So I was wondering. We had this patient who was found unresponsive foaming in the mouth and was intubated for airway protection. She has schizophrenia and is on a bunch of psych meds. We ve been unable to wean her off sedation because she gets extremely agitated. My question is if it was only for airway protection why not just take her off sedation completely take her off the vent and then control her agitation. why does she still need to be on the vent
Agitated patient on vent
- Thread starter Cadet133
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Probably easier said than done. As you back off the sedation, if the patient is extremely agitated, it is difficult to assess if they have the appropriate mental status to breathe on their own, and has gotten over whatever lead to their current situation to begin with. You would prefer a nice, calm patient who is able to participate in a spontaneous breathing trial. Occasionally in these patients you will undergo what is known as a "Kamikaze extubation", which is essentially doing what you said, just turning off sedation, pulling the tube, and see what happens, but this is suboptimal. Ideally, you'd end up finding a good balance of meds which would keep the patient calm with your SBT and eventual extubation.
In patients with an extensive psychiatric history it can be difficult, but it will usually involve throwing meds down their OG tube, getting them back on everything they are supposed to be on at baseline. Something like precedex could be helpful if they are still difficult to control.
I like how one of my attendings broke down the approach to difficult to sedate patients - essentially three classes of receptors you need to make sure you are hitting/replacing their chronic dependence - Opioids, Gaba, Dopaminergic. He would always say if we can't get patients calm enough to participate in SBTs, its our fault for not treating all these receptors.
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deleted171991
I always love these ER intubations for "airway protection". AKA "The patient is agitated and I am too busy to take care of her."
Stop all psych meds except for haldol, as much as needed. Put on a touch of fentanyl so she doesn't buck like crazy on the tube. Wait for her mind to clear.
Precedex allows for extubation with a touch of sedation.
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deleted171991
Not the best for weaning psych patients with hallucinations in the past/present. Probably Precedex is a better drug for that.
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Just pull the tube....people calm down when the plastic comes out
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i'm assuming you're also doing pressure support or minimal vent settings to minimize machine-patient dyssynchrony?
