Boston Bombing Suspect Sedated and Communicating

We continue to follow the reports of the medical care being given by Boston bombing suspect Dzhokhar Tsaranaev. The patient is reportedly intubated and sedated but able to communicate with investigators via writing.

CNN has a report that discusses this written in part by health reporter Elizabeth Cohen that uses quotes from several physicians commenting on the case. Unfortunately, these characterizations are inaccurate and wrong and were given by two physicians (Dr. Albert Wu and Dr. Corey Siegel) that obviously do not routinely sedate patients trauma patients in an ICU.

Only Dr. Athos Rassias of Dartmouth, who is Director of the Critical Care Fellowship at Dartmouth, would have direct daily experience in sedating patients in the ICU.

ICU sedation is a tricky and difficult thing to optimally effect. Generally, almost all surgical trauma patients who are intubated through the mouth or nose require some sedation. Having an endotracheal tube in the pharynx and trachea can cause a gag reflex. In addition, the mode of ventilation sometimes does not always “sync up” with the normal breathing pattern and this can cause distress.

The two most common regimens to effect sedation in the ICU are a combination of narcotic and benzodiazepine or the use of propofol. There are advantages and disadvantages to each.

In the narcotic/benzo regimen typical drugs used are fentanyl and midazolam, sometimes if the need is thought to be some a longer duration given as a continuous drip. Fentanyl is a relatively short-acting and powerful narcotic that causes some sedation and is a good drug for patients with significant wounds. Midazolam is a sedative and has largely replaced the use of lorazepam as it has fewer metabolites that build up in the system.

One problem with a narcotic/benzo combination is that the drugs buildup in the fat stores of the body over time and after they are stopped being given, sedative effects remain. Another technical problem with their use, particularly with midazolam, is that it has to be weaned off to avoid having the patient become agitated and combative.

Typically with this combination, it is not possible to go from a  heavily sedated state to being “awake” in just a few minutes as indicated is possbile in the CNN report by Dr. Corey Siegel.

Propofol (the drug used by Michael Jackson to “sleep”)  is often used in the ICU for patients who are thought to need a shorter length of sedation. This drug, which is a milky white substance with a short half-life, is given intravenously and can produce a deep level of sedation. It ideally should not be used for longer than 24 hours to avoid the rare but life-threatening complication called post-propofol syndrome.

boston bombing

It’s advantage if used for several hours is that you can go from a deep level of sedation to being alert within an hour or so of being discontinued. However, propofol does not have any analgesic properties and trauma patients being given this drug also need a narcotic such as fentanyl or hydromorphone for pain control.

The aim for every ICU patient is to have enough sedation on board to keep the patient comfortable without being over-sedated. The optimum level of sedation depends on the clinical situation (e.g. head injury, open body cavity) but generally is rated by the Ramsey Score as described below:

Ramsey Sedation Scale

1. Anxious, agitated, restless

2. Cooperative, oriented, tranquil, accepts mechanical ventilation without distress

3. Responds to commands only

4. Brisk response to light glabellar tap or loud noise.

5. Sluggish response to light glabellar tap or loud noise.

6. No Response.

Typically, in surgical ICUs with intubated gunshot patients with closed body cavities you want to aim for a Ramsey score of 2-3. A Ramsey score of 2 translates into a patient that can respond to voice and could hold a pencil or pen and write and shake their head yes or no.

This state of sedation is vastly more desirable in terms of patient outcomes. The clinical scenario of having a patient that is being kept in a deeper level of sedation for days with unresponsiveness with periodic “wakeups” that lead to alertness in minutes followed by periods of being put “back to sleep” is really not clinically experienced.

ICU outcomes are clearly linked to how much and how long the sedation of the patient is and “sedation holidays” are done as a routine matter of care and not intermittently as suggested by some of the CNN commentators.

However, the notion promulgated by today’s CNN article that you can have a patient with a Ramsey score of 5 or 6 and then have them alert in minutes is regretfully just not accurate and based on experience or fact.

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