Question 5

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.

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College answer

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

  • Staff Numbers
  • Day /night timing
  • Unit activities Plan for additional safety measures e.g. Security

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

Discussion

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:

  • Debrief
    • Assess the events of the last extubation, specifically how the sedation wean was managed
    • Assess the specific proximal cause for the escalation
    • Assess the risk of future escalation on the basis of the patients background and risk profile
    • Re-consult toxicology and review the medical history to exclude untreated toxicity or drug withdrawal 
    • Councel staff, ensure appropriate leave, encourage the submission of an incident report
  • Prepare the patient
    • Sedation while weaning anaesthetic agents:
      • Dexmedetomidine (data extrapolated from delirium literature)
      • Antipsychotics (choice is determined by side effect profile)
      • Benzodiazepines (favoured in drug and alcohol withdrawal states)
      • Opioids (where opioid dependence or untreated pain may be contributing)
    • Consider the need for physical restraints
  • Prepare the environment
    • Unbstructed exits
    • Loose items or dangerous equipment (needles, scissors) are tidied away
    • Quiet (silence monitors, ventilator) - patients with sensory sensitivity may be 
  • Prepare the staffing 
    • Wait for daytime, ideally  some period of handover or shift overlap where there are a large number of staff available
    • Add staff: security officers +/- mental health nursing staff +/- multiple ICU nurses
    • Organise the presence of a family member who is known to have a claiming influence
    • Prepare any medications to be used in case of a re-escalation of behaviour
  • Extubate in a controlled fashion
    • Commence dexmedetomidine 
    • Add an antipsychotic agent with antihistamine activity (eg. olanzapine) or a benzodiazepine/opioid if there is concern regarding withrawal
    •  Cease other sedation and extubate the patient with dexmedetomidine as a solo anaesthetic agent - supported by the DahLIA study (Reade et al, 2016)
    • Wean the dexmedetomidine gradually to allow awakening without tube-associated agitation​​​​​​​

References

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.