We do use a sedation protocol. I am surprised to see so many of you use morphine as your narcotic. We never use it on intubated patients- only fentanyl. About 50% of our kids are on a fentanyl/versed combo. Our doses can get nuts- for our really sick kids who are tubed for weeks at a time, I have seen fentanyl drips as high as 8-10 mcg/kg/hr and versed gtts at 0.3mg/kg/hr- we also can bolus q1 with pentobarb and fentanyl and ativan q3. Good grief!
We are supposed to do daily 'sedation holidays', which never usually happen. Most of the staff are worried about kids self-extubating and they are slammed caring for their other patient, who is usually also intubated. I also think sedation holidays can be cruel- who wants to be awake with a huge tube stuck down their throats? On the other hand, maybe if sedation holidays reduce the amount of withdrawal we see, we should do better in following them!
I believe someone mentioned their process of assessing readiness to extubate. We typically will start methadone 2-3 days before we anticipate extubation and then start cutting drips- slowly, by 1 mcg per day. Lots of times we still have kids on weaning doses of fentanyl when they are extubated- but they are the kids who have built up such a tolerance that I don't think it matters.
Hope that helps