Professional Documents
Culture Documents
No
Is patient comfortable and at goal for Sedation and Analgesics?
Yes
Rule out/correct reversible causes Use nonpharmacologic treatment Optimize the environment
Reassess goal daily Titrate and taper therapy to maintain goal Perform awakening trial, if appropriate
Pain
Is patient in pain? Use pain scale to assess patient Set goal for analgesia
Hemodynamically Stable - FentaNYL - HYDROmorphone - Morphine Hemodynamically Unstable - FentaNYL Renal Impairment - FentaNYL - HYDROmorphone
Signs & Symptoms of Opiate Withdrawal Pupil dilation Vomiting Primary approach for Sweating Diarrhea pain: bolus for pain Lacrimation Hypertension control and then infusion Rhinorrhoea Fever to sustain control. Piloerection Tachypnea Tachycardia Agitation TITRATING OFF INFUSIONS: The potential for opioids withdrawal should be considered for patients receiving high doses or seven (7) days of continuous therapy. Doses should be tapered systematically (i.e. 10-30% per day) to prevent withdrawal symptoms.
- FentaNYL infusion at 25 50 mcg/hr - HYDROmorphone infusion at 0.4 0.8 mg/hr - Morphine infusion at 2 4 mg/hr
Sedation
DRUG SELECTION: Anticipate sedation (< 72 hours) - Midazolam Is patient agitated / anxious? Consider - Propofol Use scale to assess patient potential causes - Dexmedetomidine Set goal for sedation Anticipate sedation (> 72 hours) - LORazepam TARGET: Patient has renal impairment Richmond Agitation Sedation Scale (RASS): 0 to -3 - LORazepam Riker Sedation-Agitation Scale (SAS): 3 to 4 - Propofol SEDATION: Use for RASS greater or equal to 2 levels below what is ordered (e.g., RASS of -2 with an ordered goal of 0) 1.) LORazepam/midazolam continuous infusion: Hold infusion until patient reaches RASS goal, then resume at one-half previous rate. Titrate per written orders. 2.) Propofol continuous infusion: Decrease rate 5-10 mcg/kg/min every 10 minutes until patient reaches RASS goal. Titrate per written orders. 3.) Morphine/HYDROmorphone/fentaNYL continuous infusion: Hold until patient reaches RASS goal, then resume at one-half previous rate. Titrate per written orders.
Delirium
Non-Pharmacologic Treatments for Delirium: Ensure Daily Awakening Trials conducted Continually reorient patient Perform early mobilization Promote effective sleep / awake cycles Perform timely removal of catheters/physical restraints - Ensure the use of eyeglasses, magnifying lenses, and hearing aids - Minimize noise/stimulation at night - Minimize Benzodiazepines for sedation
NPO: Dexmedetomidine 0.2-1.5 mcg/kg/hr (Consider in patients failing spontaneous breathing trials secondary to agitation) Is patient delirious? Consider potential Haloperidol 2.5-5mg IV q 15 min prn + delirium (suggested max 35 mg/ causes Use scale to assess patient day) (Consider decreased dose in hypoactive delirium) PO: Aripiprazole 10-15 mg po daily (Consider when baseline QTc>440 msec) Confusion Assessment Method for the ICU (CAM-ICU) Intensive Care Delirium Screening Checklist (ICDSC) Haloperidol 2.5-5 mg po q6 hr (Caution if baseline QTc >440 msec)
NOTE: Provided dosing ranges are general guidelines and are not intended to supersede clinical judgment of prescriber.
QUEtiapine 50-200 mg po q12 hr (Consider if sedative properties desired) Risperidone 0.5-1 mg po q12 hr (Caution baseline QTc >440 msec)
Repeat boluses until pain controlled. If the patient requires >2 boluses in an hour, increase rate by _______ mcg/hr (e.g., 12.525 mcg/hr) every hour. Maximum dosage = _______ mcg/hr (e.g., 100200 mcg/hr). Notify physician for oversedation or when target pain score not achieved at maximum dosage.
_________________________________________________________________________________________________
Repeat boluses until pain controlled. If the patient requires >2 boluses in an hour, increase rate _______ mg/hr (e.g., 0.2 0.4 mg/hr) every hour. Maximum dosage = _______ mg/hr (e.g., 3 mg/hr). Notify physician for oversedation or when target pain score not achieved at maximum dosage.
_________________________________________________________________________________________________
MORPHINE CONTINUOUS INFUSION (Avoid in patients with cardiovascular instability or renal impairment)
Morphine infusion at _______ mg/hr (e.g., 24 mg/hr) A. Morphine bolus at _______ mg (e.g., 1 mg) IV every 10 minutes prn pain score 2-3 (mild pain). B. Morphine bolus at _______ mg (e.g., 2 mg) IV every 10 minutes prn pain score 4-6 (moderate pain). C. Morphine bolus at _______ mg (e.g., 4 mg) IV every 10 minutes prn pain score 7-8 (severe pain).
Repeat boluses until pain controlled. If the patient requires >2 boluses in an hour, increase rate by _______ mg/hr (e.g., 12 mg/hr) every hour. Maximum dosage = _______ mg/hr (e.g., 10 mg/hr). Notify physician for oversedation or when target pain score not achieved at maximum dosage.
Alert Smiling
No Pain
Can be ignored
*Adapted from: Hockenberry MJ, Wilson D: Wongs essentials of pediatric nursing, ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby. **Adapted from: Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline No. 1. AHCPR Publication No. 92-0032: February 1992; Agency for Healthcare Research & Quality, MD; 116-117.
FACIAL EXPRESSION Score 0 1 2 ACTIVITY Score 0 1 Description Lying quietly, normal position Seeking attention through movement or slow cautious movement Description No particular smile or expression Occasional grimace, tearing, frowning, and/or wrinkled forehead Frequent grimacing, tearing, frowning, and/or wrinkled forehead
Restless excessive activity and/or withdrawal reflexes 2 GUARDING Score Description Lying quietly, no positioning of hands over area of body 0 Splitting areas of the body, tense 1 Rigid, stiff 2 PHYSIOLOGIC PARAMETER Score 0 1 Description Stable vital signs Change over past 4 hours in any of the following SBP > 20mmHg or heart rate > 20 bpm Change over past 4 hours in any of the following 2 SBP > 30mmHg or heart rate > 26 bpm RESPIRATORY Score 0 1 2 Description Baseline respiratory rate/oxygen saturation, compliant with ventilator RR > 10 above baseline or 5% decrease in oxygen saturation, mild ventilator asynchrony RR > 20 above baseline or 10% decrease in oxygen saturation, mild ventilator asynchrony Target Pain: 0-1
SCORE:
0 1
No muscle tension observed Presence of frowning, brow lowering, orbit tightening and levator contraction or any other change (e.g. opening eyes or tearing during nociceptive procedures) All previous facial movements plus eyelid tightly closed (the patient may present with mouth open or biting the endotracheal tube)
Grimacing
Body movements
(Puntillo et al., 1997; Devlin et al., 1999)
Does not move at all (doesnt necessarily mean absence of pain) or normal position (movements not aimed toward the pain site or not made for the purpose of protection) Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed Alarms not activated, easy ventilation Coughing, alarms may be activated but stop spontaneously Asynchrony: blocking ventilation, alarms frequently activated Talking in normal tone or no sound Sighing, moaning Crying out, sobbing No resistance to passive movements Resistance to passive movements Strong resistance to passive movements, incapacity to complete them Target Pain: 0 - 1 For the rating of the CPOT, the patient should be attributed the highest score observed during the observation period. The patient should be attributed a score for each behavior included in the CPOT and muscle tension should be evaluated last, especially when the patient is at rest because just the stimulation of touch (passive flexion and extension of the arm) may lead to behavioral reactions.
1 2
Tolerating ventilator or movement Coughing but tolerating Fighting ventilator Talking in normal tone or no sound Sighing, moaning Crying out, sobbing
0 1 2 0 1 2 0 1 2
__ 4.
OR
Muscle tension
Relaxed
Evaluation by passive flexion and Tense, rigid extension of upper limbs when patient is at rest (Ambuel et al., 1992) Very tense or rigid or when patient is being turned SCORE: Directions for use of the CPOT: 1. The patient must be observed at rest for one minute to obtain a baseline value of the CPOT. 2. The patient should be observed during nociceptive procedures (e.g., turning, endotracheal suctioning, wound dressing) to detect any changes in the patients behaviors to pain. 3. The patient should be evaluated before and at the peak effect of an analgesic agent to assess if the treatment was effective in relieving pain.
5.
Lorazepam _________ mg (e.g., 0.5) IV every 20 minutes prn mild agitation (e.g., RASS +1 to +2), and Lorazepam _________ mg (e.g., 1 mg) IV every 20 minutes prn moderate/severe agitation (e.g., RASS +3 to +4). ________________________________________________________________________________________________
PROPOFOL (DIPRIVAN ) Infusion (Recommended for sedation <72 hours. Avoid in patients with cardiovascular instability.)
Start propofol IV infusion at _________ mcg/kg/min (e.g., 5-10 mcg/kg/min). Bolus (if checked above) with midazolam as directed or propofol _________ mg (0.03-0.15 mg/kg, max 10-20 mg) for breakthrough agitation Titrate propofol by _________ mcg/kg/min (e.g., 5-10 mcg/kg/min) every 5 minutes until target sedation score achieved. Maximum rate = _________ mcg/kg/min (e.g., 60 mcg/kg/min). Reduce infusion rate by for SBP < _________ mm Hg. Notify physician if patient has hemodynamic instability. Notify physician if target sedation score not achieved at maximum dosages. Oversedation: Wean Propofol by 10 mcg/kg/min every 10 min until sedation score at goal. (Oversedation patient exceeds target sedation scale.) _________________________________________________________________________________________________
MIDAZOLAM (VERSED ) Infusion (Recommended for sedation <72 hours. Not recommended in impaired renal function.
Start midazolam infusion at _________ mg/hr (e.g., 1 3 mg/hr). Bolus (if checked above) with midazolam as directed for breakthrough agitation/anxiety. If the patient requires >2 boluses in an hour, increase rate by _________ mg/hr (e.g., 1 2 mg/hr) every hour. Maximum infusion rate = _________ mg/hr (e.g., 10 mg/hr). Notify physician if target sedation score not achieved at maximum dosages. Oversedation: Hold infusion until sedation score at goal. Restart infusion at previous rate. _________________________________________________________________________________________________
PATIENTS FAILING SPONTANEOUS BREATHING TRIALS DUE TO AGITATION: DEXMEDETOMIDINE (PRECEDEX ) (Recommended for short-term use. Avoid in patients with cardiovascular instability.)
Start dexmedetomidine infusion at _________ mcg/kg/hr (e.g., 0.2 0.7 mcg/kg/hr). Bolus (if checked) with midazolam for breakthrough agitation as directed below. Titrate dexmedetomidine by _________ mcg/kg/hr (e.g., 0.1 0.2 mcg/kg/hr) every hour until target sedation score achieved. Maximum rate = _________ mcg/kg/hr (e.g., 1 1.5 mcg/kg/hr). Notify physician if patient has hemodynamic instability or if target sedation score not achieved at maximum dosages.
+4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and Calm -1 Drowsy -2 Light Sedation
Overtly combative, violent, immediate danger to staff Pulls or removes tube(s) or catheter(s); aggressive Frequent non-purposeful movement, fights ventilator Anxious but movements not aggressive vigorous
Not fully alert, but has sustained awakening (>10 seconds) (eye-opening/eye contact) to voice Briefly awakens with eye contact to voice (<10 seconds)
-3 Moderate Sedation Movement or eye opening to voice (but no eye contact) -4 Deep Sedation -5 Unarousable No response to voice, but movement or eye opening to physical stimulation No response to voice or physical stimulation
Procedure for RASS Assessment: The basis of the RASS assessment is to see what amount of stimulation is necessary to evoke a response and evaluate sedation. Observe patient. a. Patient is alert, restless, or agitated. (Score 0 to +4) If not alert, state patients name and say open eyes and look at (speaker). b. Patient awakens with sustained eye opening and eye contact. (Score 1) c. Patient awakens with eye opening and eye contact, but not sustained. (Score 2) d. Patient has any movement in response to voice but no eye contact. (Score 3) When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum. e. Patient has any movement to physical stimulation. (Score 4) f. Patient has no response to any stimulation. (Score 5)
Sessler CN, et al. (2002). The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med. Vol. 166. pp. 1338-1344. Ely EW, et al. (2003). Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA ; Vol. 289. pp. 2983-2991
7 6 5 4 3 2 1
Dangerous Agitation Very Agitated Agitated Calm and Cooperative Sedated Very Sedated Unarousable
Pulling at ET tube, trying to remove catheters, climbing over bedrail, striking at staff, thrashing side-to-side Requiring restraint and frequent verbal reminding of limits, biting ETT Anxious or physically agitated, calms to verbal instructions Calm, easily arousable, follows commands Difficult to arouse but awakens to verbal stimuli or gentle shaking, follows simple commands but drifts off again Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously Minimal or no response to noxious stimuli, does not communicate or follow commands
Jacobi J, Fraser GL, Coursin DB, et al. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. Vol. 30, No. 1
Guidelines for SAS Assessment 1) Agitated patients are scored by their most severe degree of agitation as described 2) If patient is awake or awakens easily to voice (awaken means responds with voice or head shaking to a question or follows commands), that is a SAS 4 (same as calm and appropriate might even be napping). 3) If more stimuli such as shaking is required but patient eventually does awaken, that is SAS 3. 4) If patient arouses to stronger physical stimuli (may be noxious) but never awakens to the point of responding yes/no or following commands, that is a SAS 2. 5) Little or no response to noxious physical stimuli represents SAS 1 This helps separate sedated patients into those you can eventually wake up (SAS 3), those you can't awaken, but can arouse (SAS 2), and those you cant arouse (SAS 1).
ARIPIPRAZOLE (ABILIFY )
Aripiprazole _________ mg (e.g., 5 10 mg) PO daily OR _________mg (e.g., 9.75 mg) IM daily. Maximum daily recommended dose is 30 mg/day Monitor for QTc prolongation ________
QUETIAPINE (SEROQUEL )
Quetiapine _________ mg (e.g., 50 mg) PO every _________hours (e.g., 12 hours). Maximum daily recommended dose is 200 mg q12h. Monitor for QTc prolongation ________
DEXMEDETOMIDINE (PRECEDEX ) (Consider in patients failing spontaneous breathing trials secondary to agitation)
Loading dose _________ mcg (1 mcg/kg) over 20 min (not recommended due to risk of hypotension).
Start dexmedetomidine infusion at _________ mcg/kg/hr (e.g., 0.2 0.7 mcg/kg/hr). Titrate dexmedetomidine by _________mcg/kg/hr (e.g., 0.1 0.2 mcg/kg/hr) every hour until target sedation score achieved. Maximum rate = _________ mcg/kg/hr (e.g., 1 1.5 mcg/kg/hr). Notify physician if patient has hemodynamic instability or if target sedation score not achieved at maximum dosages.
Harvard CAM-ICU Flowsheet (by Houman Amirfarzan, M.D., Wes Ely, M.D.) Copyright 2003, Vanderbilt Medical Center
1A: Is the patient different than his/her baseline mental status? OR 1B: Has the patient had any fluctuation in mental status in the past 24 hours as evidenced by fluctuation on a sedation scale (e.g. RASS), GCS, or previous delirium assessment?
FEATURE 2: Inattention
Positive
Negative
First, attempt the Letters (ASE). If patient is able to perform this test and the score is clear, record this score and move to Feature 3. If patient is unable to perform this test or the score is unclear, then perform the Pictures ASE. If you perform both tests, use the ASE Pictures results to score this Feature. Score (out of 10): 2A: AUDITORY (Letter ASE) Record score (enter NT for not tested) Directions: Say to the patient, I am going to read you a series of 10 letters. Whenever you hear the letter A indicate by squeezing my hand. ____ Read letters from the following letter list in a normal tone: SAVEAHAART Scoring: Errors are counted when patient fails to squeeze on the letter A and when the patient squeezes on any letter other than A. 2B: VISUAL (Pictures - ASE) Record score (enter NT for not tested) Score (out of 10): Directions: Use the Picture Packets (A and B) on the next page. ____
Positive
Negative
Combined Score 3A: Yes/No Questions (3A + 3B): (Use either Set A or B, alternate on consecutive days if necessary): ____ (out of 5) Set A Set B 1. Will a stone float on water? 1. Will a leaf float on water? 2. Are there fish in the sea? 2. Are there elephants in the sea? 3. Does one pound weigh more than two pounds? 3. Do two pounds weigh more than one pound? 4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood? (Patient earns 1 point for each correct answer out of 4) 3A Score ____ 3B: Command Say to patient: Hold up this many fingers: (Examiner holds two fingers in front of patient) Now do the same thing with the other hand: (Not repeating the number of fingers). *If patient is unable to move both arms, for the second part of the command ask patient to Add one more finger) (Patient earns 1 point if able to successfully complete the entire command) 3B Score ____
Positive
Negative
Is the patients current level of consciousness anything other than alert such as vigilant, lethargic, or stupor (e.g., score on Richmond Agitation Sedation Scale other than 0 at time of assessment)? Alert Spontaneously fully aware of environment and interacts appropriately Vigilant Hyper alert Lethargic Drowsy but easily aroused, unaware of some elements in the environment, or not spontaneously interacting appropriately with the interviewer; becomes fully aware and appropriately interactive when prodded minimally Stupor Becomes incompletely aware when prodded strongly; can be aroused only by vigorous and repeated stimuli, and as soon as the stimulus ceases, stuporous subject lapses back into the unresponsive state. (Features 1 and 2 and either Feature 3 or 4): Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved. Overall CAM-ICU:
Positive
Negative
Packet A
Packet B
Directions: Say to the patient, Now I am going to show you some more pictures. Some of these you have already seen and some are new. Let me know whether or not you saw the picture before by nodding your head yes (demonstrate) or no (demonstrate). Then show 10 pictures (5 new, 5 repeat) for 3 seconds each (Step 2 of Packet A or B, depending upon which form was used in Step 1 above). Scoring: This test is scored by the number of correct yes or no answers during the second step (out of a possible 10). To improve the visibility for elderly patients, the images are printed on 6x10 buff colored paper and laminated with a matte finish. Note: If a patient wears glasses, make sure he/she has them on when attempting the Visual ASE.
Packet A
Packet B
HYDROmorphone (Dilaudid)
1.5-2 mg
0.2-3 mg/hr
20-30 min
3-4 hours
5-10x more potent than morphine. Avoid in hypotension. Active metabolite accumulates in renal dysfunction. May cause itching due to histamine release (not a true allergy). Decreases preload, which may be beneficial in pulmonary edema.
Morphine
10 mg
2-10 mg/hr
20-30 min
3-4 hours
NSAIDs (Parenteral) Infuse over 30 minutes. Not to exceed 3200 mg/day. Black box warnings: Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk of serious cardiovascular thrombotic events. Risk may increase with duration of use. Contraindicated in setting of CABG. NSAIDs increase the risk of gastrointestinal adverse effects. Max adult dose 120 mg/day (60 mg/d in elderly or weight <50 kg). Do not use for >5 days. Avoid use in renal dysfunction. Monitor for gastrointestinal adverse effects. Black box warning: Nonsteroidal antiinflammatory drugs (NSAIDs) may increase the risk of serious cardiovascular thrombotic events. Contraindicated in setting of CABG.
Ibuprofen (Caldolor)
400-800 mg
IVPB over 30 mg
Not reported
6 hours
Ketorolac (Toradol)
15-60 mg
IV push
1-2 hours
4-6 hours
a b
Equivalent prices and doses are approximations and may vary due by institution and due to patient-specific differences in onset and duration of effect. Doses higher than recommended in the chart above may be required. Weight-based doses are reported for the following agents, but use may result in high infusion rates (fentaNYL 0.7-10 mcg/kg/hr, HYDROmorphone 7-15 mcg/kg/hr, morphine 0.07-0.5 mg/kg/hr). Based on clinical experience, more typical infusion rates are included in the table.
References: 1. Crit Care Med. 2008. Vol. 36. pp. 953-963. 2. Crit Care Med. 2002. Vol. 30: pp. 122-123.
Propofol (Diprivan)
5-80 mcg/kg/min
1-2 min
<20 min
Midazolam (Versed)
1-6 mg
1-10 mg/hr
5-10 min
1.5-2 hours
LORazepam (Ativan)
1-3 mg
1-5 mg/hr
15-20 min6
2-4 hours
Slower onset but longer duration. Risk of propylene glycol toxicity with high doses (anion-gap acidosis, Serum Creatinine, Lactate). Monitor serum osmolality if rate > 6 mg/hour and consider possible PG toxicity if osmol gap >10-15 3-5
LORazepam is associated with increased incidents of delirium.
Dexmedetomidine (Precedex)
0.2-1.5 mcg/kg/hr
30 min
2-4 hours
Limited data for use as a 1st line agent. FDA approved for use <24 hrs (studied up to 7 days in literature). FDA approved max dose = 0.7 mcg/kg/hr (studied up to 1.5 mcg/kg/hr). No respiratory depression - consider for patient failing spontaneous breathing trial due to agitation/anxiety. Dose/rate related hypotension and bradycardiabolus not recommended. May cause hyper/hypotension. Consider higher starting dose if used as monotherapy. Expensive.
a b
Equivalent prices and doses are approximations and may vary due by institution and due to patient-specific differences in onset and duration of effect. Midazolam and LORazapem doses higher than recommended in the chart above may be required. Weight-based doses are reported for the following agents, but use may result in high bolus doses and infusion rates (Midazolam bolus 0.02-0.08 mg/kg and infusion 0.04-0.2 mg/kg/hr; LORazepam bolus 0.02-0.06 mg/kg and infusion 0.01-0.1 mg/kg/hr). Based on clinical experience, more typical bolus doses and infusion rates are included in the table.
References: 1. Crit Care Med. (2008). Vol. 36: pp. 953-963. (for all references unless indicated otherwise) 2. Crit Care Med. (2002). Vol. 30: pp. 122-123. 3. Yahwak. Chest. (2003). Vol. 124. pp. 178S. 4. Arroliga. CCM. (2004). Vol. 32: pp. 1709. 5. Barnes. Pharmacotherap. (2006). Vol. 26: pp. 23. 6. Micromedex. LORazepam monograph. (Oct 2009).
Metabolism
Sedation
Anticholinergic Effects
Orthostatic Hypotension
Black Box Warning: Increased mortality seen when used in elderly patients with dementia-related psychosis due to cardiovascular or infectious complications. The use of these agents for delirium in ICU patients has not been tested in large, randomized, placebo-controlled trials. Haloperidol (Haldol) Tab, IV injection T:: 21 hrs Hepatic CYP3A4, 2D6 2 35* Low Low High Low Low
b
* Use heightened caution and be aware that there is a dose related QT interval prolongation and torsades de pointes (TdP) risk when using in excess of >20 mg per day. QUEtiapine (SEROquel)
c
Tab
CYP3A4
125
400
Moderate
Moderate
Low
Moderate
High
Risperidone (Risperdal)
CYP2D6, 3A4
Moderate
Low
High
Low
Moderate
Aripiprazole (Abilify)
CYP2D6, 3A4
30
Low
Low
Low
Low
Low
The following agents are NOT recommended for ICU use. Ziprasidone (Geodon)
d
Capsule
CYP3A4, 1A2
40
160
High
Low
High
Low
Moderate
OLANZapine (ZyPREXA)
CYP1A2
20
Low
Moderate
Low
Moderate
Low
a Low: 3-10 msec, Medium: 10-15 msec, High: > 15 msec b Increased with IV formulation c Caution: Bone marrow suppression; blood dyscrasias d Secondary to high risk for QT prolongation e Secondary to high risk for metabolic syndrome
1. Assess for Daily Awakening Exclusions: Increased Intracranial pressure issues Neuromuscular blockade Significant ventilation support required, such as very high PEEP (____), FiO2 (____) CABG immediate post-op Other site specific exclusionary criteria:
2. Perform Daily Awakening Wean / Stop sedation Consider decreasing narcotics infusion by 25-50% 3. Is Patient Awake and Calm? Use sedation scale (SAS 3-4 or RASS 0 to -1)?
- Take opportunity to assess patients pain - Titrate narcotics as needed for pain
If no, Restart Sedation at previous dose (No Rapid Shallow Breathing Index) If yes, proceed to Spontaneous Breathing Trial 4. Assess for Spontaneous Breathing Trial (SBT) (performed by RN and RCP) *** Patient must meet all criteria to proceed to conduct SBT*** Calm and co-operative (SAS score of 3 to 4; RASS 0 to -1) Hemodynamically stable PEEP < 8 FiO2 < 0.60 PH > 7.34 SpO2 > 90% 5. Conduct SBT for 1 Minute Mode CPAP PEEP = 0 Pressure support vent. at least 5 - 10 FIO2 unchanged After 1 minute, calculate Rapid Shallow Breathing Index (RSBI):
RSBI = Respiratory Rate/Tidal Volume in liters <105 = 80% success >105 = 95% failure
SBT Termination Criteria: Respiration Rate >35/minute for >5 minutes SpO2 < 90% for > 2 minutes New Ectopy Heart Rate change 20% from baseline Blood Pressure change 20% from baseline Accessory muscle use Increased anxiety/diaphoresis __________________ Return patients who fail a SBT to their previous ventilator settings and re-screen in 24 hours Discuss with MD prn vs. continuous sedation/pain
If RSBI successful, continue to conduct SBT for up to 2 hours If RSBI failure, return to previous ventilator settings 6. Conduct SBT for up to 2 hours and Continuously Reassess ~~~ Successful Completion SBT ~~~ Discuss Arterial Blood Gases and Extubation Plan with Physician
ICU Sedation 2009