Hi, I'm a new RN in a trauma ICU. We use a LOT of pain drips and sedative drips. Typical patient has Versed and fentanyl on pumps with orders to titrate as needed to maintain sedation (MAAS score of 2-3). Sometimes they use propofol with the same order to titrate. Frequently we have specific orders to maintain, say, the Versed at no more than 6 mg/hr, so we do know when the surgeons or other docs want to limit sedative use. But otherwise, we titrate and bolus freely. For instance, if the patient's on 6 mg/hr of Versed, and gets agitated, we'll bolus 2-3 mg right then, and then consider increasing the drip if need be.
However, most of the nurses do not chart their boluses, and they've told me not to chart or document them. They're not sure that bolusing a patient is within our orders or our scope of practice.
My thing is, if you have an order to titrate, isn't a bolus like a momentary titration? A 5 mg bolus through a drip is the same as titrating up to 30 mg/hr for ten minutes and then titrating back down, right? These boluses are delivered slowly, through the pump.
The other contention many nurses have is that if you have to bolus, you probably should be titrating up anyway. But I don't really believe that. Say someone looks comfortable on 3 mg/hr, but when you stimulate them they get agitated and their vitals go nuts. I'd rather bolus then, and then let them rest and return to 3 mg/hr. It's that or jack them up to 5 or 6 mg/hr, doubling their dose indefinitely, even though they don't need it for all 60 minutes of every hour. We're not supposed to be anesthetizing these people anyway!
The problem with my approach is that the trauma team will round and see, from the charting, that the patient was comfortable on 3 mg/hr all night and we could possibly turn the sedation off, when in reality they needed a total of, say, 15 mg of boluses on top of that to keep them comfortable and turning the sedation off will lead to a self-extubation or something.
What do you think? I'd ask the docs but most of them are aware and don't care what the legal aspects are as long as patient care is accomplished. I'm afraid to ask the pharmacy because I don't want to get anyone in trouble.