ABSTRACT
Introduction: Weaning from mechanical ventilation remains a major challenge in the ICU setting. Recent studies have found that delirium is associated with difficult and prolonged weaning (1). Moreover, anxiety and agitation secondary to perceived dyspnea or "air hunger" are among common causes contributing to difficulty weaning. A recent meta-analysis supported the use of dexmedetomidine in ICU patients with extubation failure but recognized its major side effect of hypotension (2). Less robust evidence exists for the use of loxapine, quetiapine, valproic acid, and clonidine to facilitate mechanical ventilation weaning. In this case series, we describe ten cases of delirious, agitated, difficult-to-wean patients in the ICU who were trialed on Aripiprazole with the aim of facilitating mechanical ventilation weaning and reducing agitation. Method(s): An Aripiprazole trial was considered successful if it reduced agitation or anxiety associated with vent weaning based on expert evaluation by a CL psychiatrist. Result(s): Most of the patients in this case series were intubated due to respiratory failure secondary to COVID pneumonia (age range 28 to 66 years). 8 out of 10 patients had significantly reduced agitation/anxiety with aripiprazole after having failed other medication trials which included benzodiazepines, other atypical antipsychotics, antidepressants, gabapentin, buspirone, valproate, or antihistamines. Most of them responded at a dose of 30mg daily after having been intubated for more than 14 days. 5 out of 10 subjects were eventually extubated, most within 5 days of aripiprazole initiation. Discussion(s): Aripiprazole is a unique antipsychotic in view of its partial dopamine agonism. In addition, its limited anticholinergic and antihistaminergic properties reduce its sedating effects which may allow more active participation from patients. This different psychopharmacologic profile might explain its preliminary superiority over other antipsychotics in reducing vent-associated agitation or anxiety. References: 1. Jeon K, Jeong BH, Ko MG, Nam J, Yoo H, Chung CR, et al. Impact of delirium on weaning from mechanical ventilation in medical patients. Respirology. 2016;21(2):313-20. Epub 2015/11/05. PubMed PMID: 26534738. 2. Buckley MS, Smithburger PL, Wong A, Fraser GL, Reade MC, Klein-Fedyshin M, et al. Dexmedetomidine for Facilitating Mechanical Ventilation Extubation in Difficult-to-Wean ICU Patients: Systematic Review and Meta-Analysis of Clinical Trials. J Intensive Care Med. 2021;36(8):925-36. Epub 2020/07/07. PubMed PMID: 32627672. Copyright © 2022