MECHANICAL VENTILATION SEDATION PLACE LABEL HERE

CRITICAL CARE

ORDERS

The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

1. Assess and document Richmond Agitation Sedation Scale (RASS) q 2 hr. Maintain goal of: ______

Richmond Agitation Sedation Scale (RASS)
Score / Description / Definition
+4 / Combative / ·  Overtly combative, violent, immediate danger to staff
+3 / Very Agitated / ·  Pulls or removes tube(s) or catheter(s); aggressive
+2 / Agitated / ·  Frequent non-purposeful movements, fights ventilator
+1 / Restless / ·  Anxious, but movements are not aggressive, vigorous
0 / Alert and Calm / ·  Alert, able to follow simple commands
-1 / Drowsy / ·  Not fully alert, but has sustained awakening – eye opening/eye contact to voice (10 seconds)
-2 / Light Sedation / ·  Briefly awakens with eye contact to voice (<10 seconds)
-3 / Moderate Sedation / ·  Movement to eye opening or voice (but no eye contact)
-4 / Deep Sedation / ·  No response to voice, but movement or eye opening to physical stimulation
-5 / Unarousable / ·  No response to voice or physical stimulation

2. Assess and document pain q 2 hrs

3. Spontaneous awakening trial (SAT)

· Sedation Vacation q 24 hrs between 0700 - 1200

·  Hold all sedative and narcotic infusions.

·  The goal of the sedation vacation is to achieve a RASS of -1 to 0

·  Coordinate SAT with respiratory therapy and physician

· Check with the physician prior to performing SAT for patients with sedative infusions for active seizures, ethanol withdraw (CIWA Score ≥ 10), excessive agitation, or requires FIO2 ≥ 50% or PEEP > 8cm H2O to maintain SpO2 ≥ 88%

·  If re-sedation indicated (RASS of +2 or greater) and vacation over 4 hrs, change to intermittent sedation as needed to maintain target score

·  If sedation vacation < 4 hrs, resume continuous infusion at ½ of original rate after a bolus dose

o  Exclude patients with High frequency ocilation ventilator (HFOV), Neuromuscular Blocking Agents, Intracranial Pressure (ICP) monitoring or elevation, Uncontrolled arrhythmias, or Active myocardial ischemia within the last 24 hrs

The following orders will be implemented. Orders with a “q” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

4. Neuro Patients: q Do not perform wake-up assessment

q Perform wake-up assessment using guidelines below:

Diprivan (propofol): Perform wake-up assessment at scheduled times: 0400, 0800, 1200, 1600, 2000, 2400.

Allow RASS score to elevate to ≥ -1. When performing a wake-up assessment on Diprivan (propofol), decrease rate 5–10 mcg/kg/min every 5 – 10 min until RASS equal to -1 or 0

All other Anxiolytics or Analgesics: Perform sedation vacation as stated above

MEDICATIONS:

5.  Consider a combination of an analgesic and an anxiolytic for synergistic effect.

May use combination of intermittent and continuous if needed.

INTERMITTENT IV SEDATION/ANALGESIA:

If RASS is greater than ordered level and SBP > 90, give:

Analgesic (check one): q Fentanyl 25 - 100 mcg IV push q 2 hr prn

q Morphine 1 - 4 mg IV push q 2 hr prn

Anxiolytic (check one): q Versed (midazolam) 2 - 5 mg IV push q 1 hr prn

q Ativan (lorazepam) 0.5 - 2 mg IV push q 1 hr prn

If able to maintain goal RASS with boluses more than 2 hrs apart, continue to administer intermittent sedation

If patient requires boluses more frequently than q 2 hrs, notify physician to consider continuous sedation

CONTINUOUS INFUSION MAINTENANCE:

Analgesic (check one):

q Fentanyl: Continuous infusion: 0.05 - 5 mcg/kg/hr IV, initiate at lowest end of range after prn bolus

If titration upward needed, increase by 25 mcg/hr

PRN bolus: Fentanyl 25 mcg every 1 hr prn

q Morphine: Continuous infusion: 1 - 10 mg/hr IV, initiate at lowest end of range after prn bolus

If titration upward needed, increase by 1 mg/hr

PRN bolus: Morphine 2 - 4 mg q 1 hr prn

Anxiolytic (check one):

q Versed (midazolam): Continuous infusion: 0.5 - 10 mg/hr IV, initiate at lowest end of range after prn bolus

If titration upward needed, increase by 1 mg/hr

PRN bolus: Versed (midazolam) 0.5 - 2 mg IV push q 1 hr prn

q  Ativan (lorazepam): Continuous infusion: 0.5 - 10 mg/hr IV, initiate at lowest end of range after prn bolus

If titration upward needed, increase by 1 mg/hr

PRN bolus: Ativan (lorazepam) 0.5 - 2 mg IV push q 1 hr prn

q  Diprivan (propofol): Continuous infusion: start at 5 mcg/kg/min

May increase in increments of 5 - 10 mcg/kg/min q 10 min prn

Lab: Triglyceride level every 3 days if on Diprivan (propofol)

q  Precedex (dexmedetomidine) Continuous infusion: 0.2 - 1 mcg/kg/hr x 48 hours

6. Reversal agent for:

Fentanyl or Morphine: Narcan (naloxone) 0.4 mg IV in 10 ml NS, 0.5 ml q 1 min until change in alertness or max of 10 mg

Versed (midazolam) or Ativan (lorazepam): Romazicon (flumazenil) 0.5 mg IV q 5 min up to 3 mg total dose

7. Isopto Tears (hypromellose) 2 drops in each eye q 6 hrs prn dry eyes, if not already ordered.

8. Peridex (chlorhexidine) oral rinse 15 ml po BID, if not already ordered.

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Date Time Physician Signature PID Number

Copy to pharmacy

FORM 3-15395 REV. 12/2014 Page 2 of 2