Transcript Sedation, Analgesia and Tapering Guidelines for Endotracheally

Sedation, Analgesia and Tapering Guidelines for Endotracheally intubated patients
Routine daily patient assessment:
*Review patient’s sedation and analgesia goals with multi-disciplinary team
** GOALS: Patient comfort and
cooperation where possible
1st line - Non-pharmacological measures:
Self Report - Wong-Baker Faces pain scale
Observed - Comfort Score: 8-16 Deep; 1726 Optimal; 27-40 inadequate
Assess scores Q 4h & prn 6
e.g.  NOISE, optimize environment, patient position,
lighting, encourage family to participate in patient
orientation, therapeutic touch, calming music.
*NB. These guidelines do
NOT apply to patients
managed under the APS
service
Goals achieved? **
Rule out and correct
reversible causes
No
Discontinuation/Da
ily Interruption of
sedation
Evaluate daily
for suitability of:
Yes
Tapering
Sedation
Pain or
Agitation?
Agitation
Pain
1st line
1st line
Intermittent Opioid:
Morphine: 0.05-0.1 mg/kg Q 1-4 h IV
prn, (max 5mg/dose)
Or
Fentanyl : 1-2 mcg/kg Q1-2 h prn
Goals?
2nd line
Regular acetaminophen
and/or NSAIDs if not
contraindicated5
Intermittent Lorazepam
0.05-0.1 mg/kg Q 1-4 h IV prn,
Max 4mg/dose
Add opioid
Goals?
Goals?
Add benzodiazepine
If requiring prn’s
more frequent than
Q2h
If requiring prn’s
more frequent than
Q2h
Opioid infusion
Morphine: 10-100 mcg/kg/h
OR
Fentanyl: 1-5 mcg/kg/h or convert
to morphine equivalent
2nd line
Consider adjunctive medications:
1. For additional sedation: Chloral Hydrate,
25-50 mg/kg po/pr, Q6 h prn or regularly;
max 500 mg/dose
2. Antihistamine for pruritis Diphenhydramine: 0.5-1 mg/kg/dose Q6
3. For patients on opioids, start regular
lactulose and/or senna on day 1
Midazolam
Infusion: 1-3 mcg/kg/min infusion (max 6
mcg/kg/min)
and 0.05 – 0.1 mg/kg Q1h prn boluses
(D/C lorazepam)
Important Notes:
1) The objective is to maintain goals with minimum pharmacologic therapy. 1st line therapy is a single agent (for analgesia/sedation).
2) 2nd line therapy is to progress to infusion of single agent (if requiring prns more frequently than Q2h) and/or add a second agent,
according to goals for analgesia vs sedation
3) Evaluate goals frequently. Evaluate patient daily for discontinuation/interruption or tapering of sedation.
4) Fentanyl is preferable if patient is hemodynamically unstable or has adverse effects with morphine.
5) Avoid NSAIDs in patients at increased risk of bleeding or renal dysfunction.
6) Frequency of Scoring: Q 4h and prn. Document score(s) prior to and 30 mins post bolus dose or escalation in infusion
7) Doses provided are general guidelines – patients may require higher doses, and alternative medication than those recommended
here. For larger children & adolescents – beware of absolute dose.
8) Ensure patient is adequately sedated and the intermittent doses are optimized BEFORE increasing infusions.
Draft version April 22 2010
Goals?
Daily Interruption of Sedation (DIS) and Tapering Guidelines
1st line: non-pharmacological measures, rule out
reversible causes of agitation/pain
* Individualize
Patient Goals
Higher risk of withdrawal
Lower risk of withdrawal
yes
yes
Institute DIS**
Reduce IVI rate by 50%
Q am: Hold all IVI sedative infusions.
Continue intermittent sedatives as
(you may drop to this dose at once,
or wean over 1st 24h)
needed
Initiate WAT scoring
( > 5 -7 days continuous IVI/ high
cumulative dose)
(≤ 5 days continuous IVI)
3Wean
IVI by 20% of baseline
rate Q4-24h as tolerated
End-points (any 1 of the following):
• ≥ prns in 3 h
•1WAT-1 > 3
•Cardioresp instability
•Ventilator dysynchrony
yes
Despite
prn
dose(s)
Patient is in withdrawal
Administer prn doses
benzo/opioid to treat symptoms
Resume IVI sedative
infusion(s) at 50% original
rate. Adjust dose to achieve
patient goals.
** Patient is not eligible for DIS if:
1.Currently receiving muscle relaxants
2.Risk of withdrawal.
3.Continuous IVI sedation for any of the following: seizure control, ICP control,
palliative/comfort care, active cooling protocol
4.Baseline persistent (not periodic) discomfort/agitation
Important notes:
•1 If patient is at risk of withdrawal, initiate WAT-1 scoring Q 4 hrly and prn until < 3 xs 2
•2Weaning dose range: 10-50% of peak dose Q4-24h
•3Individualize duration of taper
•41st line, non-pharmacological. For delirium: Chlorpromazine: 0.5-1 mg/kg IV q6h prn (initial
max 25 mg/dose). For sleep disorder: consult MRP & PCCU pharmacist
Draft version April 22 2010
Resume/Increase background
infusion rate by 20%/more to
achieve target
WAT-1 score ≤ 3 or patient
requires < 4 prn doses/day
yes
Resume tapering algorithm
Consider delirium and/or
sleep disorder
yes
Comfort Scale: (Score after a 2 min period of observation)
fre
PAIN Scales: use to supplement the COMFORT scale, in patients who are cognitively and
physically able to respond (e.g. age ≥ 3 years)
Draft version April 22 2010
DAILY INTERRUPTION OF SEDATION (DIS)
What is DIS = focused downward titration of sedatives over time
Objectives: daily “wake-up”; minimize pharmacological intervention and prevent adverse events;
optimise patient outcomes
Rationale: DIS in adults has been shown to facilitate spontaneous breathing, and has been associated
with decreased mortality, hospital stay, withdrawal and delirium, improved ventilator free days and
psychological outcomes
Patient is not eligible for DIS if:
1.Currently receiving muscle relaxants
2.Risk of opioid/sedation withdrawal.
3.Continuous IVI sedation for:
• seizure control
• ICP control
• palliative/comfort care
• active cooling protocol
4.Baseline persistent (not periodic) discomfort/agitation
Draft version April 22 2010