Sedation Weaning in a Patient with a Substance Abuse and Psychiatric History

Abstract Background Achieving therapeutic doses of sedation and analgesia are necessary for the safety and comfort of mechanically ventilated patients. Patients with complicated psychiatric histories, are neurocritical, and have acute respiratory distress syndrome usually require maximum sedation, making sedation weaning an arduous task. Case Presentation A 42-year-old female presented with a chief complaint of headache, hypertensive crisis, confusion, and nausea. Her past medical history is notable for hypertension, attention deficit hyperactivity disorder, bipolar II disorder, manic depression, agoraphobia, anxiety, and prior suicide attempts. Noncompliance with anti-hypertensive and psychiatric medications and prior substance abuse history was reported. A head computerized tomography scan revealed multifocal intraparenchymal hemorrhages and multifocal subarachnoid hemorrhages throughout the cerebrum. Within two hours, the patient became obtunded and required intubation. The patient’s severe agitation, likely due to metabolic encephalopathy, was difficult to control. Despite being on maximum dexmedetomidine, fentanyl, and quetiapine doses, the patient’s agitation remained. Due to her substance abuse and psychiatric history, a methadone and clonidine taper was initiated to attempt sedation weaning. Conclusion Sedation and analgesia weaning protocols for patients with psychiatric or substance abuse histories may aid in decreasing time on mechanical ventilation and/or in the ICU. The successful clonidine and methadone taper utilized in this patient has potential to be utilized in patients with similar histories. Future trials and approved sedation and analgesia weaning protocols for patients with a profound psychiatric and substance abuse history are urgently needed.