Download LifeMed Alaska 2016 63 SEDATION AND ANALGESIA FOR THE

LifeMed Alaska SEDATION AND ANALGESIA FOR THE INTUBATED PATIENT 2017 SCOPE The use of medications to appropriately maintain an artificial airway in a patient who requires that level of airway control and mechanical ventilation. Can also help to facilitate mechanical ventilatory support to maximize oxygenation and ventilation SPECIAL CONSIDERATIONS 1. Titrate infusions and dosing to meet the sedation and analgesia needs of the patient 2. Consider what the patient is already receiving at a referring facility and use their infusions if appropriate. 3. Always assure adequate sedation and analgesia when patient is chemically paralyzed 4. Patient may require higher doses than those outlined above to achieve adequate sedation. Contact Medical control as needed. INSTRUCTIONS: 1. FENTANYL BOLUS DOSING: 50-­‐‑100 mcg IV every 20 min PRN sedation/analgesia. May dilute FENTANYL to 10 mcg/ml to facilitate dosing (See below) CONTINUOUS INFUSION DOSING: 1-­‐‑3 mcg/kg/hr IV INFUSION CONCENTRATION: 10 mcg/ml o DILUTION: § FENTANYL (50 mcg/ml) MIX: FENTANYL 300 mcg (6 ml) in 24 ml NS Final concentration: 10 mcg/ml (total 30 ml) ADDITIONAL BOLUSES: Use additional boluses (0.5-­‐‑1 mcg/kg max 50 mcg) IV every 10 min while receiving continuous infusion to increase level of sedation then may increase infusion rate if needed. • • • Rapid administration may result in rigid chest syndrome, reversible by paralytic agent or NALOXONE. Less cardiac effects than MIDAZOLAM No need to use FENTANYL and MORPHINE concurrently 2. MORPHINE BOLUS DOSING: 0.1-­‐‑0.2 mg/kg (max 10 mg) IV every 30 min CONTINUOUS INFUSION DOSING: 0.01-­‐‑0.1 mg/kg/hr INFUSION CONCENTRATION: 1 mg/ml 64 LifeMed Alaska 2017 ADDITIONAL BOLUSES: Use additional boluses (0.05-­‐‑0.1 mg/kg, max dose 2 mg) IV every 10 min while receiving continuous infusion to increase the level of sedation then may increase the infusion rate if needed. • • MORPHINE may release histamine, thus may decrease BP and cause puritis and dysphoria. Treat with DIPHENHYDRAMINE. No need to use MORPHINE and FENTANYL concurrently 2. KETAMINE BOLUS DOSING: 0.5-­‐‑1.5 mg/kg IV (max 50 mg for 1st bolus ONLY) every 10 minutes PRN CONTINUOUS INFUSION DOSING: 0.5-­‐‑1.5 mg/kg/hr IV • • May cause tachycardia and hypertension. Do not use in cases of CVA, angina, increased intraocular pressure, cardiac ischemia, or hypertension. May cause transient rise in ICP, nausea/vomiting, excess secretions, and emergence reactions. 4. MIDAZOLAM BOLUS DOSING: 0.01-­‐‑0.1 mg/kg (max 5 mg) IV every 30 min PRN sedation • • CONTINUOUS INFUSION DOSING: 0.1-­‐‑0.2 mg/kg/hr IV INFUSION CONCENTRATION: 1 mg/ml or may dilute further in D5W or NS (or use infusion provided by referring hospital) ADDITIONAL BOLUSES: Use additional boluses (0.05-­‐‑0.1 mg/kg, max 2 mg) IV every 10 min while receiving continuous infusion to increase level of sedation then may increase infusion rate if needed. No need to use MIDAZOLAM and LORAZEPAM concurrently Beware of hypotension 5. LORAZEPAM BOLUS: 0.05-­‐‑0.1 mg/kg (max 4 mg) IV every 1 hours PRN sedation • May cause hypotension • No need to use LORAZEPAM and MIDAZOLAM concurrently 6. PROPOFOL Use only in intubated patients in whom PROPOFOL has been initiated as an infusion at a referring facility. Receive enough additional medication for completion of the transport. CONTINUOUS INFUSION DOSING: 20-­‐‑150 mcg/kg/min IV 65 LifeMed Alaska • • • 2017 Usual dose required 20-­‐‑60 mcg/kg/min Elderly patients: Use 80% of healthy adult doses given below. Use of concurrent FENTANYL IV can provide analgesia and provide sedative effect allowing for reduction in PROPOFOL dosing without contributing to hypotension. INFUSION TITRATION: increase and decrease infusion rate by 10-­‐‑20 mcg/kg/min as needed to maintain sedation level. • • • Increase: if 1 or 2 additional boluses not effective at helping to maintain adequate sedation Decrease: if hypotension ADDITIONAL BOLUSES: Use additional boluses (0.5-­‐‑1 mg/kg, up to 40 mg) IV to rapidly achieve increased sedation level. May cause hypotension-­‐‑ maintain adequate intravascular volume SIDE EFFECTS: • • • • • • • Hypotension: treat with fluid bolus if mild and decreasing infusion rate if persists. Bradycardia: treat with decreased infusion rate if clinically significant Myocardial depression: stop infusion if significant hemodynamic instability. Myoclonus: treat with paralytic only if severe Urine discoloration: green CONTRAINDICATIONS AND PRECUATIONS: Severe shock Heart failure CHEMICAL PARALYSIS 1. ROCURONIUM 1 mg/kg IV PRN required paralysis • Use only if required to cease dangerous movement, to facilitate adequate mechanical ventilation or to reduce respiratory muscle energy expenditure. Always use adjunctive sedative and analgesic medications. 66