Sedation Woes... - page 2
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... Read More
May 20, '12Yes, pentobarb for sedation. Works wonders for these kids who build up such tolerances to fentanyl and versed.
May 22, '12DO 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
May 23, '12Are 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.
May 25, '12Jan 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!
May 26, '12yeah. 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.
Jul 23, '12I 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!
Jul 23, '12We 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
Jul 25, '12We rarely use neuromuscular blockers like Nimbex, although a few years ago we had a fellow who was doing a combined anaesthesia/critical care fellowship who loved it. (He's also the one who bequeathed us the epi "spritzer" we're using all the time now on kids who are pre-arrest... don't get me going!) We tend to use Zemuron if we're going to paralyse and then it's usually only for bedside procedures like intubation, line placement, perc drainage, chest tubes and that sort of thing. I can't even remember the last time I paralysed a kid for any other reason.
I agree with your sentiment RNx54p... lazy nurses often have stoned patients. I hate it when the first thing they try when a kid is upset is a drug. The other night I spent a solid half hour trying to settle a baby that I know well for the nurse who was assigned to him (I was charge). It was only after the 5 S's failed and the dad was getting quite antsy that the baby got some Ativan. (Followed by a fluid bolus, because he'd gotten captopril in the previous hour.) Turns out he was in withdrawal and needed a slight increase in his baseline sedation to fix him up.
We don't actually have a formula or a protocol. We kind of make it up as we go along. Morphine 20-50 mcg/kg/hr and Versed 1-4 mcg/kg/min infusions are our usual tools, depending on the kid's previous exposure. The morphine may be increased to as much as 100 mcg/kg/hr in kids on CRRT or ECMO where the circuit could be adsorbing. There will also be morphine and Ativan boluses ordered prn. 0.1 mg/kg q2h for each of them in intubated kids, half that for non-intubated, and once we can use their gut, we'll have a chloral hydrate prn, 10-20 mg/kg q3h. If we're still struggling with sedation and analgesia in a hemodynamically stable patient, clonidine is added next, 1 mcg/kg q6h. (Another
gift from our former fellow, but it actually works.) Only if all of that fails do we consider ketamine or Precedex. Having said that, we've had several kids on Precedex infusions for weeks at a time, after which we wean by 10% q12h to off to minimize risk of withdrawal effects. Our long-term kids all develop some degree of withdrawal and will be converted to enteral morphine and Ativan with a weaning schedule on the Kardex.
Our unit does a poor job of assessing pain (we use the FLACC scale with mostly infants and toddlers, for whom it is much less specific for pain than it might be for other causes of distress) and the scores aren't reported or used other than as a box to tick on our assessment charting. Neither are the sedation scores that are recorded with our q4h assessments. We don't assess for delirium. We use a neonatal abstinence scale for scoring withdrawal, which isn't really the right tool for most of our patients. Almost all of them will score high because of loose stools (lots and lots of very elemental formula used on our unit!) and work of breathing (lots of sick chests from pulmonary hypertension,
chylothorax, RV dysfunction and so on) and sleeping less than 3 hours since the last feed - they're all on continuous feeds and many of them are old enough that they wouldn't be sleeping for 3 hours at a stretch anyway. There is NO education to staff on how to use the scale, and scoring is very inconsistent. We bedside staff have absolutely no influence on any of the things we're expected to do, and aren't properly educated on how to do most of it. Very frustrating.