Sedation Protocols

Pediatric Critical Care Columnist · Apr 30, 2008

I WISH!!!!

In our unit we crank it up until the kid doesn't move. At all. We've had kids on 300 mcg/kg/hr morphine plus 8 mcg/kg/min midazolam AND intermittent ketamine or fentanyl to keep them snowed so that we can them sitting up on rolled up soakers for VAP prevention. It's insane. As for using a sedation scale, not a chance. When the chest x-ray looks like they might be ready to extubate, they order a gigantic slash, something like a 75% reduction... then the kids withdraw horribly. It's only AFTER we've made their existence so miserable that they almost self-extubate or deglove their elbows and heels that we start a formal weaning protocol and introduce methadone. S couple of our docs want the kids sitting up watching TV before they'll extubate, even if the kid's been on PSV for two days with great gases. They figure that if we take away the irritant of the tube, they'll be too sedate. It's all so distressing, but they don't listen to any of us.

sara52g · Apr 30, 2008

The protocoll where I work is after a child has been on a sedation infusion (usually Morphine) for more than a week, when they are nearly ready to extubate we start weaning the drip by 10% a day until off. Usually works pretty well and we will extubate while they are still in the wean phase.

RNNPICU, BSN, RN · Apr 30, 2008

OUr protocol is we start at .1mg/kg/hr of morphine and versed and if we have to give three nonprocedural boluses we can go up by 10-20% of the .1mg/kg. If we start reaching .3 or higher we think of adding a different agent. When we wean we wean 10-20% of the dose the pt is currently on, alternating the narcotic and the barbituate. For example if you weaned the morphine, eight hours later you would wean the versed. This helps with the withdraw. Pts sometimes need methadone and ativan to help. It helps with theextubation. There are two phases, the first is the acute phase and we can increase during this phase. When we starting weaning the narcs and barbs this is the wean to extubate phase. we also have a plateau phase that means we keep things going as they are with a wake up and then we restart at 5% of the previous dose.

AlabamaBelle · May 1, 2008

We have a sedation protocol in place. There is a scale from 1-6, 1 being relatively lighted sedated, infrequent prn doses to a score of 6, meaning continuous infusions of morphine and versed (or ativan or fentanyl) along with a paralytic gtt. We alslo have a sedation wean protocol. As we we wean the gtts, we also start methadone and ativan (each @ q6h - the kids get something every 3).

The sedation levels are specific. If a level is ordered and not met, we (the RN) will adjust the gtts to achieve the stated level. We go up or down by 0.02 if not sedated enough or too sedated. For example, Sedation Score of 3 is patient asleep most of the times, awakens with cares, resettles promptly, does not consistently overbreathe the ventilator. If not sedated enough, bolus 0.1mg/kg q15min. If 4 boluses are given in an hour's time, gtts are increased by 0.02mg/kg/hr until the goal is met. Oversedation goes opposite.

It isn't perfect, but we are doing much better with controlling the withdrawal issues since we instituted the sedation weaning protocols. We try to start the protocol when we believe we are within a couple of days close to extubation.

gal220RN, BSN, RN · May 1, 2008

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:nurse:

RNx54p · Jul 24, 2012

Please excuse my possibly stupid question....what are "rolled up soakers"?

Pediatric Critical Care Columnist · Jul 24, 2012

Please excuse my possibly stupid question....what are "rolled up soakers"?

We call the reusable waterproof pads placed under patients to preserve the linen "soakers". To keep babies sitting up in beds intended for adult patients we have to put something under their bums so that they don't slide down. A couple of "rolled up soakers" positioned at the bend in the mattress makes a little bench for them to sit on. (We use beds because that's what we have, they give lots of access to the patient from all sides and one of our physicians has a meltdown if a baby who could destabilize is in a crib.)

gal220RN, I'll be back with a response to your post later. Gotta get ready for work now.