Sedation Policies

  1. 0
    I am working on a fairly large quality improvement and educational project for the ICUs at my hospital. My focus is sedation vacations and ensuring that they are completed as necessary to improve vent outcomes. I'm curious what other critical care areas are doing for this.

    What are your hospitalís documentation standards for sedation vacations?

    How often are your staff performing sedation vacations? Daily, every shift, etc.

    Is there a method for educating or encouraging nurses to perform DSV that has significantly increased their compliance?
  2. 8 Comments so far...

  3. 0
    I work in PICU. We have no standard procedure for sedation vacations.....sometimes the doc will do one to check neuro status but that's it really. No policy that I know of. There is a box to chart it in our computer program, and many nurses erroneously chart things there when they aren't doing a sedation vacation. I think they don't know what it is.
  4. 0
    There is a huge push at my hospital for "wake up and breathe." Personally I think it is not being implemented very well. It is supposed to be a nurse and respiratory driven process but we have no written procedure or protocol. I agree that many nurses don't know how to go about it, and in our case, doctors end up ordering it for patients that it really isn't appropriate for. We are required to chart q24 under "VAP bundle" whether the patient received sedation vacation, continuous sedation weaning, or the contraindication (e.g. hemodynamically unstable). We are also to turn the sedative (propofol for now, dex coming soon) back on at half its previous rate and titrate up if necessary.
  5. 0
    Sedation holidays should be a part of the routine assessment at the start of each shift. Generally I decrease the amount of sedation my patient is currently receiving in an effort to assess his or her ability to follow commands, orientation, compare muscle strength, etc. I never just stop the sedation, I gradually decrease it until the patient begins to respond to my voice. I find they become less agitated and usually I'm able to completely stop the sedation this way. My facility policy is for the nurse to perform a sedation holiday once daily. It is typically done in the morning during change of shift throughout physician rounds (if the patient can tolerate it). The sedation holiday is considered a part of ventilator weaning thus it's relationship to VAP prevention.
  6. 0
    Daily Wake up is generally the policy for patients on sedation at our facility. However, if patient is not stable enough to consider weaning, we may only reduce sedation, not turn it off completely. Our physicians sometimes give very specific orders concerning weaning sedation.

    However some patients are extremely hard to sedate, you can have them maxed out on versed and propofol (per our vent policy guidelines) and they are still sitting up in bed pulling at restraints. For these patients a complete vacation could result in self ex-tubation.
  7. 0
    We've actually stopped doing them. There was a single study of 69 patients that suggested patients could have less vent days with sedation vacations, larger meta-analyses involving 700 patients found no difference. The current "fad" is a focus on ICU related PTSD, sedation vacations are thought to be a significant cause of PTSD in ICU patients.
  8. 0
    I usually do mine first thing in the morning, as do most nurses I work with. There are a few patients that I'll wait for clarification from the docs because for whatever reason I feel like a sedation vacation might not be the best thing for the patient (ARDS, vent dysynchrony, just last week it was a possible traumatic diaphragm rupture, bad head injuries, status). But for the most part...Off with my morning assessment.

    Usually our patients on drips usually have some PRN available for breakthrough so a lot of times what I'll do is grab a PRN and keep it with me so that I have it available if the patient ends up going crazy.
  9. 0
    Quote from MunoRN
    The current "fad" is a focus on ICU related PTSD, sedation vacations are thought to be a significant cause of PTSD in ICU patients.
    We were told that PTSD was decreased by sedation vacations, because you orient the patient rather than have their ICU stay end up one giant foggy memory. I would get up to find the powerpoint and check the sources, but my bed is too comfy after my 13 hour "fall back" nite shift!
  10. 0
    Quote from ktliz
    We were told that PTSD was decreased by sedation vacations, because you orient the patient rather than have their ICU stay end up one giant foggy memory. I would get up to find the powerpoint and check the sources, but my bed is too comfy after my 13 hour "fall back" nite shift!
    That was when we thought patients received less cumulative benzos when sedation vacations were done, and less benzos=less delirium=less ptsd. That was based on a single small study from 2000. More recent, larger studies actually show the opposite; patients getting regular sedation vacations require more cumulative benzos then those who don't.

    The correlation between benzos and delirium and PTSD is still not very well understood. It had been thought that it didn't matter which kind of Benzo was used, but there's been some suggestion that versed correlates with delirium and PTSD more strongly, which makes sense when you consider it's more psychoactive properties.

    Even so, there is a correlation with benzos, a weak one, but based on that and the bulk of evidence on how to reduce cumulative benzo load, sedation vacations may be doing more harm than good.

    Sedation vacations dont improve outcomes in ICU - PulmCCM Central


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