Halving the volume of AnaConDa: initial clinical experience with a new small-volume anaesthetic reflector in critically ill patients—a quality improvement project
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AnaConDa-100 ml (ACD-100, Sedana Medical, Uppsala, Sweden) is well established for inhalation sedation in the intensive care unit. But because of its large dead space, the system can retain carbon dioxide (CO2) and increase ventilatory demands. We therefore evaluated whether AnaConDa-50 ml (ACD-50), a device with half the internal volume, reduces CO2 retention and ventilatory demands during sedation of invasively ventilated, critically ill patients. Ten patients participated in this cross-over protocol. After sedation with isoflurane via ACD-100 for 24 h, the 5-h observation period started. During the first hour, ACD-100 was used; for the next 2 h, ACD-50; and for the last 2 h, ACD-100 was used again. Sedation was titrated to Richmond Agitation and Sedation Scale (RASS) score − 3 to − 4 and a processed electroencephalogram (Narcotrend Index, Narcotrend-Gruppe, Hannover, Germany) was recorded. Minute ventilation, CO2 elimination, and isoflurane consumption were compared. All patients were deeply sedated (Narcotrend Index, mean ± SD: 38 ± 10; RASS scores − 3 to − 5) and breathed spontaneously with pressure support throughout the observation period. Infusion rates of isoflurane and opioid, either remifentanil or sufentanil, as well as ventilator settings were unchanged. Minute ventilation and end-tidal CO2 were significantly reduced with the ACD-50, respiratory rate remained unchanged, and tidal volume decreased by 66 ± 43 ml. End-tidal isoflurane concentrations were also slightly reduced while haemodynamic measures remained constant. The ACD-50 reduces the tidal volume needed to eliminate carbon dioxide without augmenting isoflurane consumption.
KeywordsAnaesthesic reflection Carbon dioxide reflection Dead space Inhalation sedation Isoflurane
The AnaConDa-50 ml reflectors were kindly provided by the manufacturer Sedana Medical, Uppsala, Sweden. The sponsor was neither involved in data acquisition, analysis, or the design of the protocol, nor did they review the submitted manuscript which was entirely prepared by the authors.
Compliance with ethical standards
Conflict of interest
The authors declare that they did not receive any funding for realisation of this study. AM and TV received honoraria and travel expenses for lectures from Sedana Medical (Uppsala, Sweden). AM has been a consultant for Sedana Medical (Uppsala, Sweden). AM has received honoraria and travel expenses for lectures as well as research funding from Pall Medical (Dreieich, Germany).
Informed consent and Human participants were involved.
- 1.Mesnil M, Capdevila X, Bringuier S, Trine PO, Falquet Y, Charbit J, Roustan JP, Chanques G, Jaber S. Long-term sedation in intensive care unit: a randomized comparison between inhaled sevoflurane and intravenous propofol or midazolam. Intensive Care Medicine. 2011;37(6):933–41. https://doi.org/10.1007/s00134-011-2187-3.CrossRefPubMedGoogle Scholar
- 2.Romagnoli S, Chelazzi C, Villa G, Zagli G, Benvenuti F, Mancinelli P, Arcangeli G, Dugheri S, Bonari A, Tofani L, Belardinelli A, De Gaudio AR. The new MIRUS system for short-term sedation in postsurgical ICU patients. Crit Care Med. 2017. https://doi.org/10.1097/ccm.0000000000002465.CrossRefPubMedGoogle Scholar
- 5.Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, Demirakca S, Eckardt R, Eggers V, Eichler I, Fietze I, Freys S, Frund A, Garten L, Gohrbandt B, Harth I, Hartl W, Heppner HJ, Horter J, Huth R, Janssens U, Jungk C, Kaeuper KM, Kessler P, Kleinschmidt S, Kochanek M, Kumpf M, Meiser A, Mueller A, Orth M, Putensen C, Roth B, Schaefer M, Schaefers R, Schellongowski P, Schindler M, Schmitt R, Scholz J, Schroeder S, Schwarzmann G, Spies C, Stingele R, Tonner P, Trieschmann U, Tryba M, Wappler F, Waydhas C, Weiss B, Weisshaar G. (2015) Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version. GMS German Med Sci. https://doi.org/10.3205/000223.CrossRefGoogle Scholar
- 6.Grounds M, Snelson C, Whitehouse T, Willson J, Tulloch L, Linhartova L, Shah A, Pierson R, England K. (2014) Intensive care society review of best practice for analgesia and sedation in the critical care. Sedation committee of the Intensive Care Society United Kingdom. http://www.ics.ac.uk/ICS/guidelines-and-standards.aspx. Accessed April 21, 2017.
- 7.Celis-Rodriguez E, Birchenall C, de la Cal MA, Castorena Arellano G, Hernandez A, Ceraso D, Diaz Cortes JC, Duenas Castell C, Jimenez EJ, Meza JC, Munoz Martinez T, Sosa Garcia JO, Pacheco Tovar C, Palizas F, Pardo Oviedo JM, Pinilla DI, Raffan-Sanabria F, Raimondi N, Righy Shinotsuka C, Suarez M, Ugarte S, Rubiano S. Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. Med Intensiva. 2013;37(8):519–74. https://doi.org/10.1016/j.medin.2013.04.001.CrossRefPubMedGoogle Scholar
- 9.Meiser A, Bellgardt M, Belda J, Rohm K, Laubenthal H, Sirtl C. Technical performance and reflection capacity of the anaesthetic conserving device—a bench study with isoflurane and sevoflurane. J Clin Monit Comput. 2009;23(1):11–9. https://doi.org/10.1007/s10877-008-9158-4.CrossRefPubMedPubMedCentralGoogle Scholar
- 10.Bomberg H, Veddeler M, Volk T, Groesdonk HV, Meiser A (2018) Volumetric and reflective device dead space of anaesthetic reflectors under different conditions. J Clin Monit Comput (in press).Google Scholar
- 13.Jabaudon M, Boucher P, Imhoff E, Chabanne R, Faure JS, Roszyk L, Thibault S, Blondonnet R, Clairefond G, Guerin R, Perbet S, Cayot S, Godet T, Pereira B, Sapin V, Bazin JE, Futier E, Constantin JM. Sevoflurane for sedation in acute respiratory distress syndrome. A randomized controlled pilot study. Am J Respir Crit Care Med. 2017;195(6):792–800. https://doi.org/10.1164/rccm.201604-0686OC.CrossRefPubMedGoogle Scholar
- 14.Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RK. The Richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338–44. https://doi.org/10.1164/rccm.2107138.CrossRefPubMedGoogle Scholar
- 18.Chabanne R, Perbet S, Futier E, Ben Said NA, Jaber S, Bazin JE, Pereira B, Constantin JM. Impact of the anesthetic conserving device on respiratory parameters and work of breathing in critically ill patients under light sedation with sevoflurane. Anesthesiology. 2014;121(4):808–16. https://doi.org/10.1097/aln.0000000000000394.CrossRefGoogle Scholar
- 19.Bomberg H, Meiser F, Daume P, Volk T, Sessler DI, Groesdonk HV, Meiser A. Halving the volume of AnaConDa: evaluation of a new small-volume anesthetic reflector in a test lung model. Anesth Analg. 2018 (accepted for publication).Google Scholar