Sedation Vacation

[IHeartDukeCTICU]

Hey all, so I'm one of the co-chairs of the safety/clin practice committee in the CT-ICU and we are in the process of implementing a "Sedation Vacation" protocol. I'm trying to gather more information on it from people who may have a protocol in place on their units.

For those who may not know what it is:

For patients who are sedated/paralyzed, a sedation vacation is a daily or shift assessment where the sedation is weaned or turned off to allow a neurovascular check and assess readiness to extubate. This applies to patients who are hemodynamically stable enough to tolerate being off sedation. If pt requires sedation during trial, sedation is restarted at 75% rate.

That's the basics of it, we are looking at initiating the sedation vacation at 0600, during our AM house officer shift change and then continuing until grand rounds are over, usually at 0800-0900. This would allow adequate time for sedation/paralyzation to wear off, and allow for neuro checks. After initiation of protocol, basic neuro check qhour... ours is leaning towards three criteria (awake, moving extremities, and following commands). If the three criteria for basic neuro aren't met, then further detailed neuro check is requires i.e. cranial nerves etc. Additionally, sedation is left off until pt is arousable, HO is notified every hour until so, then either d/ced or restarted.

Most of the other ICU's here have some sort of protocol here, however our pt's are rarely sedated longer than 24 hours. I know it's pretty much common sense to try and get an underlying neuro assessment on pt's who are on sedation ASAP, especially on prolonged sedation, however we have nothing official in place.

I'm looking at a few studies regarding this protocol, however it would be nice to see what other hospitals and units do. My specific questions:

1. Is your protocol initiated for every patient who is sedated, or just for patients who are prolonged... and what does your unit considered prolonged?

2. What is your unit's criteria for being "hemodynamically stable" enough to tolerate a sedation vacation protocol (i.e. open chest, ECMO, combative, crap hemodynamics)

3. Is your sedation vacation assessment a daily or qshift thing?

4. If you have a protocol in place, has your average LOS and length of mech ventilation improved?

Any opinions would be great! Any more information about your protocols or any new ideas would be much appreciated, thanks all!

Brian

[HiHoCherry-O]

For most of our intubated patients we do a daily "sedation vacation." The RT's do a SBT (spontaneous breathing trial) every morning during which all sedation is turned off (or substantially lightened). We monitor how well the patient responds and the RT draws a blood gas after an hour. We also check to see how well our patient responds to our commands. If the patient does not do well, especially RT wise, the RT will put them back on a rate and sedation will be re-initiated. Sometimes it can be reinitiated at a lower amount; sometimes not. Even for patients we know will not be extubated anytime soon, we still do a sedation vacation to check neuro.

[icurn99]

We do daily drug holidays at 6 am. Sedation is stopped, then restarted at 1/2 the rate it was running when the patient reaches a riker score of 1....depending on how it's tolerated. We also do as the poster above notes...RT does a SBT...ABG's..

[mpccrn, BSN, RN]

We do sedation vacations on every patient. It not only gives us time to evaluate the neuro statis of the patient, their readiness for extibation but also allows a better idea of how much sedation is actually needed for the patient. Too sleepy is not always good, comfortable is better. We do VS and a Ramsey scale every 15 minutes during the trial. Hope this helps.