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  1. Nov 29, '05 by rookreck
    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

  2. 24 Comments so far...

  3. Dec 1, '05 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. Dec 1, '05 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. Dec 1, '05 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 **** 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. Dec 1, '05 by Phishininau
    We are required to use either the BIS monitoring system or the RASS (Richmond agitation sedation scale) to monitor sedated patients.
  7. Dec 1, '05 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. Dec 1, '05 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. Dec 1, '05 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. Dec 3, '05 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. Dec 3, '05 by ZASHAGALKA
    http://www.mc.vanderbilt.edu/surgery...Guidelines.pdf


    http://www.sccm.org/professional_res.../Sedatives.pdf

    http://www.sccm.org/professional_res...arBlockade.pdf

    Hope this helps.

    ~faith,
    Timothy.