Sedation Titration

[arblackburn90]

Hi fellow nurses! I work in a Surgical Trauma ICU at a Level 1 Trauma Center and I'm currently precepting a new graduate nurse who is struggling a bit with understanding when and why to titrate sedation up or down. We've talked about it multiple times but she is more of a visual learner so I was wondering if any of you had any quick reference guides that I could print out and give to her to help with her learning process! Thanks in advance!

[LovingLife123]

I feel likes it's something you just kind of learn.

You could use the RASS scale with her.

My general rule of thumb is if I give 2 bonuses and that's not fixing my sedation issues, I up the sedation.

There's just so much to look at though. Like where are their BP and HR. How are their sats? Are they coughing a lot? Are they in sync with the vent?

I'm just not sure there's an easy print out for it.

[arblackburn90]

Yeah we use the RASS scale and individual order sets for each patient, and like you said, there are so many factors that go into it. I was just wondering if anybody had any type of hand outs that kind of hit the high notes so to speak. I have some similar hand outs for pressor titration but couldn't find anything for sedation. But thanks!

[PaSSiNGaS, MSN]

I commend you for making this post. I see many people who precept students or new grads and actually hate teaching but still precept. You are actually trying to find ways to help this person to make them better.

I would suggest the person read up a lot more on the actual pharmacokinetics and dynamics of the drug (propofol, versed, fentanyl, etc). If you know exactly how a drug works and things like the context sensitive half life and ED95 they would have a better idea how much of a drug is required and when it may start to wear off.

[arblackburn90]

Thank you! I love teaching and precepting because, as cliche as it sounds, I feel like with each new nurse, I learn new things and refresh my memory/sharpen skills not routinely used and I LOVE watching those moments when you can tell that something "clicks".

That's a great suggestion about the pharmacokinetics component. Our MARs have education leaflet hyperlinks that we can print out that discuss the indications/pharmacokinetics/side effects/adverse reactions so maybe that will help her better correlate her patients' clinical presentation to what the gtt rate should be! Thanks!

[BedsideNurse]

"Watch your numbers, but just jimmy the rate up or down until they look good."

Maybe it's a good thing I didn't go into nursing education.

[MunoRN, RN]

It depends on what version of appropriate analgesia/sedation exists where you work.

There's the 'old-school' version where you just continuously sedate to a RASS of around -3 except for daily 'sedation vacations'.

The next generation is where sedation/analgesia is done using only bolus doses, with additional doses given only once the RASS increases, typically into positive numbers.

More current practice would be a combination of the two, some recommendations are to start initially with bolus doses, using the 'analgesia first' rule, and then after the dosing requirements can be established to take have that hourly amount as a continuous infusion and use prn doses beyond that to achieve analgesia/sedation goals. What those goals are should usually be patient specific, as well as what's used to achieve those goals.