Assistant Professor UT health/TIRR Memorial Hermann Houston, Texas, United States
Case Diagnosis: Hypoxic brain injury secondary to cardiac arrest during epidural injection for chronic pain management.
Case Description: A 57-year-old man with history of CRPS and spinal stenosis presented with a hypoxic brain injury following a cardiac arrest from a T1 epidural injection. He was admitted to a disorders of consciousness (DOC) program at TIRR Memorial Hermann after being intubated and mechanically ventilated for functional rehabilitation and ventilator weaning. This patient tolerated 3 hours of physical, occupational and speech therapy per day, while PM&R managed ventilatory recovery to achieve functional goals. The patient was successfully weaned from mechanical ventilation and was decannulated prior to discharge. The patient achieved his goals of developing a functional communication system, demonstrating ability to drive a power wheelchair with supervision, and maintaining 4 hours twice daily of power wheelchair use.
Discussions: There is ongoing research showing the benefits of early interventions with physical, speech and occupational therapies in the DOC population. Ventilator status is often an exclusion criteria for admission to inpatient rehabilitation. This case illustrates the benefits of weaning mechanical ventilation during the inpatient stay. TIRR Memorial Hermann uses a weaning protocol that begins by performing a spontaneous breathing trial on days 1-2. Further efforts commence in 3 phases. Phase 1 begins with a 2-day trial of the patient tolerating 1 and 2 hours twice daily without ventilation. Phase 2 consists of a 3-day trial of 6, 8 and 10 hours and phase 3 includes a trial of 12, 14, 16, 18, and 20 hours with concurrent use of a PMV or cap. Following a severe brain injury resulting in ventilator dependence, this patient successfully tolerated 3 hours of therapy while undergoing ventilatory weaning, achieving decannulation before discharge.
Conclusions: DOC patients admitted to inpatient rehabilitation while on mechanical ventilation can achieve similar functional goals to those admitted without mechanical ventilation.
