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Behind the research: Implementing practice change amidst a pandemic

Dr. Angela Jerath
Written by Samantha Sexton

In the early days of the COVID-19 pandemic, intravenous sedatives — sleep-inducing medications patients require to tolerate the uncomfortable procedure of being put on a breathing machine — were in short supply. With more COVID-19 patients being ventilated, global shortages of both ventilators and the sedatives needed, were a cause for concern.

“I started getting all these calls from my colleagues around the world asking, how do we run inhaled sedatives,” says Dr. Angela Jerath, an anesthesiologist and scientist in the Schulich Heart Program at Sunnybrook.

Dr. Jerath is an expert in volatile sedation, the inhaled form of sedation commonly used in operating rooms. Before the pandemic, her research was already laying the groundwork for assessing the safety of this form of sedative in intensive care units.

“When I saw the news reports that Friday night, I called Sunnybrook’s Director of Pharmacy to see what shape we were in and how I could help,” says Dr. Jerath.

Within six short weeks, Dr. Jerath and her colleagues in critical care, pharmacy, respiratory therapy and anesthesia had implemented a new sedation care pathway for COVID-19 and non-COVID patients requiring ventilation. This practice change would not only ease the pressure on IV sedation stocks, but also led to the launch of the largest trial of its kind to investigate the effectiveness of inhaled sedatives for COVID-19 patients.

Below, Dr. Jerath shares how the team got the SAVE-ICU trial underway and where they are now.

What is the study investigating?

Dr. Jerath: We’re comparing inhaled volatiles — a cheaper and more widely available anesthetic that is commonly used in operating rooms — versus the standard of care (IV sedation). In addition to easing the pressure on IV sedation stocks, there is some evidence to suggest that these drugs may also have therapeutic properties that reduce lung inflammation, which may speed up recovery and reduce the time patients spend on a ventilator. We’re measuring patient outcomes such as length of ventilation and survival to assess the effectiveness of this form of sedation.

What was involved in getting the trial up and running?

Dr. Jerath: Thankfully, a lot of the safety groundwork had already been established with previous studies, but there was still lots to do logistically to get this new care pathway set up. I negotiated pricing and sourced the products needed. We had discussions with pharmacy, ICU nursing, respiratory therapy and anesthesia assistants, and got the necessary approvals from leadership and the pharmacy and therapeutics board at Sunnybrook. Dr. Martin Chapman and I spent 2-3 weeks training the teams.

Where are you now with the study?

Dr. Jerath: We now have 12 sites on board at hospitals across Canada and we continue to recruit more sites and patients regularly. We plan to recruit approximately 750 patients in total.

What have been the most rewarding and the most challenging parts about launching the study?

Dr. Jerath: One of the main reasons we go into research is to implement practice change. This is one of the few times in my career where I’ve seen something go from an idea to a change at the bedside. Implementation can typically take years, so it has been incredibly motivating and rewarding for me that we could implement this new care pathway in a few short weeks during a pandemic. Given how fast paced this has been, it’s also been incredibly challenging, especially with a very small research team. I receive calls any time of the day or night about individual challenges hospitals are facing. A lot of the work in implementing a new practice is about managing people and practices so it requires lots of patience, and back and forth.

What could the findings of this trial mean for patients?

Dr. Jerath: If inhaled sedatives are effective at shortening the duration of ventilation, we can potentially reduce the pandemic’s strain on ventilator capacity while also improving patient outcomes. If successful, the results of this trial could also result in a significant paradigm shift in how we sedate critically ill patients in ICUs around the world.

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About the author

Samantha Sexton

Samantha is a Communications Advisor at Sunnybrook Research Institute.

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