Download Patient Monitoring and Documentation

Patient Monitoring and Documentation
Interaction Level 1: patient should be able to communicate presence of pain or anxiety.
This should correspond approximately to a VICS interaction score of at or above 24/30.
If the patient is agitated but is unable to communicate presence of pain or anxiety call MD to assess
patient for delirium.
Documentation:
1) VICS q4h on ALL patients
2) VICS pre and post intervention to treat pain, agitation/delirium or anxiety
3) Pain Intensity with Numeric Rating Scale (0-10) pre and post intervention to relieve pain
4) In patients who cannot communicate presence of pain, document clearly in the SAD record
perceived signs of pain that trigger intervention.
Analgesia



Administer 5 MIN prior to procedures that may cause pain (to allow time for drug to act; 80% of
peak effect is reached in approx 5 MIN)
To relieve pain in patients who communicate need for intervention
To treat signs of pain in patients who cannot communicate but pain is suspected given clinical
situation. Review signs of inferred pain with MD q4h.
Bolus morphine 0.5 mg, 1 mg, 2mg, 4mg, 6mg Q 5 MIN prn until effect or adverse event seen
(e.g. hypotension)
Assessment:
1) Assess patient’s response 5 MIN following each dose.
 Goal is to reduce patient’s pain intensity rating to
3/10 (NOT 0 / 10) or as patient directs
2) If administering analgesia to patients who cannot communicate presence of pain but pain is
suspected given clinical situation
 Review with MD signs of perceived pain that trigger intervention
Q4H or earlier if signs are not corrected.
Call MD if infusion considered necessary after 6 hrs of bolus therapy
At this time discuss with MD role of:
1) Non-narcotic analgesia: Tylenol or NSAID
2) Whether epidural analgesia is appropriate
Peri-procedural sedation



Explain procedure to patient as fully as possible
Administer 3 MIN prior to procedure
Find minimal effective dose
Bolus midazolam 0.5 mg, 1mg, 2mg, 4 mg, 6 mg IV Q 3 MIN prn
Anxiety
Patient must be able to confirm that they are anxious
Enquire into source of anxiety and provide reassurance
Lorazepam 0.5 mg to 1mg SL/IV Q4H PRN x 24h
Delirium
Delirium is characterized by:
Inattention & fluctuating interaction WITH EITHER
disorientation OR agitation OR withdrawn; hallucinations may be present
Physician should rule out agitation due to: withdrawal from alcohol, sedatives, analgesics or nicotine; or
other reversible causes (e.g. suboptimal ventilator settings or metabolic disturbances).
For delirium that is not associated with alcohol or other withdrawal states:
 Discontinue opioids and benzodiazepines if possible
 Reassure and re-orientate patient to environment (ensure access to eyeglasses/ hearing aids if
applicable)
Use the pre-printed orders “ICU orders for delirium”
Physician to order either:
Haloperidol 2.5 mg to 10 mg IV Q 20 to 30 MIN prn
 Dose may also be on a fixed schedule e.g. 1 mg to 5 mg IV/NG bid.
 If it is ordered on a prn schedule a maximum dose should be specified over a
12 hr interval e.g. 40 mg.
 If maximum dose is reached medical team needs to review and justify continuation
OR
Methotrimeprazine 5 mg to 25 mg IV Q 20 to 30 MIN prn
 If ineffective (dosing level 5 reached) or symptoms worsening call MD to reassess
 reassess with MD if patient received 150 mg in a 12 hr interval
ESCALATING REGIMEN FOR HALOPERIDOL AND METHOTRIMEPRAZINE (NOZINAN)
Dosing level 1 to 3 can be given 20 mins apart if needed
.
Dosing Level
Haloperidol IV Q 30 MIN (mg)
Methotrimeprazine (Nozinan )
IV Q 30 MIN (mg)
1
2.5
5
2
5
12.5
3
5
12.5
4
10
25
5
10
25
If at any time agitation is dangerous to patient or caregiver
call MD for a midazolam bolus order
ADVERSE EVENT MONITORING
1) Measure QT and RR interval from rhythm strip before first dose of haloperidol
2) Use Table 1 to determine QTc.
3) Measure QT and RR interval from rhythm strip before each dose successive of haloperidol.
4) Discontinue haloperidol if QTc increases by 25% from baseline.
5) Observe and assess patients for any signs of stiffness or parkinsonian-like effect or hypotension
( with methotrimeprazine ).
MAINTENANCE REGIMEN
For escalating haloperidol or methotrimeprazine regimen, the following applies:
If a patient’s target symptoms are corrected call MD to write a maintenance regimen.
 Add up first 24-hour dose requirement.
 Give 50% of this dose over the next 24 hours in 4 divided doses i.e. Q6H
 Reduce maintenance dose by 25% each day if patient’s symptoms remain controlled.
 Continue prn regimen as needed for breakthrough agitation that is presumed due to delirium .
Sedation for physiologic goals
Monitoring
Document VICS score q4h
Infusion rates must be reassessed q 6h and adjusted accordingly; reduce by 25% if clinical goals are met
Medical team must perform daily review and justify continued need for sedation goals
Sedation goals
1) O2 demand during shock state
2) prevent patient movement
3) other as specified on order
OR
OR
Midazolam 1 mg, 2 mg, 4mg, 6mg IV Q3 MIN prn
Refer to table on infusion titration to determine if an infusion should be started
To suppress respiratory drive (that is associated with  O2 sat)
Morphine 1 mg, 2mg, 4mg, 6mg Q 3 MIN prn
With
Midazolam 1 mg, 2 mg, 4mg, 6mg IV Q3 MIN prn
If ineffective or if BP falls call MD
If effective refer to table on infusion titration to determine if an infusion should be started
Sedation and analgesia in patients with elevated ICP
1. Ensure that Head Injury Protocol has been instituted.
2. Start morphine and midazolam infusions at rate ordered.
ICP IS ELEVATED (>20mmHg)  IS IT RELATED TO NOXIOUS STIMULI?
a)YES
b)NO
1) Remove stimulus
2) Pre-medicate patient with
midazolam prior to future
planned non-painful stimuli
(use morphine if painful)
3) If ordered and ICP remains
elevated despite removal of
stimulus follow guidelines for
procedural boluses of
midazolam to treat this
episode of ICP elevation
4) If ICP >20 for > 5 MIN

1. Open drain and
leave open x 5
minutes.
2. Review head injury
protocol
>20 for < 5 MIN

5) Do not increase infusion
rates based on procedural
boluses.
NO ACTION
c) NO
>20 for > 5 MIN

1) Open drain and leave open
x 5 minutes.
2) Call MD to determine
management
3) Review head injury
protocol
Sedation and analgesia prior to initiation of neuromuscular blockade


Titrate analgesia to achieve pain relief prior to starting neuromuscular blockade.
Ensure patient is deeply sedated so that they are unarousable, with in addition, no
physiologic (HR/BP) response to stimuli.
Midazolam bolus 1, 2mg, 4mg, 6 mg IV Q 3 MIN to achieve unarousable state
and no response to physiologic stimuli then start midazolam infusion 5 to 10 mg/hr as
needed (refer to table on infusion titration).
Maintenance protocol for titration of morphine and midazolam infusions
TO DETERMINE INITIAL RATE OF MORPHINE OR MIDAZOLAM INFUSIONS
AND SUBSEQUENT RATE INCREASES:
TO START
FIRST 6 HOURS: Total
amount of drug patient
responded to (not including
procedural boluses):
<6mg
6-12mg
13-18mg
19-30mg
>30mg
Initial rate - mg/hr
No infusion
No infusion
1
2
3
SUBSEQUENT ADJUSTMENT
Total bolus doses given in last
6 hours (not including
procedural boluses)
<6mg
6-12mg
13-18mg
19-25mg
>25mg

For physiologic goals, may start an infusion (if ordered) within 6 hours
1)
2)
3)
4)
Titrate to minimal effective dose
Infusion rates must be reassessed q 6h
Reduce by 25% if clinical goals are met.
If infusion rate is 1mg/h discontinue infusion and use bolus prn.
Rate increase –
mg/hr
0
1
2
3
4
Vancouver General Hospital ICU
Protocols for sedation, analgesia and delirium
Last revision date: May 2006