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VOLUME 26 , ISSUE 8 ( August, 2022 ) > List of Articles

Original Article

Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study)

Kushal Rajeev Kalvit, Tarun Kumar Sahu, Meshach M Dhas, Gautam Gondal, Swapna Charie, Anjana Shrivastava, for the INhaled SedaTion IN CriTically ill patients – (INSTINCT) study group

Keywords : Anesthesia conserving device, Delirium, Inhaled sedation, Mechanical ventilation, Richmond agitation sedation scale score

Citation Information : Kalvit KR, Sahu TK, Dhas MM, Gondal G, Charie S, Shrivastava A, for the INhaled SedaTion IN CriTically ill patients – (INSTINCT) study group. Safety and Feasibility of AnaConDa™ to Deliver Inhaled Isoflurane for Sedation in Patients Undergoing Elective Postoperative Mechanical Ventilation: A Prospective, Open-label, Interventional Trial (INSTINCT I Study). Indian J Crit Care Med 2022; 26 (8):906-912.

DOI: 10.5005/jp-journals-10071-24264

License: CC BY-NC 4.0

Published Online: 30-07-2022

Copyright Statement:  Copyright © 2022; The Author(s).


Aim: Sedation is essential during invasive mechanical ventilation, and conventionally intravenous analgesic and sedative drugs are used. Sedation with inhaled anesthetics using anesthesia conserving device (ACD) is an alternative. There is no data on the safety and ease of use of AnaConDa™ from India. Materials and methods: After IEC approval and informed consent, we used AnaConDa™-S for Isoflurane sedation in 50 hemodynamically stable (need for <0.5 µg/kg/min of Noradrenaline infusion), ASA I and II patients aged 18–80 years, undergoing elective mechanical ventilation for up to 24 hours after elective oncosurgeries. Patients with mental obtundation (GCS <14), or if pregnant, were excluded. The primary outcome was time spent between RASS scores of -3 and -4, while secondary outcomes were incidence of delirium, technical problems with AnaConDa™, and adverse systemic effects of isoflurane. Bolus doses of isoflurane 0.2–0.5 mL were given if the Richmond agitation sedation scale (RASS) score was not achieved. Results: Fifty patients received isoflurane infusion for a median of 720 (IQR 630–900) minutes, and all remained in the target sedation range. Median time to awakening [19 (IQR, 5–85) minutes], to follow simple verbal commands [20 (IQR 5–180) minutes], and extubation after stopping the infusion of isoflurane was quick [100 (10–470) minutes]. All patients remained hemodynamically stable. None of the patients had delirium. Conclusion: Target sedation levels were achieved with initial boluses of isoflurane using AnaConDa™-S. Isoflurane sedation delivery using AnaConDa™-S is safe and feasible.

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  1. Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 2018;46(9):e825–e873. DOI: 10.1097/CCM.0000000000003299.
  2. Chawla R, Myatra SN, Ramakrishnan N, Todi S, Kansal S, Dash SK. Current practices of mobilization, analgesia, relaxants and sedation in Indian ICUs: a survey conducted by the Indian Society of Critical Care Medicine. Indian J Crit Care Med 2014;18(9):575–584. DOI: 10.4103/0972-5229.140146.
  3. Shah PN, Dongre V, Patil V, Pandya S, Mungantiwar A, Chouliwar A. Comparison of perioperative ICU sedation between dexmedetomidine and propofol in Indian population. Indian J Crit Care Med 2014;18:291–296. DOI: 10.4103/0972-5229.132485.
  4. Gerlach AT, Blais DM, Jones GM, et al. Predictors of dexmedetomidine-associated hypotension in critically ill patients. Int J Crit Illn Inj Sci 2016;6(3):109–114. DOI: 10.4103/2229-5151.190656.
  5. Riker RR, Shehabi Y, Bokesch PM, Ceraso D, Wisemandle W, Koura F, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial. JAMA 2009;301(5):489–499. DOI: 10.1001/jama.2009.56.
  6. Martin J, Heymann A, Bäsell K, Baron R, Biniek R, Burkle H, et al. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care–short version. Ger Med Sci 2010;8:Doc02. DOI: 10.3205/000091.
  7. Blondonnet R, Quinson A, Lambert C, Audard J, Godet T, Zhai R, et al. Use of volatile agents for sedation in the intensive care unit: a national survey in France. PLoS One 2021;16(4):e0249889. DOI: 10.1371/journal.pone.0249889.
  8. Farrell R, Oomen G, Carey P. A technical review of the history, development and performance of the anaesthetic conserving device “AnaConDa” for delivering volatile anaesthetic in intensive and post-operative critical care. J Clin Monit Comput 2018;32(4):595–604. DOI: 10.1007/s10877-017-0097-9.
  9. Enlund M, Wiklund L, Lambert H. A new device to reduce the consumption of a halogenated anaesthetic agent. Anaesthesia 2001;56(5):429–432. DOI: 10.1046/j.1365-2044.2001.01900.
  10. Sackey PV, Martling C-R, Granath F, Radell PJ. Prolonged isoflurane sedation of intensive care unit patients with the Anesthetic Conserving Device. Crit Care Med 2004;32(11):2241–2246. DOI: 10.1097/01.ccm.0000145951.76082.77.
  11. Kong KL, Willatts SM, Prys-Roberts C. Isoflurane compared with midazolam for sedation in the intensive care unit. BMJ 1989;298(6683):1277–1280. DOI: 10.1136/bmj.298.6683.1277.
  12. Spencer EM, Willatts SM. Isoflurane for prolonged sedation in the intensive care unit; efficacy and safety. Intensive Care Med 1992;18(7):415–421. DOI: 10.1007/BF01694344.
  13. L'her E, Dy L, Pili R, Prat G, Tonnelier J-M, Lefevre M, et al. Feasibility and potential cost/benefit of routine isoflurane sedation using an anesthetic-conserving device: a prospective observational study. Respir Care 2008;53(10):1295–1303. PMID: 18811990.
  14. Bellgardt M, Bomberg H, Herzog-Niescery J, Dasch B, Vogelsang H, Weber TP, et al. Survival after long-term isoflurane sedation as opposed to intravenous sedation in critically ill surgical patients: retrospective analysis. Eur J Anaesthesiol 2016;33(1):6–13. DOI: 10.1097/EJA.0000000000000252.
  15. Yildirim V, Doganci S, Aydin A, Bolcal C, Demirkilic U, Cosar A. Cardioprotective effects of sevoflurane, isoflurane, and propofol in coronary surgery patients: a randomized controlled study. Heart Surg Forum 2009;12(1):E1–E9. DOI: 10.1532/HSF98.20081137.
  16. Gamperl AK, Hein TW, Kuo L, Cason BA. Isoflurane-induced dilation of porcine coronary microvessels is endothelium dependent and inhibited by glibenclamide. Anesthesiology 2002;96(6):1465–1471. DOI: 10.1097/00000542-200206000-00028.
  17. Kersten JR, Schmeling TJ, Hettrick DA, Pagel PS, Gross GJ, Warltier DC. Mechanism of myocardial protection by isoflurane. Role of adenosine triphosphate-regulated potassium (KATP) channels. Anesthesiology 1996;85(4):794–807. DOI: 10.1097/00000542-199610000-00015.
  18. Bösel J, Purrucker JC, Nowak F, Renzland J, Schiller P, Perez EB, et al. Volatile isoflurane sedation in cerebrovascular intensive care patients using AnaConDa(®): effects on cerebral oxygenation, circulation, and pressure. Intensive Care Med 2012;38(12):1955–1964. DOI: 10.1007/s00134-012-2708-8.
  19. Zaal IJ, Devlin JW, Hazelbag M, Klien Klouwenberg PMC, van der Kooi AW, Ong DSY, et al. Benzodiazepine-associated delirium in critically ill adults. Intensive Care Med 2015;41(12):2130–2137. DOI: 10.1007/s00134-015-4063-z.
  20. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA 2004; 291(14):1753–1762. DOI: 10.1001/jama.291.14.1753.
  21. Shehabi Y, Chan L, Kadiman S, Alias A, Ismail WN, Ismail Tan MAT, et al. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study. Intensive Care Med 2013;39(5):910–918. DOI: 10.1007/s00134-013-2830-2.
  22. Sackey PV, Martling C-R, Nise G, Radell PJ. Ambient isoflurane pollution and isoflurane consumption during intensive care unit sedation with the Anesthetic Conserving Device. Crit Care Med 2005;33(3):585–590. DOI: 10.1097/01.ccm.0000156294.92415.e2.
  23. González-Rodríguez R, Muñoz Martínez A, Galan Serrano J, Moral García MV. Health worker exposure risk during inhalation sedation with sevoflurane using the (AnaConDa®) anaesthetic conserving device. Rev Esp Anestesiol Reanim 2014;61(3):133–139. DOI: 10.1016/j.redar.2013.11.011.
  24. Berton J, Sargentini C, Nguyen J-L, Belii A, Beydon L. AnaConDa reflection filter: bench and patient evaluation of safety and volatile anesthetic conservation. Anesth Analg 2007;104(1):130–134. DOI: 10.1213/01.ane.0000248221.44383.43.
  25. Hashiguchi H, Morooka H, Miyoshi H, Matsumoto M, Koji T, Sumikawa K. Isoflurane protects renal function against ischemia and reperfusion through inhibition of protein kinases, JNK and ERK. Anesth Analg 2005;101(6):1584–1589. DOI: 10.1213/01.ANE.0000184044.51749.B8.
  26. Röhm KD, Mengistu A, Boldt J, Mayer J, Beck G, Piper SN. Renal integrity in sevoflurane sedation in the intensive care unit with the anesthetic-conserving device: a comparison with intravenous propofol sedation. Anesth Analg 2009;108(6):1848–1854. DOI: 10.1213/ane.0b013e3181a1988b.
  27. Gallego L, Soro M, Alvariño A, Noguera I, Belda FJ. Renal and hepatic integrity in long-term sevoflurane sedation using the anesthetic conserving device: a comparison with intravenous propofol sedation in an animal model. Rev Esp Anestesiol Reanim 2015;62(4):191–203. DOI: 10.1016/j.redar.2014.05.009.
  28. Campagna JA, Miller KW, Forman SA. Mechanisms of actions of inhaled anesthetics. N Engl J Med 2003;348(21):2110–2124. DOI: 10.1056/NEJMra021261.
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