The authors reply.

We appreciate the comments by Xiao and Zhao (1) on our newly article published recently in Critical Care Medicine (2). Our group and others reported that patients with coronavirus disease 2019 (COVID-19)–induced acute respiratory distress syndrome (ARDS) received higher doses of hypnotics than patients with ARDS of other etiologies and experienced higher acute brain dysfunction (3, 4). Our study (2) adds the important information that overuse of sedatives increases the risk of prolonged coma, which increases the vulnerability to a fatal outcome.

Xiao and Zhao (1) speculate around possible reasons of the overuse of sedatives in patients with COVID-19–induced ARDS, and we agree with these thoughts: ICU providers may have been overfocused on the goal of preventing self-extubation and the associated risk of virus transmission to providers in an overburdened healthcare system. During the pandemic, often one nurse was responsible for numerous COVID-19 patients, and personal protective equipment may have not been available without restrictions. Continuous infusions of sedative medications were preferred in these circumstances, which made titration to light sedation very challenging. In addition, short-acting sedatives were not always available, such that long-acting benzodiazepines were used.

In our study (2), we ensured that differences in case acuity did not bias our conclusions. There were no differences between patients with and without COVID-19 in Pao2:Fio2 ratio, minute ventilation, pH, Sequential Organ Failure Assessment scores, or brain pathology. Thus, those differences in cases severity did not explain the overuse of sedative medications and the higher percentage of coma in patients with COVID-19, which we found mediated an increase in in-hospital mortality.

Our study (2) emphasizes the importance of avoiding prolonged, deep sedation. A light sedation goal in mechanically ventilated critically ill patients with ARDS decreases the risk of prolonged coma and helps decrease in-hospital mortality in patients with severe ARDS.