Sedation protocol

Hi,

We have policies regarding the administration of sedation, but no protocol per se. RN's use their judgement with orders that look like this: Propofol IV drip 0-50mcg/kg/min titrate for sedation. Or, Versed IV drip 0-5 mg/hr titrate for sedation. Almost always there's an order for a fentanyl drip as well when propofol or versed are used. We sometimes end up with orders for dopamine, neo, or epi as well if the patient must be sedated, but their pressure doesn't tolerate it well.

There are protocols however that I'm not familiar with for other floors for conscious sedation, but not in the ICU.

Hi,

We have policies regarding the administration of sedation, but no protocol per se. RN's use their judgement with orders that look like this: Propofol IV drip 0-50mcg/kg/min titrate for sedation. Or, Versed IV drip 0-5 mg/hr titrate for sedation. Almost always there's an order for a fentanyl drip as well when propofol or versed are used. We sometimes end up with orders for dopamine, neo, or epi as well if the patient must be sedated, but their pressure doesn't tolerate it well.

There are protocols however that I'm not familiar with for other floors for conscious sedation, but not in the ICU.

Having a fentanyl drip along with Diprivan sounds fantastic. The doctors often don't realize that Diprivan is not a pain-killer and become frustrated when the nurses call and ask for pain meds - "just increase their diprivan."

What does the order/protocol for the Fentanyl gtt look like? And why Fentanyl versus Morphine?

Having a fentanyl drip along with Diprivan sounds fantastic. The doctors often don't realize that Diprivan is not a pain-killer and become frustrated when the nurses call and ask for pain meds - "just increase their diprivan."

What does the order/protocol for the Fentanyl gtt look like? And why Fentanyl versus Morphine?

Our Diprivan, Versed, and Ativan drips do not have a written protocol...but they are what we use for sedation....

We use a lot of Diprivan for our vent patients...and our Pulmonolist generally discontinues all anti anxiety, pain, or other medications that affect the respirtatory drive...

We occasionally use Versed or Ativan drips..but Diprivan is the most common..

We also have a Alcohol withdrawal protocol....it is written out...in a specific form....Would you like a copy of it?

What does the order/protocol for the Fentanyl gtt look like? And why Fentanyl versus Morphine?

There isn't a protocol for the fentanyl, rather an order like fentanyl IV drip 50-100mcg/hr.

Of course with all of these drugs, prop, versed, fent. the dosages can be much much higher depending on the patient's response to them.

I don't know the rationale for using fentanyl over morphine as a drip, except that there is a general feeling by the docs that fentanyl is a kinder, gentler drug...on the elderly especially. We use fentanyl over morphine, I'd say, 80% of the time with plain prn orders.

I would NEVER run a sedative without a pain med. There are some exceptions with neuro patients. For our patients who are fresh post-op hearts who we plan to wake up and extubate within 4-6-8 hours, we don't necessarily have a fent drip running with the propofol as we wean it to off. But we are requried to give prn boluses of narcs as the patient's wake up (they may still be on a bit of propofol as they wake). It's considered unethical to sedate but not cover for possible pain, and most of the charge nurses will get after those who do not give prn pain meds to a sedated patient.

We really only use propofol in our unit...our population is primarily cardiac surgery or post cardiac arrest/or cardiac issue that reqires intubation...on rare occassion we do use a versed or ativan gtt. Depending on the patient, we usually try to titrate to a a light sedation level...RASS score of -2 or -3.

If need be we snow the patient...we do have a protocol that has a starting point but I can't seem to remember it right now. Our protocol states that we do a wake-up assessment once shift and then restart at half of the previously set dose for resedation with titration up from there (if patient condition permits...) If the patient remains on propofol for an extended period we do a triglyceride level...if it is too high, we switch to a different sedative gtt. On our post op heart, we always run a fentanyl gtt. We usually start at 50 mcg/hr and titrate up as needed...our protocol states 50-100 mcg/hr but we can go higher if need be. I don't think that we have ever used a morphine gtt. If we are trying to extubate our heart patient, we just turn off the fent 30 minutes before weaning parameters...

I would love a copy of that protocol.

Our Diprivan, Versed, and Ativan drips do not have a written protocol...but they are what we use for sedation....

We use a lot of Diprivan for our vent patients...and our Pulmonolist generally discontinues all anti anxiety, pain, or other medications that affect the respirtatory drive...

We occasionally use Versed or Ativan drips..but Diprivan is the most common..

We also have a Alcohol withdrawal protocol....it is written out...in a specific form....Would you like a copy of it?

We mostly use Diprivan and Fentanyl gtts which are both in our Pyxis (thank God)....We also use Ativan and Versed gtts at times....We use a Ramsey scale....you might see an order titrate sedation to a Ramsey III...but most usually the order basically says titrate for sedation....You could probably do a search for the Ramsey scale to get exact parameters....

We have a sedation order sheet that has diprivan, versed, morphine, norcuron, etc. on it. One is checked off and then the rest is fill-in-the-blanks. Bolus, starting dose, max dose and titrate to ...(ramsey scale of..., comfort, sedation). There's also a place on the sheet that reminds the nurse to remove the sedation once a day to check neuro status with no sedation. Often times the patient starts getting restless and starts fighting against the ventilator, so the assessment has to be quick and the sedation gets started up again.

Is this the sort of protocol you were looking for?

We have a sedation order sheet that has diprivan, versed, morphine, norcuron, etc. on it. One is checked off and then the rest is fill-in-the-blanks. Bolus, starting dose, max dose and titrate to ...(ramsey scale of..., comfort, sedation). There's also a place on the sheet that reminds the nurse to remove the sedation once a day to check neuro status with no sedation. Often times the patient starts getting restless and starts fighting against the ventilator, so the assessment has to be quick and the sedation gets started up again.

Is this the sort of protocol you were looking for?

hi

can you scan and attach a copy of your order sheet? I would like to see it for ideas.

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thanks

i hope to God that your patients are intubated prior to this sedation - otherwise you are throwing yourselves to the wolves.

Had a patient vented the other day on a fentanyl drip, 230mcgs/hr, and he was sitting up writing notes to use. I later found out he was extubated on 130 mcgs/hr of fentanyl. the nurse forgot about it cuz he was doing so well, and well, just turned it off afterward. as far as I know, the max IV dose for fentanyl is 300 mcgs/hr.

My unit is getting ready to due Diprivan drips. We have been using Versed and Ativan drips for our vent patients. They don't always work. I had a patient recently where we had the Versed infusing at 100mg/hr and it wasn't even touching them. We now have standing orders written for all these drips.

Schroeder