Sedation vacation for pt on paralytics

Altra, BSN, RN · May 23, 2012

Daily wakeups are performed to assess neuro status - they are not part of the VAP protocol.

A patient that additionally requires continuous paralytics will not get the daily wakeup - they are too unstable.

Perpetual Student · May 23, 2012

Daily wakeups are performed to assess neuro status - they are not part of the VAP protocol.
A patient that additionally requires continuous paralytics will not get the daily wakeup - they are too unstable.

Not to mention you're not going to get a useful neuro exam on someone who's paralyzed. And of course it would be incredibly cruel to let someone be awake and paralyzed, unable to communicate.

Creamsoda, ASN, RN · May 23, 2012

If your paralyzing them its for a reason. usually oxygenation/ventilation issues and you need total control. Untill those issues are resolving, no please dont suddenly stop giving them their paralytics and sedation just for a "sedation vacation". It would be contraindicated. Discuss with the MD in rounds and let them decide when to start working on weaning. Things like seizures, ETOH withdrawl, aggitation, paralytics, myocardial ischemia, high dose pressors, high ICP, high FIO2/ vent settings, arrythmias are all reasons to leave em be.

Creamsoda, ASN, RN · May 23, 2012

Daily wakeups are performed to assess neuro status - they are not part of the VAP protocol.
A patient that additionally requires continuous paralytics will not get the daily wakeup - they are too unstable.

I would disaree in that its not part of VAP...preventing VAP focuses on earliest possible extubation and doing daily sedation vacation will help assess neuro status and readiness for extubation. The sooner the tube is out the better. An ETT is just another source of possible infection that is bypassing a natural barrier to introduce bacteria.

Karolyte · May 24, 2012

Thank you all for your input.

Zookeeper3 · May 26, 2012

creamsoda... the point is that any patient on a paralytic is not, a candidate for a sedation vacation. i'm thinking your not an icu nurse and thats ok. but vap protocols are different than intubation weaning protocols. your patient has to be on 60-% fio2 or less and definately not on a paralytic to even wean... a vap protocol might say hob >30 degrees and oral care q4hr.

you don't need to assess readiness for extubation, because any patient that is paralyzed...... isnt.

i would disaree in that its not part of vap...preventing vap focuses on earliest possible extubation and doing daily sedation vacation will help assess neuro status and readiness for extubation. the sooner the tube is out the better. an ett is just another source of possible infection that is bypassing a natural barrier to introduce bacteria.

sauconyrunner · May 26, 2012

The sedation Vacation is to assess readiness for extubation (and neuro status in general). Taking down the sedation on a patient in itself will not prevent VAP. DUring a Sedation vacation, some other things are sometimes done, such as adjusting the vent rate, to see how well the pt is breathing with less vent support.

Getting the tube out quickly will help to prevent VAP. So yes, a sedation Vacation will help assess for it, but in a patient who is clearly not ready to be extubated, the sedation vacation is not going to do anything to prevent VAP. In fact, in a patient that is not ready to be extubated turning down sedation can make VAP more likely, as they may become agitated and microaspirate or just plain aspirate.

But if you have a patient on paralytics, they are on them for a reason, and are not ready for extubation.

So I want to be clear that Most ICU patients are sedated, but NOT on paralytics. Use of a Paralytic is for certain circumstances and is not the norm for an ICU patient, (though it may be more the norm in certain ICU settings.

Good Morning, Gil · May 26, 2012

Also, it would be cruel and unusual to give someone on paralytics a sedation vacation. Think about what a paralytic does. The patient is paralyzed, but can feel, hear everything (assuming their neuro status is intact), but cannot move their body at all. That would be truly awful. That is why you never start a paralytic until after you have started continuous sedation on your patient, and you assess their baseline TOF.

You will learn all of this as you get into your ICU clinical experiences, though. And, a patient on a paralytic is very unstable for any number of reasons. Paralytics are rare in my ICU, as well.

Scarlette Wings · May 27, 2012

At my facility the sedation vacation is part of the VAP protocol and the VAP bundles in infection controls risk assessment. It is used as a neuro and respiratory assessment and to see if the patient is ready for weaning and capable of following commands. The sooner a patient can breath on their own and maintain their Sats then the sooner they can be weaned and extubated which does decrease the potential for a vent associated pneumonia. It part of an entire bundled process used with vent patients.

Creamsoda, ASN, RN · May 31, 2012

creamsoda... the point is that any patient on a paralytic is not, a candidate for a sedation vacation. i'm thinking your not an icu nurse and thats ok. but vap protocols are different than intubation weaning protocols. your patient has to be on 60-% fio2 or less and definately not on a paralytic to even wean... a vap protocol might say hob >30 degrees and oral care q4hr.
you don't need to assess readiness for extubation, because any patient that is paralyzed...... isnt.

i am an icu nurse. i think you misunderstood my posts. my 2 posts are in response to 2 different issues. no kidding you dont do sedation vacation on a paralyzed patient. i said that in my first post.

these are all reasons that we clearly do not interupt sedation(things like seizures, etoh withdrawl, aggitation, paralytics, myocardial ischemia, high dose pressors, high icp, high fio2/ vent settings, arrythmias are all reasons to leave em be. )

sedation vacations on an appropriate patient who is weaning off the vent, minimizing sedation to assess readiness to extubate is certainly part of vap protocols. the longer that ett is in, the higher risk of them gettin vap

i hope that clears it up

Creamsoda, ASN, RN · May 31, 2012

At my facility the sedation vacation is part of the VAP protocol and the VAP bundles in infection controls risk assessment. It is used as a neuro and respiratory assessment and to see if the patient is ready for weaning and capable of following commands. The sooner a patient can breath on their own and maintain their Sats then the sooner they can be weaned and extubated which does decrease the potential for a vent associated pneumonia. It part of an entire bundled process used with vent patients.

That was the point I was trying to get across. If were not doing daily sedation vacations on appropriate intubated candidates we run the risk of keeping them intubated longer than necessary. Its all part of the bundle.