmapheresis
  • Adequate peripheral venous access for plasma donation (as judged by the examiner)
  • Willingness to have samples stored
  • Any sign of active illness of any kind including COVID-19 illness
  • Participation in medical research that includes:
    • Protocols that are currently ongoing or will start during the duration of this study that require more than 100 mL of blood to be given in any 8-week period of time
    • Administration of any unlicensed drug within the last 3 months or during the duration of this study
    • Administration of any unlicensed vaccine within the last 12 months or during the duration of this study.
  • Subjects that have participated in previous plasma collection or other cell component collection procedures within the last 3 months may have restrictions to participation based on the site plasma collection SOP. In this scenario, discussion should occur with the blood establishment to ensure eligibility to donate plasma.

Recruiting: Donors

NIAID

 

Adam Skrzekut

206-689-6689

Covid19study@bloodworksnw.org

 

Tocilizumab

Clinical Trial

Inclusion Criteria

Exclusion Criteria

Contact Info

NCT04320615

(COVACTA)

WA42380

  • Hospitalized with COVID-19 PNA confirmed per WHO criteria (including a +PCR of any specimen-respiratory, blood, urine, stool other body fluid) and evidenced by CXR or CT scan
  •  SPO2</=93% or PaO2/FiO2<300mmHg
  • Known severe allergic reactions to TCZ or other monoclonal ab
  • Active TB infection
  • Suspected active bacterial, fungal, viral, or other infection (besides COVID-19)
  • In the opinion of the investigator, progression to death is imminent and inevitable within the next 24hrs
  • Have received oral anti-rejection or immunomodulatory drugs (including TCZ) in the past 3 months
  • Participating in other drug trials (other COVID-19 anti-viral trials may be permitted if approved by Medical Monitor)
  • Pregnant or breastfeeding
  • Any serious medical condition or abnormality of clinical laboratory tests that, in the investigator's judgment, precludes the patient's safe participation in and completion of the study
  • ALT or AST > 10 x ULN
  • ANC < 1000/mL
  • Plt < 50,000/mL

 

Hoffmann-La Roche

888-662-6728

 

global-roche-genentech-trials@gene.com

 

NCT04361552

 

  • Diagnosis with SARS-CoV-2 by FDA approved assays
  • Should be hospitalized and exhibit at least 1 of the following:
    • Age >= 65 years
    • Current smoker (smoked >= 100 cigarettes in life and actively smoking)
    • COPD
    • Diabetes
    • Hypertension
    • Coronary artery disease
    • CVA
    • CKD (Cr >= 2 mg/dl)
    • Cancer
    • CRP >= 10 mg/L
    • D-dimer >= 0.5 mg/L
    • Procalcitonin >= 0.5 mg/L
    • LDH >= ULN
  • Patients or authorized family member willing to sign informed consent
  • Pregnant or lactating women
  • Hypersensitivity to tocilizumab
  • Uncontrolled TB, or any uncontrolled fungal infection (eg: candidemia)

 

Emory University

Shondolyn D. Richburg

404-778-3612

Shondolyn.k.richburg@emory.edu

 

Remdesivir:

Clinical Trial

Inclusion Criteria

Exclusion Criteria

Contact Info

NCT04401579

(ACTT-II)

  • Admitted for COVID-19
  • Provides informed consent
  • Male or non-pregnant female>/=18yo
  • Confirmed infection by PCR or other assay:
    • PCR+ < 72hrs prior to randomization; OR
    • PCR+>/=72hrs prior to randomization, documented inability to obtain a repeat sample AND progressive disease
  • Illness of any duration, and at least one:
    • Radiographic infiltrates by imaging, OR
    • SpO2</=94% on room air, OR
    • Requiring supplemental O2, OR
    • Requiring mechanical ventilation or ECMO
  • Women of childbearing potential must agree to either abstinence or use contraception until Day 29
  • Agrees to not participate in another trial for COVID-19 until Day 29
  • ALT or AST > 5 X ULN
  • eGFR < 30 ml/min (including patients receiving HD or HF)
  • Neutropenia (<1000cells/uL)
  • Lymphopenia(<200cells/uL)
  • Pregnancy or breast feeding
  • Anticipated discharge from the hospital or transfer to another hospital which is not a study site within 72 hours.
  • Allergy to any study medication.
  • Received cytotoxic or biologic treatments or T/B cell targeted therapies or TK inhibitors or interferon within 4wks
  • Received TNF inhibitors within 2wks
  • Received convalescent plasma or IVIG
  • Received corticosteroids at high doses within 2wks
  • Suspected or diagnosed co-infection
  • Received any live vaccine within 4wks
  • Has history of VTE (DVT or PE) within 12wks

NIAID

Central Contact

1-301-761-7948

DMIDClinicalTrials@niaid.nih.gov

Status: Recruiting

NCT04280705

(ACTT-I)

  • Admitted with symptoms of COVID-19
  • Male or non-pregnant female>/=18yo
  • Confirmed infection by PCR or other assay:
    • PCR+ < 72hrs prior to randomization; OR
    • PCR+>/=72hrs prior to randomization, documented inability to obtain a repeat sample AND progressive disease
  • Illness of any duration, and at least one:
    • Radiographic infiltrates by imaging, OR
    • SpO2</=94% on room air, OR
    • Requiring supplemental O2, OR
    • Requiring mechanical ventilation
  • Women of childbearing potential must agree to either abstinence or use contraception until Day 29
  • Agrees to not participate in another trial for COVID-19 until Day 29
  • ALT or AST > 5 X ULN
  • eGFR < 30 ml/min (including patients receiving HD or HF)
  • Pregnancy or breast feeding
  • Anticipated discharge from the hospital or transfer to another hospital which is not a study site within 72 hours.
  • Allergy to any study medication.

NIAID

Contact: 20-0006 Central Contact

1-301-761-7948

DMIDClinicalTrials@niaid.nih.gov

Status: Enrollment closed

 

NCT04292730
  • >/=12yo and be able to provide consent. For 12-18yo, parent or guardian able to provide written consent
  • Confirmed infection by PCR test</=4 days before randomization
  • Currently hospitalized and requiring medical care for COVID-19
  • SpO2 > 94% on room air at screening
  • Radiographic evidence of pulmonary infiltrates
  • Participation in any other trial for COVID-19
  • Concurrent treatment with other antiviral activity against SARS-CoV-2 < 24 hours prior to study drug dosing
  • Requiring mechanical ventilation at screening
  • ALT or AST > 5 X ULN
  • CrCl < 50 mL/min 

Gilead Clinical Study Info Center

1-833-445-3230 (GILEAD-0)

Gileadclinicaltrials@gilead.com

NCT04292899
  • Aged>/=18yo (at all sites), or >/=12 and </=18yo weighing >/=40 kg 
  • Confirmed infection by PCR test</=4 days before randomization
  • Currently hospitalized
  • SpO2</=94% or requiring supplemental oxygen at screening

 

  • Participation in any other trial for COVID-19
  • Concurrent treatment with other antivirals against SARS-CoV-2 is prohibited < 24hrs prior to study drug dosing
  • Evidence of multiorgan failure
  • Mechanically ventilated (including V-V ECMO)>/=5 days, or any duration of V-A ECMO.
  • Requiring mechanical ventilation at screening
  • ALT or AST > 5 X ULN
  • CrCl < 50 mL/min

 

Gilead Clinical Study Info Center

1-833-445-3230 (GILEAD-0)

Gileadclinicaltrials@gilead.com

 

Last Updated 4 months ago
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