Extubation Difficulties

Specialties CCU

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Specializes in Cardiac, Transplant, Vascular, NICU.

HI All!

I have a puzzle for you all. My patient is a male with cardiomyopathy and an EF of 30%. He came in to the ED with shortness of breath and was intubated and has been for about a week now. My patient's labs that came back indicated marijuana with cocaine mixed with some benzos. The patient has been on volume control for 7 days with no success of attempting to extubate. He is normally on Fentanyl, Ativan, and Precedex for sedation due to the fact that when he is "awake", he pulls at every single line he can grab onto. His vital signs are stable, his labs signs are normal. When we have attempted to extubate him in the past, we weaned down the drips (or just turned them off) and put him on the CPAP setting. Unfortunately, he can't stay calm enough to actually breath on his own so that we can extubate. When we take him off sedation, he becomes tachycardic, hypertensive, and tachypnic.

My hunch is this is patient is going through withdrawal. If the patient is going through withdrawal, what are some suggestions you have with weaning off the drips so wake him up, yet keeping him calm enough to breath on his own during the CPAP trial? Or does anyone else have any other suggestions?

Thanks :)

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How does your patient do if you wean off everything but precedex? Have you added high dose haldol? Sometimes you just need to extubate the agitated patient if you feel they will "fly" once extubated...you get a "feeling" about it once you get enough experience. If the patient is withdrawing off the benzos, sometimes you have to resume them once extubated and wean those slower.

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Specializes in Cardiac, Transplant, Vascular, NICU.

Well on 35% his CO2 is 65 and his PO2 is 85... That makes me nervous to extubate quite yet. I haven't tried the haldol though! I'll bring that up next time I see ICU :)

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Specializes in Critical Care.

It's almost to be expected that after a week on fentanyl/ativan the patient will have at least some delirium, which is likely what you're seeing during a sedation vacation/weaning trial. In my experience, properly dosed haldol is your best bet (2-10mg, not a typical floor patient dose which is often only 0.5-1 or 2mg). Precedex during the wean and extubation can help some, but I don't find it all that effective in a patient that has anything more than some mild anxiety.

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Specializes in ER/ICU/STICU.

I always find these type of patients do better after a couple of days on seroquel. If not then he is going to buy himself a trach and eventually he will be weaned.

How about a different vent setting for weaning like SIMV and let him build up some strength.

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Specializes in Cardiac, Transplant, Vascular, NICU.

So the group of doctors working with my patient prefer not to use haldol but he was started on Seroquil!

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Specializes in Critical Care.

Haldol is actually the only evidence based treatment for delirium. Atypical antipsychotics are often used as adjunctive treatments along with haldol in best practice recommendations, although there is really no proof that seroquel, zyprexa, or other atypical antipsychotics are all that effective (in my experience they do "seem" to work, although not as well as haldol and aren't usually sufficient without also using haldol, they just seem to decrease the amount of haldol needed).

Current standards for treatment of ICU delirium are relatively new, and many docs have a poor understanding of haldol and delirium, so aggressive education of docs is usually needed.

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When patients come in that are positive for drugs/etoh we normally start a long acting oral benzo (librium, klonopin). It (normally) makes it easier to wean the gtts a few days into it.

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Specializes in ICU.

This is going to sound awful, but in my experience, these patients do quite well when they self- extubate.

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Specializes in Cardiac, Transplant, Vascular, NICU.

He actually just self-extubated today so hopefully he will "fly"! Thank you for all the advice!

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Seems I'm too late but self extubation does wonders for these pts. Not that I advocate it but I've been there lol. This case does sound more like delirium than withdrawal. Your time frame would suggest he be past that point anyway. After 5 days your golden

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