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Health-care professionals working in the intensive care unit (ICU) are familiar with unpredictable and stressful situations, and complex patient loads. But a highly contagious viral pandemic and global shortages of critically important drugs created new challenges, even for seasoned professionals.

Lisa Burry, an assistant professor at the University of Toronto’s Leslie Dan Faculty of Pharmacy, is an experienced ICU pharmacist at Mount Sinai Hospital. Burry worked in the ICU during the SARS outbreak in 2003, giving her and her colleagues a sense of what was to come as COVID-19 intensified.

“Some of the fear and anxiety that we dealt with through SARS probably helped us cope better with COVID-19. We had some insight as to the potential impact,” she says. “However, we were also fearful because we knew what was coming.”

That included familiarity with the discomfort associated with wearing personal protective equipment all day long, the stress of being exposed to highly contagious patients for full shifts and demanding case loads. It also meant preparing for a surge of ICU patients and potential drug shortages.

As a member of the Society of Critical Care Medicine’s Fundamental Disaster Management Working Group and the American College of Chest Physicians’ Task Force for Mass Critical Care and Disaster Management Steering Committee, Burry had important insight and access to resources, which she says was key to helping the ICU prepare for COVID-19.

The hospital prepared for the height of the pandemic when ICU capacity threatened to be overwhelmed by creating temporary ICUs in areas of the hospital that were no longer being used such as post-op recovery rooms.

Burry’s research expertise – sedation and delirium in the ICU – put her in high demand to lead and support various research projects. Current practice for many conditions recommends that patients on ventilators receive pain medication to be calm and comfortable, but as alert and interactive as possible. However, this wasn’t possible with patients with COVID-19 who were put on ventilators, as they needed to be deeply sedated.

“Patients with COVID-19 in the ICU were ventilated for very long periods of time and had huge drug requirements for pain, agitation and delirium just to make their ventilation safe,” Burry says.

Hospitals across the country all experienced the same scenario and tried to access the same sedatives, causing supplies to run low. Now, on top of dealing with high numbers of patients and complex cases, pharmacists were facing shortages of criticial drugs.

“In the beginning, those of us in critical care were trying to solve these problems in isolation and not recognizing that another site was dealing with the same thing,” says Burry. “That led to a group of us working together to deal with the issue on a provincial level and ultimately led to research to test new strategies to manage it.”

Challenges in patient care leads to new clinical trials

At a time when Burry’s clinical work was busier than ever, research opportunities were also growing rapidly. She worked closely with multi-disciplinary teams to develop research proposals to study potential solutions to the drug shortages they were facing in the ICU – two of which were successful. As a co-investigator, Burry brings a valuable pharmacy perspective to research examining alternatives to traditionally used intravenous sedatives for patients on ventilators.

One trial, led by Angela Jerath and Brian Cuthbertson from Sunnybrook Health Sciences Centre and U of T’s Faculty of Medicine, as well as Claudio Martin and Marat Slessarev from London Health Sciences Centre, will compare inhaled gases typically used in the operating room to intravenous sedatives for COVID-19 patients on ventilators. Inhaled sedatives are not used outside of operating rooms in North America, but are cheap, widely available and reduce lung inflammation and improve oxygen levels. 

“We know the way in which we sedate people, the drug we select, how we do it and how long we do it can all impact how long they spend with us and their overall recovery,” says Burry.

The trial is receiving more than $2 million from the Canadian Institutes of Health Research (CIHR) COVID-19 Rapid Response Competition.

“While the trial may be COVID-centric, it addresses issues we can apply far beyond this pandemic. This is valuable work because it has the ability to improve patient care, but also deal with drug shortages and issues without compromising patient care,” says Burry.

The second clinical trial, funded through a McMaster Medicine Associates Innovation Grant, is led by Alison Fox-Robichaud at Hamilton Health Sciences and James Downar at the Ottawa Hospital. It is examining whether adding the old beta-blocker propranolol to standard sedation regimens reduces the amount of primary sedative required, another approach to decrease the consumption of essential sedatives.

As Burry reflects on the challenges of the last several months, she says she is proud of the work that she has done serving both her patients and her profession through participating in the new research projects and the professional working groups.

“Access to drugs is an important part of disaster management and I’m proud to have contributed to guidelines and protocols that have helped in this pandemic,” she says. “I’ve been given some good opportunities to be part of championing work that we’ve published about supply shortages.

“Despite all the challenges of COVID, I’ve made new connections, built new research networks and learned to do things more quickly and efficiently. The research we are doing may improve treatment for COVID-19 and should lead to shorter ICU stays and improved outcomes. Some positive things have come out of the last few months.”