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How to manage the intubated critically ill patient while keeping them awake, non-delirious, and mobile, with Dr. Dale Needham, FCPA, MD, PhD.
Dr. Needham is a Professor of Pulmonary and Critical Care Medicine as well as Physical Medicine and Rehabilitation at the Johns Hopkins University. He is also director of their Outcomes After Critical Illness and Surgery (OACIS) group, an attending intensivist in the medical intensive care unit, and the medical director of the Critical Care Physical Medicine and Rehabilitation program.
Takeaway lessons
- Start vent sedation with as-needed boluses of fentanyl alone. This is primarily for tube-related discomfort, with the assumption that patients may not need sedation per se unless they demonstrate the need. More fentanyl is often needed early on. If a long-acting paralytic was used for intubation, do consider a one-time benzo push or a larger opioid bolus for the initial period of paralysis.
- 25 mcg of fentanyl PRN every hour is a good starting point unless the patient is larger or opioid-tolerant. However, you can rapidly escalate the dose as needed. Even large bolus doses in a patient who has proven the need is preferable to routinely using a drip. Reserve the opioid drips for patients who require frequent boluses, and reserve sedatives for those who remain agitated after analgesia is in place.
- Soft restraints will often be used initially as patients emerge, but then may come off if patients prove to be well-oriented and cooperative. Very loose restraints are also an option over tightly restrictive restraints, serving only as a reminder.
- Mobility can start as soon as the day of intubation if the clinical picture and logistics are amenable.
- Well-trained nurses may be the best people to determine the need for additional sedation, restraints, sitters, etc. Restraints may sometimes worsen delirium and agitation; assess for their effects.
- Even in delirious patients, start with analgosedation (e.g. fentanyl)—these patients can’t tell you when they have pain, and pain is itself deliriogenic. After that, consider escalating to either dexmedetomidine, or PRN antipsychotics like haloperidol (which you can convert to oral quetiapine if it works).
- Remember that antipsychotics will neither prevent or treat delirium, and are only acting as a sedative for safety’s sake. If electing that approach, monitor QTc, start low (e.g. 1 mg haloperidol IV) and double it as needed until good effect is seen.
- Benzos are a last line, except in special circumstances (seizure, alcohol withdrawal) as they may worsen delirium, even if they temporarily hide it by extinguishing signs of agitation. Mostly, they defer the delirium to someone else’s shift. Hardly any patient goes from deep sedation to wakefulness without passing through a period of frank delirium.
- Mobilize early, even in patients modestly delirious and confused; it helps engage them, manages the pain of immobility, and tires them out to enable better sleep. It does require some attention towards safety by nursing and therapists; safety events related to mobility are minimal in good systems.
- It’s always hard to “escape” the vicious cycle of sedation and delirium once severe agitation is requiring multiple drips and deep sedation. Skilled nursing is key, with the shared understanding that sedation is harmful and needs to be (safely) weaned ASAP. Start with weaning the most deliriogenic medications, like benzos, then perhaps propofol. Expect a period of agitation and treat it with dexmedetomidine or PRN antipsychotics; use the approach of escalating antipsychotic as above, and if it works consider an oral antipsychotic for more steady state effect.
- “Chronic” ICU patients (stuck there for weeks or months, often due to disposition issues) can engage in highly aggressive PT/OT with multiple sessions for day. They are generally not delirious. SLP can attempt measures like in-line speaking valves or “talking trachs” and evaluate for swallowing while the trach is in place. Many such patients develop anxiety and cognitive issues, which is often best addressed via therapy (e.g. by rehab psychologists) rather than medications.
- In well-evolved systems with good practices around these areas, COVID-19 should ideally change things relatively little. Many patients can remain lightly sedated and mobile. Use video conferencing in lieu of visitation to redirect patients; you can even do it during a rehab session, using family as motivators and for redirection, and activity to keep them awake.
- Severe ARDS (e.g. from COVID) does take its toll. Proning can lead to shoulder injuries, and deep sedation and paralysis leaves severe physical and cognitive deficits. Agitation may lead to vent dyssynchrony leading to derecruitment. Try to have a slow, steady plan for weaning the vent and sedatives, and stick to it even across multiple shifts.
Resources
- 10th Annual Johns Hopkins Critical Care Rehabilitation Conference, November 4–6 2021, virtual format. Extensive material from prior conferences is available here as well.
- Staying Woke: review of sedation, mobility, and delirium
- Hopkins OACIS group
- Hopkins: Activity and Mobility Promotion
- Hopkins toolkit for early rehab programs
References
- Strom et al. “No sedation on the vent” trial
- Kollef et al. “Bolus vs continuous sedation” trial
- Hager et al. Reducing deep sedation and delirium in acute lung injury patients: a quality improvement project
- Needham et al. Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project
- An example of nurse-controlled analgesia pumps