Page 720 - Clinical Application of Mechanical Ventilation

686 Chapter 19

was treated with surgical resection of the tongue with extensive resection of bone
and soft tissue. The malignancy progressed rapidly despite treatment and resulted
in extensive tissue necrosis resulting in the following distressing symptoms:
1) strong nasal quality and loss of tongue made speech completely unintelligible,
2) extensive loss of teeth coupled with loss of tongue making it very difficult to
swallow, 3) severe facial disfigurement, and 4) necrotic nonhealing oral ulcer
causing severe malodor and facial pain.
Initially Mr. P’s pain and symptoms were relatively well controlled with:

• Methadone (50 mg thrice daily), a powerful synthetic opioid for long-term
Why are methadone, analgesia
morphine sulfate, haloperidol,
and lorazepam needed? The • Immediate-release morphine sulfate (50 mg every 4 hours, prn) for severe
patient has multiple types of
discomfort requiring different pain
pharmacologic therapies.
• Haloperidol (0.5 mg every 6 hours) for nausea and vomiting
• Lorazepam (0.5 mg every 4 hours) for anxiety

This regimen worked well for several weeks, but the pain worsened secondary to
extensive local tissue necrosis from progression of the disease, leading to hospital
admission for symptom control.

Pulse Oximetry and Pulse Co-Oximetry

SpO 89% on 3 L/min, SpHb 11.8 g/dL, and SpOC 14.5 mL O /dL (vol%) blood
2
2
via noninvasive pulse oximeter.
Clinical Course

Numerous interventions were attempted to relieve Mr. Peace’s pain, including:
Changing to morphine
sulfate administration by • Switching from methadone to continuous subcutaneous infusion of morphine
PCA allows the patient to (6 mg/h)
participate in determining
when dosing is needed and
eliminates waiting for a nurse • Patient-controlled anesthesia (PCA) of morphine sulfate infusion 2 mg every
to deliver doses. While PCA 15 minutes as needed
imposes clinician-set limits
on maximum dose per time it • Lorazepam (0.5 mg every 4 hours)
does not completely eliminate
the possibility of overdose. • Metronidazole gel applied to the ulcerated tissue on the face (to control local
infection and thereby the bad odor)

• Nasal cannula at 6 L/min; and a fan gently blowing on his face.
Unfortunately, none of the treatments alleviated or attenuated his sense of severe
It is important to monitor pain. At this point, a family meeting was held to elicit goals of care and the follow-
ventilation in spontaneously
breathing patients when us- ing was determined:
ing high levels of sedation
and/or analgesia. Capnogra- • Mr. Peace adamantly refused further surgery, chemotherapy, and radiation
phy is a noninvasive means of
monitoring ventilation. therapy, and received complete support from his wife and adult children.
• Heroic life-prolonging measures (endotracheal intubation with mechanical
ventilation, etc.) was discussed with Mr. Peace and his family; however, they

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