Critical Care Explorations (Feb 2024)

Inhaled Volatiles for Status Asthmaticus, Epilepsy, and Difficult Sedation in Adult ICU and PICU: A Systematic Review

  • Kevin Gorsky, MD,
  • Sean Cuninghame, MD,
  • Kesikan Jayaraj, RN,
  • Marat Slessarev, MD, PhD, FRCPC,
  • Conall Francoeur, MD,
  • Davinia E. Withington, BM, FRCA, MRCP(UK),
  • Jennifer Chen,
  • Brian H. Cuthbertson, MBBS, PhD,
  • Claudio Martin, MD,
  • Martin Chapman, MD, FRCPC,
  • Saptharishi Lalgudi Ganesan, MBBS, MD, DM, FACNS,
  • Nicole McKinnon, MD, PhD,
  • Angela Jerath, MD, MSc, FANZCA, FRCPC,
  • on behalf of the SAVE-ICU Study Investigators,
  • Martin Chapman,
  • Damon Scales,
  • Julie Nardi,
  • Beth Linseman,
  • Phil Lau,
  • Boris Yakubov,
  • Eily Shaw,
  • Francois Carrier,
  • Emmanuel Charbonney,
  • Michaël Chassé,
  • Martin Girard,
  • Antoine Halwagi,
  • Guillaume Plourde,
  • Han Ting Wang,
  • Frédérick D’Aragon,
  • Maxime Tissot-Therrien,
  • François Lamontagne,
  • Dominique Bérard,
  • Yiorgos Alexandros Cavayas,
  • Martin Albert,
  • Francis Bernard,
  • Karim Serri,
  • David Williamson,
  • Virginie Williams,
  • Patricia Martinez Barrios,
  • Sabrina Araujo De Franca,
  • Etienne J. Couture,
  • Adreanne Côté,
  • Mathieu Simon,
  • Pierre-Alexis Lépine,
  • Dave Gleeton,
  • John Basmaji,
  • Marat Slessarev,
  • Ahmed Hegazy,
  • Tracey Bentall,
  • Eileen Campbell,
  • Michelle Stephens,
  • Tim Winterburn,
  • Roupen Hatzakorzian,
  • Kosar Khwaja,
  • Peter Goldberg,
  • Jason Shahin,
  • Jeremy Richard Grushka,
  • Jonathan Hooper,
  • Sherissa Microys,
  • Hilary Meggison,
  • David Leilipovitz,
  • Jessica Haines,
  • Irene Watpool,
  • Rebecca Porteous,
  • Stephanie Dunster,
  • Sylvie Bourbonnais,
  • Ewan Goligher,
  • Lorenzo Del Sorbo,
  • Niall Ferguson,
  • Philip Graham,
  • Michael Long,
  • Tina Yan,
  • Denise Morris,
  • Maria Kobylecky,
  • Hesham Abdelhady,
  • Tina Romagnuolo,
  • Bourke Tillman,
  • Ian Randall,
  • Elizabeth Wilcox,
  • Michael Jacka,
  • Oleksa Rewa,
  • Vincent Lau,
  • Sean Bagshaw,
  • Nadia Baig

DOI
https://doi.org/10.1097/CCE.0000000000001050
Journal volume & issue
Vol. 6, no. 2
p. e1050

Abstract

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OBJECTIVES:. Inhaled volatile anesthetics support management of status asthmaticus (SA), status epilepticus (SE), and difficult sedation (DS). This study aimed to evaluate the effectiveness, safety, and feasibility of using inhaled anesthetics for SA, SE, and DS in adult ICU and PICU patients. DATA SOURCES:. MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. STUDY SELECTION:. Primary literature search that reported the use of inhaled anesthetics in ventilated patients with SA, SE, and DS from 1970 to 2021. DATA EXTRACTION:. Study data points were extracted by two authors independently. Quality assessment was performed using the Joanna Briggs Institute appraisal tool for case studies/series, Newcastle criteria for cohort/case–control studies, and risk-of-bias framework for clinical trials. DATA SYNTHESIS:. Primary outcome was volatile efficacy in improving predefined clinical or physiologic endpoints. Secondary outcomes were adverse events and delivery logistics. From 4281 screened studies, the number of included studies/patients across diagnoses and patient groups were: SA (adult: 38/121, pediatric: 28/142), SE (adult: 18/37, pediatric: 5/10), and DS (adult: 21/355, pediatric: 10/90). Quality of evidence was low, consisting mainly of case reports and series. Clinical and physiologic improvement was seen within 1–2 hours of initiating volatiles, with variable efficacy across diagnoses and patient groups: SA (adult: 89–95%, pediatric: 80–97%), SE (adults: 54–100%, pediatric: 60–100%), and DS (adults: 60–90%, pediatric: 62–90%). Most common adverse events were cardiovascular, that is, hypotension and arrhythmias. Inhaled sedatives were commonly delivered using anesthesia machines for SA/SE and miniature vaporizers for DS. Few (10%) of studies reported required non-ICU personnel, and only 16% had ICU volatile delivery protocol. CONCLUSIONS:. Volatile anesthetics may provide effective treatment in patients with SA, SE, and DS scenarios but the quality of evidence is low. Higher-quality powered prospective studies of the efficacy and safety of using volatile anesthetics to manage SA, SE, and DS patients are required. Education regarding inhaled anesthetics and the protocolization of their use is needed.