ICU Cases · Sedation & paralysis
ICU delirium in the ventilated patient — the bundle and dexmedetomidine
A short case on ICU delirium — the CAM-ICU positivity, the midazolam driver, the prevention-and-treatment bundle, and the switch to dexmedetomidine.
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Prompt
On day 4 of a prolonged ICU admission, a ventilated patient is inattentive, fluctuating and pulling at his lines, with a positive CAM-ICU. He has been on a midazolam infusion.
Presentation
On day 4 of a prolonged ICU admission for a complicated laparotomy, a 70-year-old ventilated man has become inattentive and fluctuating over the last 24 hours. He pulls at his lines, he does not reliably follow commands, and his sleep–wake cycle is disrupted. He has been on a midazolam infusion for sedation. The CAM-ICU is positive (an acute fluctuating change, inattention, and disorganised thinking).[1]
[1]References4ShowHide
- [1]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
- [2]Reade MC, Finfer S Sedation and delirium in the intensive care unit. New England Journal of Medicine, 2014.PMID 24476433
- [3]Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomidine vs midazolam for sedation of critically ill patients: a randomized trial (SEDCOM). JAMA, 2009.PMID 19188334
- [4]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.