Download Mechanical Ventilation Sedation Critical Care Orders

PLACE LABEL HERE
MECHANICAL VENTILATION SEDATION
CRITICAL CARE
ORDERS
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
1.
Assess and document Richmond Agitation Sedation Scale (RASS) q 2 hr. Maintain goal of: __________
Richmond Agitation Sedation Scale (RASS)
Score
Description
Definition
+4
Combative

Overtly combative, violent, immediate danger to staff
+3
Very Agitated

Pulls or removes tube(s) or catheter(s); aggressive
+2
Agitated

Frequent non-purposeful movements, fights ventilator
+1
Restless

Anxious, but movements are not aggressive, vigorous
0
Alert and Calm

Alert, able to follow simple commands
-1
Drowsy

Not fully alert, but has sustained awakening – eye opening/eye contact to
voice (>10 seconds)
-2
Light Sedation

Briefly awakens with eye contact to voice (<10 seconds)
-3
Moderate Sedation

Movement to eye opening or voice (but no eye contact)
-4
Deep Sedation

No response to voice, but movement or eye opening to physical stimulation
-5
Unarousable

No response to voice or physical stimulation
2.
Assess and document pain q 2 hrs
3.
Spontaneous awakening trial (SAT)

Sedation Vacation q 24 hrs between 0700 - 1200

Hold all sedative and narcotic infusions.

The goal of the sedation vacation is to achieve a RASS of -1 to 0

Coordinate SAT with respiratory therapy and physician

Check with the physician prior to performing SAT for patients with sedative infusions for active seizures, ethanol
withdraw (CIWA Score ≥ 10), excessive agitation, or requires FIO2 ≥ 50% or PEEP > 8cm H2O to maintain SpO2 ≥
88%

If re-sedation indicated (RASS of +2 or greater) and vacation over 4 hrs, change to intermittent sedation as
needed to maintain target score

If sedation vacation < 4 hrs, resume continuous infusion at ½ of original rate after a bolus dose
o
Exclude patients with High frequency ocilation ventilator (HFOV), Neuromuscular Blocking Agents,
Intracranial Pressure (ICP) monitoring or elevation, Uncontrolled arrhythmias, or Active myocardial
ischemia within the last 24 hrs
Order writer’s initials _______
Copy to pharmacy
*3-15395*
FORM 3-15395 REV. 12/2014
Page 1 of 2
MECHANICAL VENTILATION SEDATION
CRITICAL CARE
ORDERS
PLACE LABEL HERE
The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.
Initial all handwritten order modifications and the bottom of each page when indicated (multipage).
4.
 Do not perform wake-up assessment
 Perform wake-up assessment using guidelines below:
Diprivan (propofol): Perform wake-up assessment at scheduled times: 0400, 0800, 1200, 1600, 2000, 2400.
Allow RASS score to elevate to ≥ -1. When performing a wake-up assessment on Diprivan (propofol),
decrease rate 5–10 mcg/kg/min every 5 – 10 min until RASS equal to -1 or 0
All other Anxiolytics or Analgesics: Perform sedation vacation as stated above
Neuro Patients:
MEDICATIONS:
5. Consider a combination of an analgesic and an anxiolytic for synergistic effect.
May use combination of intermittent and continuous if needed.
INTERMITTENT IV SEDATION/ANALGESIA:
If RASS is greater than ordered level and SBP > 90, give:
Analgesic (check one):
 Fentanyl
25 - 100 mcg IV push q 2 hr prn
 Morphine 1 - 4 mg IV push q 2 hr prn
Anxiolytic (check one):
 Versed (midazolam)
2 - 5 mg IV push q 1 hr prn
 Ativan (lorazepam)
0.5 - 2 mg IV push q 1 hr prn
If able to maintain goal RASS with boluses more than 2 hrs apart, continue to administer intermittent sedation
If patient requires boluses more frequently than q 2 hrs, notify physician to consider continuous sedation
CONTINUOUS INFUSION MAINTENANCE:
Analgesic (check one):
Fentanyl:
Continuous infusion: 0.05 - 5 mcg/kg/hr IV, initiate at lowest end of range after prn bolus
Morphine:
Anxiolytic (check one):
Versed (midazolam):
 Ativan (lorazepam):
 Diprivan (propofol):
If titration upward needed, increase by 25 mcg/hr
PRN bolus: Fentanyl 25 mcg every 1 hr prn
Continuous infusion: 1 - 10 mg/hr IV, initiate at lowest end of range after prn bolus
If titration upward needed, increase by 1 mg/hr
PRN bolus: Morphine 2 - 4 mg q 1 hr prn
Continuous infusion: 0.5 - 10 mg/hr IV, initiate at lowest end of range after prn bolus
If titration upward needed, increase by 1 mg/hr
PRN bolus: Versed (midazolam) 0.5 - 2 mg IV push q 1 hr prn
Continuous infusion: 0.5 - 10 mg/hr IV, initiate at lowest end of range after prn bolus
If titration upward needed, increase by 1 mg/hr
PRN bolus: Ativan (lorazepam) 0.5 - 2 mg IV push q 1 hr prn
Continuous infusion: start at 5 mcg/kg/min
May increase in increments of 5 - 10 mcg/kg/min q 10 min prn
Lab: Triglyceride level every 3 days if on Diprivan (propofol)
 Precedex (dexmedetomidine) Continuous infusion: 0.2 - 1 mcg/kg/hr x 48 hours
6.
Reversal agent for:
Fentanyl or Morphine:
Versed (midazolam) or Ativan (lorazepam):
7.
8.
Narcan (naloxone) 0.4 mg IV in 10 ml NS, 0.5 ml q 1 min until change in
alertness or max of 10 mg
Romazicon (flumazenil) 0.5 mg IV q 5 min up to 3 mg total dose
Isopto Tears (hypromellose) 2 drops in each eye q 6 hrs prn dry eyes, if not already ordered.
Peridex (chlorhexidine) oral rinse 15 ml po BID, if not already ordered.
Copy to pharmacy
FORM 3-15395 REV. 12/2014
Page 2 of 2
MECHANICAL VENTILATION SEDATION
CRITICAL CARE
ORDERS
_________________
______________
Date
Time
PLACE LABEL HERE
____________________________________
Physician Signature
_________________
PID Number
Copy to pharmacy
FORM 3-15395 REV. 12/2014
Page 2 of 2