Page 721 - Clinical Application of Mechanical Ventilation

Case Studies 687

elected to forgo ventilatory support and chose to continue with symptomatic
therapy, invoking the Russell’s do-not-resuscitate election in light of the futil-
Heroic life-prolonging ity of intubation and assisted ventilation.
measures can mean more
than intubation and mechani- • Patient and family refused a feeding tube.
cal ventilation. It is important
to have the patient and • They elected for comfort care.
health care surrogate decision
maker define what heroic Noninvasive ventilation could be a life-prolonging measure, but this patient’s re-
life-prolonging measures are
desired. cent orofacial surgery makes even a nasal mask unlikely.
Over the next week, the patient’s pain worsened despite aggressive pain manage-
ment, and spontaneous ventilation is starting to worsen. The nasal cannula was
changed to a high-flow nasal cannula (70% oxygen at 35 L/min BTPS), resulting in
an SpO of 93%, SpHb 11.7 g/dL, and SpOC 14.7 mL O /dL blood. The patient
2
2
was able to rest more easily after implementation of the high-flow nasal cannula.
Midazolam, a benzodiaz- Mr. Peace was clearly suffering greatly and this caused severe distress to his wife
epine, was chosen to provide
Mr. Peace’s sedation because and children who could not bear to see him suffer in this manner. Since his pain
of its short half-life. There is
extensive clinical experi- was unendurable and refractory to all palliative measures, palliative sedation was
ence with its use as sedative proposed as a humane and compassionate approach to allay his suffering.
pharmacotherapy at the end
of life. After explanation of the procedure, both he and his family readily agreed to deep
and continuous palliative sedation. An informed consent document was signed, and
a note describing the indications and plans for palliative sedation was recorded in
the patient’s medical record.
Phenobarbital is a cost-
effective and efficacious agent End-of-Life Sedation
that can be used as a first- or
second-line medication and
would have been added to Mr.
Peace’s regimen had a high A 4-mg subcutaneous bolus of midazolam was then administered, followed by a
dose (i.e., 120-200mg/d) of continuous subcutaneous infusion of 1.5 mg of midazolam per hour. The Ramsay
midazolam failed to provide
adequate sedation. Sedation Scale was utilized to monitor depth of sedation, and the dosage of mid-
azolam was titrated upward to maintain a deep level of sedation (a 4-mg bolus every
30–60 minutes, as needed, was utilized, with the continuous infusion increased by
0.5 mg/h after each bolus).
Propofol has also been He was sedated within 10 minutes, but after 30 minutes he was still arousable
touted as a valuable agent for with verbal stimulation and he complained of pain. A second bolus of midazolam
palliative sedation; however,
its cost and intravenous route was administered and his infusion increased to 2 mg/h.
of administration limit its Titration of midazolam continued over the next few hours until he was deeply
use outside of an intensive
care unit. sedated, with an eventual dose of 5 mg/h required to maintain deep and continuous
sedation. He died 4 days later, sedated, peaceful, and with his family at his bedside.

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