I appreciate the research you have done, but I'll disagree and here are the gaps. I'll preface this with, this is not every single patient, but this more than a good number of them. If you get intubated, it's probably 50/50 at this point.
A trauma patient who is otherwise healthy would get a sedation holiday, you are correct. They are often doing stuff like running around being healthy before getting hit by a car, getting shot or playing a sport or crushing a pelvis while riding a motorcycle. If a trauma patient gets intubated, it's like 2 or 3 days ish if lucky, certainly more days more if surgery is needed.... Stop the bleeding, stabilize the electrolytes, surgery, extubate and heal and they bounce up and then get them moving. They do get sedation holidays because they are not in ARDS and are otherwise healthy.
It's the ARDS from COVID that makes a difference. That's where you need to start looking for details on COVID. About half or so of them go into ARDS in the ICU roughly. You see, it's an inflammatory process that ruins the lungs and we cannot come off the sedation because of the risk of trauma to the lungs from the pressure against the fluid and leakage in the lungs so they need gentle pressure. Otherwise, they can get a pneumothorax and then need a chest tube. Because the pressure has to be so gentle, you don't lift the sedation because then they over breathe and fight the vent and cause more long term damage. Many of them don't get a sedation holiday because of the risk of damage from fighting a viral infection. It's very different because we are drying them out via diuretics to keep them dehydrated to keep the leaking into the lungs down. Sedation holidays don't apply in these cases unless we catch them early enough and they have all the right factors like small BMI, no history of hypertension, no diabetes, no abdominal girth that keeps the breathing well. This isn't every patient, but it is the sicker ones and I would argue that more get intubated for along period of time than just a few days.
In the more severe cases these patients, we go deeper on sedation because they are also paralyzed with certain meds so they cannot fight the vent at all and we put them on a BIS monitor, which is like an EKG but for the brain, to make sure their brain waves are so low, they are not arousable. They definitely don't get sedation holidays because can you image waking up and you're paralyzed? It's PTSD city, and cruel to do to someone. Those meds take a lot of time to wear off. When weaning COVID patients, we come down by 20% per day to keep withdrawals down and this can take a week or so just to come down. Anyone who gets proned, is not getting a sedation holiday, because if the wake up at all, they are going to pull their tube.
To give you an idea of what dosing looks like, you can get a bronchoscopy with 2-5 mg of versed and 1oo of fentanyl and you're in twilight. Awake, but in a trance. Recovery time is a few hours. colonoscopy can be 2oo of fentanyl and 5 -7 of versed. Go home same day. These are one time doses.
These COVID patients are getting 5-10 of ketamine per hour, 10-20 mg of versed an hour, 50-100 mcg of fentanyl per hour, and 20-80 mcg of propofol per hour, for 2-6 weeks straight, nonstop. Tweaning a little here and there. The risk of withdrawal is high because meds like Versed and Ketamine, it stores in the fat and cannot be excreted all at once so we come down very slowly. No more than 20% per day. For fentanyl, we transition over to oxycodone that is scheduled and then as needed while monitoring for withdrawal symptoms. The risk of coming off these meds at such high doses is seizures, vomiting, which can lead to a new infection called aspiration pneumonia. If we are monitoring for withdrawal in the hospital, my concern is what happens when they leave. I mean, they're stable right? But they still have to deal with the withdrawal, even though they are not in the hospital any more. It doesn't just go away because they went home.
All this circles back to how much sedation these patients are getting and those long term effects, which we are not covering right now. Another comparison, a trauma patient maybe on 2 or 3 or 4 drips. A COVID patient can be on 6 to 9 drips. It's a big difference and the reason why they go into kidney failure. They can't handle processing all the diuretics needed to get the fluid off that we are giving them. That's why they go into heart and kidney failure. It's too much fluid from too much sedation and pressers to keep their BP up. But you can't undersedate them or we'll blow their lungs sideways and they'll die. It's the ARDS.
I'm posting this link below on ARDS if you want more detail on it.
Acute Respiratory Distress Syndrome
Treatment of ARDS
Many patients who develop ARDS need a ventilator, a machine that delivers oxygen through a breathing tube (endotracheal tube).
Some patients become so sick that they may need medications that make them less awake or even paralyze them so the ventilator can be as safe and useful as possible. Some patients may need to be turned in the bed from their back to their stomach (placed
prone), and the sickest patients may require a machine that takes over the work of their heart and lungs (
extracorporeal membrane oxygenation). Sometimes, even these measures may not be able to provide enough oxygen to the body, and if this is the case, organs such as the brain and heart may be damaged.
ARDS is very dangerous. When patients need life support, they may develop new problems from being so ill and in the hospital. Common problems are collapsed lung (
pneumothorax), infections from any large intravenous catheter or from the ventilator itself, a blood clot from lying still in the hospital bed, or injury and scarring to the lungs.
Long-term Effects of ARDS
More and more patients are surviving ARDS. Patients can have lasting effects from being so sick. Most patients find that they are weak and have breathing problems. Some patients get better over several months, while others find that they continue to have limitations for the rest of their lives. Patients and family members may also feel depressed, and some patients have disturbing memories associated with the trauma of being so seriously ill. Many ARDS survivors need ongoing care, including mental health support and physical or occupational therapy.
