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Consensus for the Management of Analgesia, Sedation and Delirium in Adults with COVID-19-Associated Acute Respiratory Distress Syndrome

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Consensus for the Management of Analgesia, Sedation and Delirium in Adults with COVID-19-Associated Acute Respiratory Distress Syndrome ARTIGO ESPECIAL Manuel Donato1,2,3 , Federico Carlos Carini4 , María Julia Meschini5, Ignacio López Saubidet6 , Consenso para el manejo de la analgesia, sedación Adela Goldberg7, Marisol García Sarubio5, Daniela Olmos8, Rosa Reina5 em nombre del Comité de y delirium en adultos con síndrome de distrés Analgesia, Sedación y Delirium de la Sociedad Argentina de Terapia Intensiva respiratorio agudo por COVID-19 Consensus for the management of analgesia, sedation and delirium in adults with COVID-19-associated acute respiratory distress syndrome 1. Hospital General de Agudos José María Penna RESUMEN Sedación y Delirium de la Sociedad - Buenos Aires, Argentina. Argentina de Terapia Intensiva. 2. Ministerio de Salud de la Nación Argentina – Objetivo: Proponer estrategias Resultados: Se acordaron Buenos Aires, Argentina. agile para este abordaje integral de 3. Instituto de Efectividad Clínica y Sanitaria - recomendaciones y se desarrollaron la analgesia, sedación, delirium, Buenos Aires, Argentina. herramientas para asegurar un 4. Hospital Italiano de Buenos Aires - Buenos implementación de movilidad abordaje integral de analgesia, Aires, Argentina. temprana e inclusión familiar del sedación, delirium, implementación 5. Hospital Interzonal General de Agudos General paciente con síndrome de dificultad San Martín - La Plata, Argentina. de movilidad temprana e inclusión respiratoria aguda por COVID-19, 6. Centro de Educación Médica e Investigaciones familiar del paciente adulto con Clínicas “Norberto Quirno” - Buenos Aires, Argentina. considerando el alto riesgo de infección síndrome de dificultad respiratoria 7. Sanatorio de La Trinidad Mitre - Buenos Aires, que existe entre los trabajadores de Argentina. aguda por COVID-19. salud, el tratamiento humanitario 8. Hospital Municipal Príncipe de Asturias - Córdoba, Discusión: Ante el nuevo orden Argentina. que debemos brindar al paciente y generado en las terapias intensivas su familia, en un contexto de falta por la progresión de la pandemia de estrategias terapéuticas específicas COVID-19, proponemos no dejar contra el virus globalmente disponibles atrás las buenas prácticas habituales, a la fecha y una potencial falta de sino adaptarlas al contexto particular recursos sanitarios. generado. Nuestro consenso está Metodos: Se llevó a cabo una respaldado en la evidencia científica, la revision no sistemática de la evidencia experiencia nacional e internacional, científica en las principales bases de y será una herramienta de consulta datos bibliográficos, sumada a la atractiva en las terapias intensivas. experiencia y juicio clínico nacional e internacional. Finalmente, se realizó un Descriptores: COVID-19; SARS- consenso de recomendaciones entre los CoV-2; Dolor; Analgesia; Sedación integrantes del Comité de Analgesia, profunda: Delirium; Respiración artificial Conflictos de interés: Ninguno. Sometido el 12 de noviembre de 2020 Aceptado el 29 de diciembre de 2020 INTRODUCCIÓN Autor correspondiente: Manuel Donato La enfermedad por el Coronavirus 2019 (COVID-19 - Coronavirus Disease Hospital General de Agudos José María Penna 2019) es una patología respiratoria de humanos producida por la infección Avenida Almafuerte, 406 (1) Código Postal 1437 por un nuevo coronavirus identificado con la sigla SARS-CoV-2. El 11 Buenos Aires, Argentina de marzo de 2020 la Organización Mundial de la Salud (OMS) declaro al E-mail: [email protected] COVID-19 como una pandemia, y desde ese momento hasta el 10 de Octubre Editor responsable: Viviane Cordeiro Veiga se ha reportado aproximadamente 36.754.395 casos confirmados y la muerte de 1.064.838 personas en todo el Mundo.(2) A esa fecha en Argentina se han DOI: 10.5935/0103-507X.20210005 reportado 1.262.476 casos confirmados y 34.183 muertes, siendo estos números superiores respecto a la mayoría de los países de Latinoamérica.(2,3) Rev Bras Ter Intensiva. 2021;33(1):48-67 Este es un artículo de acceso abierto bajo la licencia CC BY (https://creativecommons.org/licenses/by/4.0/). Consenso para el manejo de la analgesia, sedación y delirium en adultos con síndrome de distrés respiratorio agudo por COVID-19 49 Debido a que no existe un fármaco específico contra paciente crítico con COVID-19 SDRA, incluye principalmente este virus o vacuna globalmente disponible, aunque la la evaluación sistemática de la analgesia, sedación y delirium dexametasona y la hidrocortisona han demostrado mejorar la (ASD), asociado a la prevención de la inmovilidad y la inclusión sobrevida en casos graves de COVID-19 y que las heparinas familiar. Todo ello se ve reflejado en la guía de práctica clínica jugarían un rol importante en la prevención de trombosis para la prevención y el manejo del dolor, la agitación/sedación, el venosa profunda también en casos graves, actualmente la delirium, la inmovilidad y la interrupción del sueño en pacientes mejor estrategia poblacional para lidiar con la pandemia es la adultos en la UCI (PADIS - pain, agitation/sedation, delirium, prevención de la infección con medidas de políticas públicas.(4) immobility, and sleep disruption) de 2018 y el paquete de El período de incubación de la infección por SARS-CoV-2 es medidas conocido como ABCDEF (Figura 1), publicadas por de 2 a 14 días y la mayor parte de los contagios se producen la Society of Critical Care Medicine.(14,15) El SDRA, generalmente persona a persona, siendo de alta transmisibilidad.(5) El severo, producido por SARS-CoV-2 durante la pandemia departamento de medicina interna del Hospital de Brigham por COVID-19 desafió nuestra capacidad de crear, adaptar de la escuela de medicina de Harvard ha postulado una y mantener protocolos de trabajo, como los propuestos en el clasificación clínico-terapéutica de la enfermedad que paquete ABCDEF. También, la mejor evidencia disponible para divide el curso de la misma en diferentes etapas y a su vez el manejo de estos pacientes provino de países de altos ingresos identifica dos subconjuntos patológicos superpuestos pero con sistemas de salud preparados, donde usualmente los diferentes entre sí, desencadenados el primero de ellos por protocolos tienen una alta tasa de aceptación y no suele haber el virus y el segundo por la respuesta del huésped al virus.(6) falta de recursos sanitarios. La Etapa I o leve ocurre en el momento de la inoculación y el establecimiento temprano de la enfermedad; la Etapa II ocurre cuando se establece un compromiso pulmonar en la persona; y la Etapa III o grave se manifiesta como un síndrome de hiper-inflamación sistémica extrapulmonar. La mayor morbilidad y mortalidad por COVID-19 se debe en gran medida a la neumonitis viral aguda que evoluciona a síndrome de distrés respiratorio agudo (SDRA).(7) Algunos informes sugieren que hasta el 20% de las personas infectadas desarrolla una enfermedad grave que requiere hospitalización, siendo mayoritariamente casos en pacientes de edad avanzada y con comorbilidades (obesidad, diabetes, enfermedad crónica renal, hipertensión, enfermedad cardiaca y enfermedad (14) pulmonar crónica).(5,6) Finalmente, se estima que entre un 5 y Figura 1 - Componentes del paquete de medidas ABDCEF. 8% del total de los infectados necesita admisión en la unidad de cuidados intensivos (UCI).(7-11) En nuestro país, a través El objetivo de este consenso es proponer estrategias de una política pública precoz, se ganó tiempo para preparar y herramientas ágiles para el manejo óptimo de la ASD la capacidad de respuesta del sistema de salud a la pandemia, en esta población, teniendo en cuenta el elevado riesgo logrando aumentar principalmente el abastecimiento de de contagio que existe entre los trabajadores de la salud, insumos hospitalarios necesarios y en 12.450 camas, casi un el trato humanitario que debemos brindar al paciente 50% más que en condiciones pre-pandémicas para UCI.(12,13) y su entorno familiar, pero en un contexto de falta Sin embargo, últimamente se está observando una progresiva de estrategias terapéuticas especificas contra el virus y peligrosa saturación del sistema de salud argentino, globalmente disponibles hasta el momento y una potencial parcialmente explicado por un aumento significativo de los falta de recursos sanitarios que podría ocurrir al saturarse ingresos a las UCI de todas las provincias donde prácticamente el sistema de salud.(16) no existía circulación comunitaria del virus. Este hecho ha MÉTODOS puesto en tensión la aplicación de diversos protocolos en la UCI, principalmente por el aumento exponencial de la El presente documento se realizó mediante el consenso utilización de recursos sanitarios y los cuidados para reducir el de grupos nominales. El documento obtenido se basó riesgo de contagio del personal de salud. en una revisión no sistemática de la evidencia científica, En la UCI el abordaje integral para lograr comodidad, sumado al juicio y experiencia clínica del grupo de expertos seguridad y facilitar intervenciones para el soporte vital del participante y otros grupos en el resto del mundo. Rev Bras Ter Intensiva. 2021;33(1):48-67 50 Donato M, Carini FC, Meschini MJ, Saubidet IL, Goldberg A, Sarubio MG, et al. Las búsquedas bibliográficas diseñadas por los salida. Inicialmente para cada etapa, se analizaron las autores se realizaron en la Base de datos Cochrane de mencionadas fuentes de información bibliográfica y se revisiones sistemáticas (CDSR), el Registro central establecieron recomendaciones. Cochrane de ensayos controlados (CENTRAL), la Base Un grupo de expertos independientes conformó el de datos de resúmenes de revisiones de efectos (DARE), Comité
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