II.

Evaluarea schimbului gazos pulmonar

Se poate efectua prin măsurarea factorului de transfer gazos prin membrana alveolocapilară a
dioxidului de carbon (DLco), respectiv prin determinarea gazelor respiratorii în sângele arterial
(ASTRUP). DLco furnizează date asupra integrităţii membranei alveolo-capilare, iar gazele respiratorii
asupra potrivirii raportului ventilaţie/perfuzie în toate unităţile funcţionale pulmonare. Astfel unii
pacienţi pot prezenta hipoxemie cu un DLco normal (astm bronşic sever), iar alţii valori normale ale
oxigenului în sângele arterial asociat cu un DLco scăzut (emfizem pulmonar).

Desfluranul este un anestezic general de tip eter halogenat, utilizat pentru inducerea și

menținerea anesteziei generale la adulți și pentru menținerea anesteziei generale la copii.[9][10]
[11]

Demand for Ventilator Drugs

‘Unprecedented’
The danger that there won’t be enough medications to facilitate mechanical
ventilation in COVID-19 patients is sharply rising just as coronavirus infections surge
in hotspots around the nation, according to a new Vizient analysis of 13 critical
sedatives, opioids and paralytic drugs.

“What we’re seeing right now is an unprecedented demand for these medications,
and we’re not at an apex yet from what our data are showing,” said Dan Kistner,
PharmD, the group vice president of pharmacy solutions at Vizient Inc. “My biggest
fear is that in a few weeks down the road, we’re going to see pictures on the news of
ventilators in a closet that can’t be used because we don’t have the drugs.”

Erin Fox, PharmD, BCPS, the senior director of Drug Information and Support Services
at the University of Utah Health, in Salt Lake City, said, “Hospitals are facing two to 10
times their normal ventilated population. This means that you need two to 10 times
the amount of medications. That is not so easy in these days of allocations and
limits placed on the amounts of controlled substances you can order.”

Vizient normally tracks about 200 acute and chronic “workhorse medications” used
in hospitals, Dr. Kistner said. “About 69 drugs have our special attention because of
the unusually high demand we’re seeing across the country,” he said. For this
analysis, Vizient focused on 13 of the hardest hit—each often administered to
facilitate mechanical ventilation and patient comfort throughout the course of
therapy.

The study used purchase order data from Vizient’s hospital and health-system
members to calculate customer demand and fill rate trends for the 13 agents in
March. They were divided into three groups: Six in the first group were sedatives or
anesthetics; opioid analgesics made up the second group; the third consisted of four
neuromuscular blocking agents.

In the sedative/anesthetic group—which included propofol, dexmedetomidine and

lorazepam—the end-of-March fill rate was down to as low as 48% just as demand
was increasing by 91%. For the three opioids in the second group—hydromorphone,
fentanyl and morphine—March demand rose 79% while the fill rate decreased to as
low as 71%. The trend was the worst for the four neuromuscular blockers: Demand
was up by 105% as the fill rate declined to as low as 37%.

In all three groups, Dr. Kistner pointed out, the green line on the chart denoting the
raw fill rate continued to decline throughout March. “You can’t wait till it gets to 50%,”
he said in an earlier interview. “You have to act now, because it takes weeks to bring
new sterile infusion products to market.” Vizient later updated the data to show that
the fill rate had already fallen below 50% for two of the groups.

John W. Devlin, PharmD, a professor of pharmacy at Northeastern University, in

Boston, and the chair of the Society of Critical Care Medicine’s 2018 “Guidelines for
the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility,
and Sleep Disruption in Adult Patients in the ICU,” said the shortages of sedatives,
opioids and neuromuscular blocking agents are only likely to worsen as new COVID-
19 cases surge across the country.

“In the Boston area, we are seeing an ever-increasing prevalence of COVID-19-

associated acute respiratory distress syndrome (ARDS),” he said. “The complex
ventilator settings and proning required to treat the severe hypoxemia found in these
ARDS patients sometimes requires deep sedation to reduce oxygen consumption,
high-dose opioids to reduce respiratory drive, and paralysis with neuromuscular
blockers to reduce airway pressure and optimize ventilator compliance.”

Dr. Devlin recalled the critical propofol shortage that occurred during the 2009-2010
H1N1 pandemic, which caused problems but was obviated by the increased use of
benzodiazepines like midazolam. The current situation is far more difficult, he said,
because the shortages “are really across the board.”