ICU Cases · Sedation & paralysis
Hot case — the bedside: an over-sedated patient failing a spontaneous breathing trial
A CICM hot case — a bedside encounter on an over-sedated patient failing to wean. Tests the RASS assessment, the daily-interruption principle, the switch to a shorter-acting agent, and the recognition that over-sedation (not the lungs) is the weaning barrier.
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CICMFFICMEDIC
Prompt
At the bedside of a 65-year-old woman, day 6 of ventilation for pneumonia, who has just failed a spontaneous breathing trial. Assess her sedation at the bedside and manage the over-sedation that is delaying her weaning.
Presentation
You are taken to the bedside of a 65-year-old woman who is on day 6 of ventilation for a community-acquired pneumonia. She has improved — the fever has settled, the infiltrates are clearing, and the team has just attempted a spontaneous breathing trial, which she failed, remaining tachypnoeic and not opening her eyes. She is on a midazolam and fentanyl infusion. The nurse asks you to assess her sedation and the reason for the failed trial.
[1]References4ShowHide
- [1]Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine, 2000.PMID 10816184
- [2]Devlin JW, Skrobik Y, Gélinas C, et al. Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS). Critical Care Medicine, 2018.PMID 30113379
- [3]Reade MC, Finfer S Sedation and delirium in the intensive care unit. New England Journal of Medicine, 2014.PMID 24476433
- [4]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.