In this, the 6th installment of the NEJMs interactive critical care case series, we turn our attention to ICU sedation and delirium. Having survived his severe septic shock, ARDS and, most recently, acute liver injury we are asked to consider if and how we would sedate this critically unwell 77 year old with a background of alcohol abuse and mild cognitive impairment.
A 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment is admitted to the intensive care unit (ICU) of a university hospital from the operating room after a Hartmann’s procedure that was performed for fecal peritonitis due to a perforated sigmoid colon.
On arrival in the ICU, he was in septic shock. He is undergoing mechanical ventilation with the use of a low-tidal-volume protocol with positive end-expiratory pressure (PEEP). His arterial blood pressure is supported with a norepinephrine infusion. His acute liver failure is being treated by removal of acetaminophen from his treatment regimen.
Analgesia is being provided by a continuous morphine infusion.
How would you provide this patient with sedation?
- Intermittent intravenous lorazepam.
- Continuous intravenous infusions of propofol to facilitate daily cessation of sedation to assess the ongoing need for sedation and analgesia.
- An intravenous infusion of alpha-2-adrenoceptor agonist such as dexmedetomidine with daily cessation to assess the ongoing need for sedation.
- I would not sedate this patient.
Once youve thought of your answer, check the results here.
