A 78-year-old woman is admitted to the intensive care unit (ICU) with confusion, fever, hypotension, and tachypnea. She is intubated and started on antibiotics for septic shock caused by a urinary tract infection. Norepinephrine infusion is started via an internal jugular venous catheter. The ventilator is set on continuous mandatory ventilation (CMV) mode and the patient is sedated with midazolam and fentanyl infusions. Chest x-ray shows mild subsegmental atelectasis and appropriate positioning of endotracheal and orogastric tubes.
Which of the following is likely to decrease this patient's length of stay in the ICU and reduce the number of days she requires mechanical ventilation?

Question

A 78-year-old woman is admitted to the intensive care unit (ICU) with confusion, fever, hypotension, and tachypnea.  She is intubated and started on antibiotics for septic shock caused by a urinary tract infection.  Norepinephrine infusion is started via an internal jugular venous catheter.  The ventilator is set on continuous mandatory ventilation (CMV) mode and the patient is sedated with midazolam and fentanyl infusions.  Chest x-ray shows mild subsegmental atelectasis and appropriate positioning of endotracheal and orogastric tubes.
Which of the following is likely to decrease this patient's length of stay in the ICU and reduce the number of days she requires mechanical ventilation?

Quizplus · Accepted Answer

Multiple meta-analyses have shown that use of sedation protocols (daily interruption/algorithm-based sedation) reduces duration of mechanical ventilation and length of stay in the intensive care unit (ICU). Both techniques aim to minimize the total sedative dose. Some trials have shown improved one-year mortality. Sedation interruption allows for a daily spontaneous breathing trial and assessment of the patient's neurologic status and may reduce the need for neurodiagnostic testing. (Choice B) Studies of early tracheostomy in medical ICU patients have shown that it has no benefit and may even cause a worse outcome. (Choices C and D) Low tidal volume ventilation with higher positive end-expiratory pressure and neuromuscular blockade may be beneficial in patients with acute respiratory distress syndrome (ARDS). This patient likely has metabolic acidosis with respiratory compensation causing tachypnea. There is no evidence of ARDS. (Choice E) There is no evidence to suggest that synchronized intermittent mandatory ventilation is a better mode of mechanical ventilation than continuous mandatory ventilation. Educational objective: Protocolized sedation refers to the use of a sedation algorithm or daily sedation interruption. It has been shown to reduce duration of mechanical ventilation and length of intensive care unit stay. __________ References: Treatment algorithms in critical care: do they improve outcomes? (http://www.ncbi.nlm.nih.gov/pubmed/21507794)

A 78-Year-Old Woman Is Admitted to the Intensive Care Unit