Neurally Adjusted Ventilatory Assist Improves Patient-Ventilator Synchrony in a Patient With Tetanus and Unstable Diaphragmatic Electrical Activity

Abstract

A 79-y-old man with generalized tetanus was admitted to the ICU. A left-forearm wound was surgically debrided, and the wound was closed. On postoperative day 1, after the patient experienced opisthotonos and convulsions, endotracheal intubation was performed. Propofol and diazepam were infused but failed to stop the convulsions. Morphine, midazolam, dantrolene, and rocuronium were used to ameliorate the muscle spasms. Magnesium sulfate was also infused. On postoperative day 15, patient-ventilator asynchrony was apparent. The patient showed recurrent tachypnea and bradypnea, which seemed typical of Cheyne-Stokes respiration. A neurally adjusted ventilatory assist (NAVA) catheter was inserted transnasally, and electrical activity of the diaphragm (E di ) was monitored. Readings showed regular attempts to breathe at 40 -50 breaths/min with periodic changes in E di amplitude. NAVA mode improved patient-ventilator synchrony. Periodic breathing continued for 2 weeks. We stopped monitoring E di on postoperative day 39. He began respiratory rehabilitation and was transferred to a hospital for rehabilitation on postoperative day 80. We encountered periodic respiration in a patient with tetanus. E di monitoring revealed periodic amplitude change. The cause of the periodic breathing pattern in this patient could not be determined but may be attributable to side effects of the pharmacologic interventions or the natural history of the disease itself. NAVA mode improved patient-ventilator synchrony.

Neonatal tetanus

“…Morphine sulfate (0.5-1.0 mg/kg/hour, continuous IV infusion) is frequently used to sedate and control the autonomic dysfunction by diminishing cardiac and vascular sympathetic tone. This drug adjusts cardiac instability without compromising 24) . Only magnesium sulfate has been evaluated in a randomized clinical trial of severe tetanus 25) , and in several series for managing spasm including NT [26][27][28][29] .…”