sedation protocol mechanically ventilated patient

  1. I am a staff nurse at a small community hospital. My boss would like me to develop a protocol/policy for sedating mechanically ventilated patients. I would apprectiate any copies of policies or protocols. Thanks G
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  2. 24 Comments

  3. by   Phishininau
    As far as protocol, we dont have one. Sedation for mech vent pts should be on a case to case basis. If someone is unstable and being awake makes their stability more fluid, then by all means they need to be sedated. If the patient is having difficulty pulling their TV or has high PIPs or they are just "bucking the vent," so to speak, put them to sleep.

    I prefer to use propofol. We arent allowed to bolus it, due to nursing practice in my state, but we can titrate it for therapuetic effect. It is best given centrally. On our propofol infusion orders we are allowed to titrate up to 50mcg/kg/min, and beyond that if the physician orders you to do so. I can tell you that they have no problem with this though. VORV to the rescue!!

    Some physicians at my facility are opposed to propofol and prefer to use ativan or versed. I like propofol better because they wake up faster for t-piece trials than with the benzos. With these two we use standard bolus doses. We dont use versed drips. Ativan drips are dosed mg/hr, we usually start with a 2-4mg bolus then go from 1-10mg/hr on continuous infusion. Sometimes as high as 15mg. I hate ativan because in the experience I have had it crushes my pts pressure.

    We also use a few paralytics. Pavulon, 0.1mg/kg bolus with repeat in 1-3 hrs. Zemeron 0.6-1.2mg/kg. Nimbex 1-1.7mcg/kg/min infusion. We used to use succs but have gone towards Nimbex more in the recent months. Succs is bad for those with high K, such as burns, crush injuries, and renal pts. Nimbex is also the paralytic of choice with increased HR, decreased MAP, bronchospams, or renal insufficiency/failure.

    Unfortunately we are not using fentanyl any longer.

    Anyone else have different experiences?
  4. by   zambezi
    We use propofol 99% of the time in our unit. We titrate to effect...Occassionally on a longer term patient we use ativan for sedation...Our standard for post op hearts is propofol and fentanyl...Most typically for pain control we use a fentanyl drip (use MS IVP if no continuous drip).
  5. by   dfk
    evidenced based, both personally and word of literature, is that using a ramsey scale seems to give the nurse the autonomy, since we are the ones that are with the pt all shift all the time.. by ramsey, for those who don't know, is a tool developed to assess pt actions/responsed on a numeric scale, such as 1 for agitated/restless, 2 for tranquil/cooperative, 3 for responds to commands, 4 for responds to gentle shaking, 5 for responding to noxious stimuli, and 5 for no response to firm nail bed/nipple pressure... again, this is what we and many others that i have come across are using.. it's effective and still gives us the control to titrate (we use titrate to a ramsey of 3-4).. sort of a standing protocol.. i guess i am lucky that the residents listen to the nurses, well most of them anyway (if they're smart they will).. just remember, let them docs know not to piss a nurse off.. could be hell for them (teaching facility emphasized here).. i am curious what u will do.. and, good luck.. anymore info, pm me---
  6. by   Phishininau
    We are required to use either the BIS monitoring system or the RASS (Richmond agitation sedation scale) to monitor sedated patients.
  7. by   nurseman99
    we use the ramsey scoring system.with pt sedation it is best to know if they are going to be vented for awhile as in ards or are they a quick extubation in the a.m.for short term i think diprivan is now 10x;s better that we have discovered it can be piggybacked to far more meds than previously thought.it does require frequent checking of volume left because once the imed beeps empty the pt has only 1minute or 2 before they sense the confinement of the ett.and in icu with codes and crashing pt;s it;s not easy if the pt is on 30mcg or more.diprivan is also a cause of hypotension in the unit.now,versed and fentanyl are used frequently at my hospital because of cost and the the synergy of sedation and pain control.just remember that pt;s unfortunately develop a tolerance to all meds and on monday are on 30 of fentanyl and 6 of versed and the next night it;s 40% higher in dosage to keep the pt calm.
  8. by   dfk
    we use bis for intubated pt's coming from the PAR (which is popular among anesthesia), and the PAR sees more of it than my sicu - there are a good handful of scales and the like, and any one could apply to various situations. it definitely is a touch and go type situation.. that's all part of the learning process, both for me and everyone else.
  9. by   zambezi
    We also use the RASS scale to monitor sedated patients.

    We used the Ramsey scale up until about 1.5 years or so ago.
  10. by   anney1981
    I was just wondering what kind of qualifications do you have that your boss would ask you to develop this policy? I can understand if maybe they asked you for your input, but to develop it???? I think that if you are developing this it would be best to consult mds that are more qualified when it comes to the care of mechanically ventilated patients. This is not meant to be demeaning to you but to ask you to be more specific about the development of your facilities policies and procedures.
  11. by   ZASHAGALKA
  12. by   rookreck
    The management at my hospital uses the staff nurses for project management in many areas. It is actually very rewarding. I won't be doing this on my own. I will discussing the project with a pharmacist, pulmonologist, and anesthesiologist. Also there is alot of evidence based medicine on this topic. I am actually proud to work at a facility that uses staff nurses for different projects. I have been a nurse for 16 years and I think that I am up to the challenge.
  13. by   candyndel
    Of course you could write a policy- think of all the administrators (who dont touch patients) that do!!
    If it is your first time, I will give you a couple of pointers...
    1- Do your homework- (do a thorough lit search). It is important to use current literature as your references, esp being in an 'Evidenced Based Profession'
    (he he).
    2- Know your JCAHO regs for your procedure (if there are any for your particular topic). The form/flow sheet you create should allow the staff to easily comply with the regs...
    3- Know your state dept of health regs...see above.
    4- Talk to your staff and involve them in the drafts...Especially when you set out to create the form (and in this case you need one). Trial the flow sheet and find out what works/doesnt before you commit. When ready, this flow sheet will most likely have to be approved by your hospital's Forms Committee...and they usually rip everything apart a few times (so dont worry when that happens).
    5- Check with your national organizations (ACCN, ASPAN, CRNA's (?), ASA, ENA, SCCM, etc)
    6- Dont reinvent the wheel. Plenty of hospital policies are on line.

    As far as sedation protocol goes...
    We have a MV Sedation Protocol. The MD specifies which drug they'd like to use (prop, ativan, haldol and there are several reasons why one would choose one over the other...) and at what level of sedation they want the patient.
    We use the MAAS score to determine level of sedation...there are a couple of others (scores) mentioned already on this site.
    Dont forget you need a sedation holiday and this should be part of your protocol and flow sheet. If u r unfamiliar with this term, research it- its important.

    I can fax u a copy of ours bc I cant locate the pdf file I have it on!!

    good luck!!
  14. by   gizelda196
    The nurses in my hospital always write the policies One is usually chosen and then she "recruits" help from her peers. committees are formed . It is very rewarding in that hospitals are nurse run and who better to write new policies then the nurses who are there doing it. Mds should not be writing nurse policies nor should administrators it should come from the bedside . Like someone else said use evidence based research and make up tools like polls and questionnaires to start like "In your practice how have you found it to get sedation orders from and MD at 3am While your vented pt is sitting bolt upright in restraints?" Something like this would track a need to have standard sedation orders that could be activated on admission to the unit and co signed by an md in the am. Most of our pts start with what we call 2&2 (2mg versed 2 mg mso4) Q1hr prn. This works well until the pulmonologist makes it in in the am . But ods and etohs really should just be propofoled so shouldn't pts one certain types of ventilation where if they even moved a finger they could have a lung blown out. All these factors need to be taken into consideration. Oh and don't forget the 80 year old woman who is intubated a hundred times and is a pro and requires no sedation. you could gear it for like a clinical pathway if this is the alertness level give this. I think the lovely JACHO is even screwing with how orders are written and meds are given now like One perc for pain 1-4 and two percs fro pain 5-6 and they have to be clearly written like that So no more tit rate to sedation I cant wait to see how this is going to fly! Imangine trying to gear the pt on levophed, neo and propofol with jacho 's idea of things. geez but this is another topic. gather all the info and go from there good luck

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