Sedation Woes... - page 2

by MegNeoNurse

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What do you use routinely for sedation on patiently requiring mechanical ventilation? Our first line routine is fentanyl @ 1mcg/kg/hr and midazolam at 1mcg/kg/min and we increase as patient needs to illicit acceptable sedation. ... Read More


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    Do you increase these doses? These are starter doses and most of our intubated patients wouldn't last very long at these rates. We start with 0.1mg/kg/hr of Versed and 1 mcg/kg/hr Fentanyl, bolus and increase as needed. It depends on the dr where we end and add in other drugs, up to 0.25-0.3 mg/kg/hr of Versed, maxing out about 7mg/hr. Fentanyl about 2.5mcg/kg/hour. In general, next we go to Precedex gtts.

    If they've been intubated for several days, we'll start Ativan and Methadone as we're getting ready to extubate for withdrawal.

    Quote from MegNeoNurse
    What do you use routinely for sedation on patiently requiring mechanical ventilation? Our first line routine is fentanyl @ 1mcg/kg/hr and midazolam at 1mcg/kg/min and we increase as patient needs to illicit acceptable sedation. The unit I work in has a large population of transplant patients that get sick and are readmitted, required ventilation, but have a great tolerance to drugs. Our institution allows for Precedex infusions of no longer than 24 hours (bummer!). I've seen them switch to a ketamine gtt( and the kids freak if there's no benzo on board as well), pentobarbital gtt (love!), and all the PRNS under the sun: lorazepam, chloral hydrate. We use paralyzingly agents only if indicated, but as we know this isn't a sedative. Any input greatly appreciated!
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    Pentobarbital for sedation? Interesting. I work with adults, but we use pentobarb to induce coma (literal, no cough, gag, movement, corneals, etc...) for refractory status
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    Typically precedex + an analgesic and midazolam. I've read about precedex drips having a 24 hr limit at other facilities but our facility sometimes has patients on precedex for weeks.
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    Yes, pentobarb for sedation. Works wonders for these kids who build up such tolerances to fentanyl and versed.
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    DO you guys like precedex? We've been using it more and more lately but I seem to find that we have kids on the max dose and they are still wide awake and require the versed anyway...We used to only be able to use it for 24 hrs but now its up to the MD's discretion...we've been using it a lot on our ENT patients
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    Are they wide awake and agitated, or just wide awake? I don't get too bothered if a kid's awake and calm. I don't even get too upset for an ECMO patient to be awake as long as they're not trying to roll over or are hypertensive and causing flow issues.

    We're running Precedex (dexmedetomine) on select patients (due to cost) and have reasonable success with it. But usually we're also running either ketamine, fentanyl or morphine too, sometimes with a little midazolam chaser. I'm still a little leery of the various and contradictory things I've heard about it. Some will say that it's like propofol... turn it off and in a little while the patient wakes up. Others tell me that there's a significant withdrawal issue when it's used for more than the recommended 24 hours. There's such a paucity of pediatric literature it's hard to know what's correct. I'm going to be speaking with a rep for the manufacturer tomorrow and hope to clear some of these things up.
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    Jan I would be interested to hear if you learn anything from the rep. I have seen both, some kids awake and calm on the max dose of precedex, and also awake and agitated. I've also given it as a PRN to one particular chronic patient and it would knock him out for 12 hrs sometimes and other times not even have the slightest effect...So all in all i'm unsure how I feel about precedex but it is still relatively new so i guess we'll see!
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    yeah. about that. i never did find the rep at nti. the expo wasn't as easily-navigated as in past years and my feet were already killing me. i know i saw a huge sign with precedex prominently visible, and i saw it several times, but when i had the time to talk to them i couldn't remember where they were.
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    I have been trying to do research and find out what other units are doing. I come from an adult ICU unit and have been in PICU for a year. Our unit uses mostly Fentanyl, Versed and Nimbex PRN. This bothers me, but I have not been able to find a lot of info on what others are doing. Babies do self extubate much easier, and Fentanyl and Nimbex are given together, but the Nimbex really bothers me. I think the doses of the sedatives should be increased or drips started rather than leaving all the PRN's left to nursing discretion (in my opinion...lazy nurse=stoned kid). What kind of success do you have with Precedex? I went to an information dinner when I was in the adult Trauma ICU, but have never seen it used on kids. I am very interested in this topic and am hoping for more replies. I, of course, have much more to say , but am just trying to make it short!
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    We have sedation pathways that have just recently been renovated. Here's the gist of it:

    Fast track: Goal - wake & wean from vent in 12-24 hrs from admission (post cardiac surgery). Goal pain score <3. Use non pharm management when appropriate, medical management includes morphine (0.05-0.2mg/kg qhr pain >4), tylenol q4x48 hrs, toradol q6 x 48hrs, oxy 0.1mg/kg q6 when taking po, PCA for children >8yrs after extubated.

    Recovery phase: pt recovered from acute illness, not on ecmo, goal MMAAS 0-1. Pt is on either a morphine/versed or fentanyl/versed gtt. Gtts are weaned q12 (alternating) by a certain amount depending on the drug, PRN's are still used while weaning so long as no more than 3 in 8 hours are needed, if pt on drips >5 days methadone/ativan are also started. Once extubated start on fact track pathway

    Acute phase - Acutely ill pts, goal MMAAS is -1 to -2. Pts on ECMO start with morphine gtts, pts not on ecmo start with fentanyl. Per the protocol if greater than 3 boluses are used in 6 hours RN's may increase the gtt rate, if the gtt needs to be increased twice then a versed gtt is added.

    The acute phase track is the most complicated one but the overall understanding is that physicians order the level of sedation they want the patient at and we follow protocol from there to obtain the goal. In the acute phase if movement/agitation is affecting hemodynamics then vec PRN's are used and a vec gtt may be initiated (per the MD of course, not the RN)

    Every unit of course too has their chronics. I have seen everything under the sun used for the kids that are tolerant to it all. We certainly use precedex and I have seen ketamine gtts and dilaudid gtts


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