Sedation Protocols for Intubated Patients

[Stormy]

I am curious as to whether there are any ICU's who have a protocol in place for sedation of their intubated patients. At present, physicians write orders on an individual basis for each patient. Some discussion has arisen about the possibility of developing "standing orders" for nurses to sedate at their discression (within the parameters of the guidelines, of course). I have some concerns and reservations about implementing a protocol such as this.

Any comments??

[kersti]

A sedation protocol- unfortunately we don't have one and it does cause a lot of pointless running after the docs begging for more propofol et al because the pat. is restless, trying to pull out various lines etc. Sounds like a great idea! Wonder how long it would take me to convince the docs that this is a good idea????

[RN34TX]

Sounds like a great idea! Wonder how long it would take me to convince the docs that this is a good idea????

It depends on how big of control freaks your docs are and how receptive they are to new ideas outside of their world.

[housoj]

Would you be able to share these protocal order sheets? I am trying to find examples as our hospital is in the process of developing these "sedation holiday" protocols. It is all part of the bundle orders for prevention of VAP?

housoj at aol if possible

[dorimar, BSN, RN]

I am sure JACHO will be all over this very soon. I thought every place was using sedation protcals, sedation vacations, and vent bundles already(evidenced based practice).

[millkay]

I thought every place was using sedation protcals, sedation vacations, and vent bundles already(evidenced based practice).

Unfortunately, it takes some time for even evidence based practices to trickle to some facilities, namingly rural areas- not that the right things aren't being one. I've experienced a recent situation where orders for sedation and vent bundles are done by daily written order of a control-freak pulmonologist/intensivist as opposed to unit or facility protocols. Usually the orders reflect evidence-based best practices, but leave the nurse little to no leeway for using judgement.

[dorimar, BSN, RN]

But if it is really evidenced based practice, bravo to that pulmonologist! I see so many people resistant to change, despite what evidence has proven. Less sedation, and waking the patient every day, has decreased ICU stays, and decreased vent days, and increased positive outcomes. Just like the new insulin protocals. Some nurses are not familiar with the research... Some nurses can't understand why a patient is on an insulin drip with BS of 200, so asks the Doc she knows whill agree, to DC said insulin drip (Q 1 Hour accuchecks and insulin adjustment is a lot of work). Just so wrong. Now instituting sepsis bundles is my next goal (early goal directed therapy). Who can argue with EVIDENCE. But some always will.

[skelley5]

I work at a hospital that has a vent sedation protocol and I love it! The MD usually orders this w/ every vented pt but not always. It's based on the pt's age and wt as to how much you can give. The protocol starts off w/ ativan 1-2 mg IVP every so many mins prn to reach a specified RASS (Richmond Agitation Sedation Scale) w/ 0 = alert/calm -1 = drowsy w/ eye opening greater than 10 secs, etc. The MD will write an order for the RASS score to keep the pt at. If ativan doesn't work, then you can start giving fentanyl IVP prn every so many mins to reach the certain RASS. The if you use over a certain amt of ativan and fentanyl in a certain amt of time, you start the pt on an ativan and/or fentanyl gtt. If on both gtts for over 24 hrs and the RASS level can still not be achieved under a certain amt, the final step is to start the pt on a propofol gtt stoping sedation q 12 hrs to check neuro status. I think it's great as long as nurses follow the protocol strictly. Two places seem to get people into trouble. One, the don't follow the sequence and go straight to the diprivan. Two, the q shift neuro check gets neglected a lot of the time, so, if you had a pt that didn't have a neuro check for over 3 shifts, the pt could have had a stroke that could have improved w/ interventions but it was caught too late.

[working4aBSN]

We have preprinted orders for ventilation patients and on the these orders is had a protocol for sedation and I have seen some hospitals use the Ramsey scale and the Riker scale. We currently use the Riker scale and usually is a 3-4 which means the patient is sedated but comfortable. I like this protocol because it gives me the opportunity to judge and see what is comfortable for the patient. We also do sedation vacations so we can assess the neuro status of the patients.

[anichols]

does anyone have any sedation protocols they are willing/able to share? our facility is just now trying to get started with a protocol, and we would be extremely appreciative if we could get an idea of what is working well for others that we may want to implement.

[criticalHP, MSN, RN]

We used a sedation protocol that included propofol, ativan , or precedex. The md ordered it, and the RN titrated to desired effect-SAS 3-4. A sedation holiday was done every morning to assess for spontaneous breathing, neuro, and so on. If sedation was still needed the dose was re-stared at half the original dose.

Have your ICU pharmacist and pulmonologists involved with the protocol if you are trying to develop one for your unit. Multidisciplinary involvement is needed to gain buy-in and train staff on things like propofol infusion syndrome and so on. Overall, protocols are the way to go, and give nurses in ICU's great autonomy.

[RN1982]

We have sedation protocols. One continuous the other intermittent. We use the continuous mostly. We titrate the drips according to MAAS score.