ICU Cases · Sedation & paralysis
Severe ARDS — deep sedation and the paralysis decision
A long case on the sedation and paralysis of the severe early ARDS patient — deep sedation as the platform, the ACURASYS-versus-ROSE paralysis decision, the train-of-four and the safeguards, and the plan to lighten sedation and reverse paralysis as the lung injury resolves.
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A 48-year-old man is admitted to the ICU with severe influenza A pneumonitis. He is intubated and ventilated with a lung-protective strategy (tidal volume 6 mL/kg predicted body weight, PEEP titrated) and proned, yet his gas exchange remains poor: PaO2/FiO2 of 90 on FiO2 0.8, with a ventilator driving pressure of 22 cmH2O and ongoing patient-ventilator dyssynchrony. He is currently sedated with propofol and fentanyl but continues to "fight" the ventilator and desaturate with each effort.
[3]References5ShowHide
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- [2]Moss M, Huang DT, Brower RG, et al. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome (ROSE). New England Journal of Medicine, 2019.PMID 31112383
- [3]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
- [4]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.
- [5]Marino PL The ICU Book. 4th edition, Lippincott Williams & Wilkins, 2014.