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

Kevin Gorsky; Sean Cuninghame; Kesikan Jayaraj; Marat Slessarev; Conall Francoeur; Davinia E Withington; Jennifer Chen; Brian H Cuthbertson; Claudio Martin; Martin Chapman; Saptharishi Lalgudi Ganesan; Nicole McKinnon; Angela Jerath

doi:10.1097/CCE.0000000000001050

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

Crit Care Explor. 2024 Feb 20;6(2):e1050. doi: 10.1097/CCE.0000000000001050. eCollection 2024 Feb.

Authors

Kevin Gorsky¹, Sean Cuninghame², Kesikan Jayaraj³, Marat Slessarev^{2

4}, Conall Francoeur⁵, Davinia E Withington⁶, Jennifer Chen⁷, Brian H Cuthbertson^{1

8

9

10}, Claudio Martin², Martin Chapman^{1

8}, Saptharishi Lalgudi Ganesan^{4

11}, Nicole McKinnon¹², Angela Jerath^{1

13

9

10}

Affiliations

¹ Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada.
² Department of Medicine, University of Western Ontario, London, ON, Canada.
³ Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
⁴ Western Institute for Neuroscience, Western University, London, ON, Canada.
⁵ Department of Pediatrics, Laval University Faculty of Medicine, QC, Canada.
⁶ Department of Anesthesiology, McGill University Faculty of Medicine, Montreal, QC, Canada.
⁷ Department of Medical Biophysics, University of Western Ontario, London, ON, Canada.
⁸ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
⁹ Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
¹⁰ Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
¹¹ Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
¹² Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada.
¹³ Cardiovascular Program, ICES, Toronto, ON, Canada.

Abstract

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.

Keywords: critical care; sedation; status asthmaticus; status epilepticus; volatile anesthetics.

Publication types

Review