Mechanical Ventilation with Sedation

A few weeks ago I had a patient in the ICU who had been intubated and placed on a ventilator. This patient had critical aortic stenosis and was placed on a ventilator following an attempted right internal jugular line placement that resulted in a massive right hemothorax. On the day that I was in the ICU the physician and primary RN decided that they would taper the patient down off the Sublimaze (fentanyl) and Versed (midazolam) being used for analgesia and sedation. The team’s ultimate goal was to see if the patient was ready to be extubated. In addition, the patient was placed on CPAP as a trial. In this particular case it was very important that the patient be monitored for any signs of agitation or distress due to the fact that increased stress would activate the sympathetic nervous system and increase the workload on the heart. Due to the severe aortic stenosis and compromised cardiac function, an increase in workload would be poorly tolerated by the patient. By noon the patient started to respond to stimulation. The patient would open his eyes in response to voices and became agitated during suctioning and turning. The increased heart rate that accompanied the agitation required that the Sublimaze and Versed be initiated once again. Ultimately, the respiratory therapist, nurse, and physician agreed that based on the trial CPAP and spontaneous awakening trial, the patient was not ready to be extubated. Ventilation and sedation are often a necessary treatment for a person with severely compromised cardio-pulmonary function. Nonetheless, these treatments have to be used judiciously with constant reappraisal of the situation in order to minimize the potential short- and long-term consequences of ICU-acquired delirium and weakness. During my next ICU clinical I look forward to investigating the procedures and protocols that are instituted in the hospital units.