Weaning/extubating vented patients

Our unit is looking at making changes to the weaning/extubation process for vented patients. Currently they get orders to start the weaning in morning report, but with the delays of the day, it often gets pushed until later in the day when the pulmonologists are no longer on the unit. We're a small hospital and do not have continuous provider staffing. A proposal has been made that night shift wean sedation at 5am so patients will be evaluated for extubation before day shift arrives.

One of our concerns, for example, is that if sedation is stopped, we technically need a new order and have to follow the protocols like increasing propofol by 5 mcg/kg/min every 5 minutes, and it will make re-sedating agitated patients very challenging. We also have many ETOH detoxers that are intubated, and they're often difficult to sedate, so turning down sedation at 5am when we're doing labs, meds and care could also be a challenge.

Any insight into practices on other units would be appreciated.

For younger, agitated or alcoholics, Precedex is a much better sedation for weaning than diprivan. You don't even need to turn it all the way off for extubation.

We start weaning off sedation around 6am. Usually have orders for mittens to be applied just in case they awake enough to pull at lines, IVs, etc.

Our providers write orders for "Sedation vacation at _____" (usually 0500 so they can see the patient on their 0600 handoff rounds; sometimes 0800 which the night shift RNs and RTs like much better!). I chart that I stopped their sedation gtts (probably some combo of Propofol/Versed/Fentanyl/Precedex/Ketamine) in the MAR and then if we don't extubate I chart that I turned them right back on at the levels they were at before. I definitely don't need an order to "restart" the drip, and even if I did I wouldn't titrate it up as though I was titrating a "new" drip. Sometimes we let patients do spontaneous breathing for a couple of hours (depends on the patient) and let their sedation wear off a little more. Our MAR allows us to do a handoff of a critical gtt that's stopped--that's what we chart--so I don't have any discomfort with handing off a stopped Versed gtt to the day nurse and knowing that they will either restart it if need be or take it down and waste it during their shift.

For patients who I know will be really wild I have the same concerns as you do--holding their sedation right when we're getting ready for shift change *and* the doctors are coming around writing new orders on everyone is not my favorite. We usually do our labs around 0400, but there's always some other new order to take care of! We restrain if we have to; we don't need an order for mittens.