A 34-year-old patient presents to the emergency department with a suspected recreational drug overdose and is intubated for a low Glasgow Coma Scale (GCS). There is no past medical history of note. On day 3, the patient is de-sedated, extubated, and subsequently assaults the bedside nurse.
The patient is re-sedated and re-intubated.
Discuss your management plan for de-sedating and extubating this patient.
Syllabus topic/section:
2.1.8 Neurological Intensive Care: Acute behavioural disturbances: L1
2.1.19 Intensive care Procedures: Intubation
Discussion:
This was a very practical question asking for an approach to a relatively common ICU problem. Candidates that did not provide a structure to their answer frequently missed important elements that would normally be considered when extubating a patient with a history of aggression and safety risks to self and staff. Candidates that did well in this question considered the potential reasons for his post-extubation aggressive behaviour, including organic, psychiatric and toxidrome factors, addressed the logistical issues when considering a second extubation, understood the importance of staff and patient safety and had a back-up plan in case it failed.
Both pharmacological and non-pharmacological strategies when extubating the patient should be considered. For an above standard answer, it was important to include some details about the different pharmacological options that might be used. Please see the below rubric for examples of the elements required. Please note that this is not the only structure/ headings possible. Many differently structed answers with equal content gained the same marks.
The marking rubric is included to aid the candidate’s future study.
|
Below standard |
At standard |
Above standard |
|
|
Considers underlying reasons for aggression in previous extubation (2 marks) |
Fails to consider reasons for failed extubation Doesn’t consider staff or patient safety Lack of a back-up plan if fails extubation 0-0.5 marks |
Considers some potential underlying reasons for behaviour 1-1.5 marks |
At standard plus Considers a broad range of underlying reasons including medical/ psychiatric & toxidrome 2 marks |
|
Staff Safety (3 marks) |
None or inaccurate consideration. 0-1 marks |
Partial consideration to items listed in the column on above standard 1.5-2marks |
Considers the points listed below Considers logistics
2.5-3.0 marks |
|
Patient safety and plan for smooth emergence (3 marks) |
None or inaccurate Considerations 0-1 marks |
Consideration of some pharmacological and non- pharmacological techniques 1.5-2marks |
Considers non- pharmacological and pharmacological techniques for smooth emergence Considers contacting specialty services for advice where applicable. 2.5-3.0 marks |
|
Team Plan (2 marks) |
None or inaccurate considerations 0-1 marks |
Mention made of a backup plan but no mention of team preparedness. 1 mark |
Team communication of detailed backup plan for aggressive emergence 1.5-2 marks |
The rubric is enlightening because the structure is generic for the management of basically any situation where the patient and the staff have interacted in some way that led to the detriment of both (i.e. these can be generalised to questions about needle stick injury, open disclosure, complaint resolution, and so on). The last time this happened, it was in Question 27 from the first paper of 2018, where the college focused on managing the misbehaviour, with a strong focus on pharmacological options. This time prevention seems to be the focus. An effective strategy for candidates to adopt appears to be a structure that resembles the management of delirium:
Drury, Thomas. "Recognizing the potential for violence in the ICU." Dimensions of Critical Care Nursing 16.6 (1997): 314-327.
Kynoch, Kate, Chiung‐Jung Wu, and Anne M. Chang. "Interventions for preventing and managing aggressive patients admitted to an acute hospital setting: a systematic review." Worldviews on Evidence‐Based Nursing 8.2 (2011): 76-86.
Reade, Michael C., et al. "Effect of dexmedetomidine added to standard care on ventilator-free time in patients with agitated delirium: a randomized clinical trial." Jama 315.14 (2016): 1460-1468.