Sedation Hold/Interruption and Weaning Protocol ( Wake-up and Breathe )

Transcription

1 PROTOCOL Sedation Hold/Interruption and Weaning Protocol ( Wake-up and Breathe ) Page 1 of 6 Scope: Population: Outcome: Critical care clinicians and providers. All ICU patients intubated or mechanically ventilated and receiving sedative and/or analgesic therapy and who meet the inclusion criteria, unless otherwise ordered by prescriber. Minimization of prolonged sedation; facilitated weaning from mechanical ventilation in an effort to reduce complications associated with prolonged sedation and ventilation during ICU admission. Protocol: Outcome Measures and Assessment: Patients on continuous infusion (CI) or around the clock (ATC) sedatives and who do not have any contraindication to sedation hold/interruption or weaning will have their sedatives turned off, held or weaned down until they wake up to a target Richmond Agitation-Sedation Scale (RASS) of -1 to +1. Patient tolerating hold/interruption will be evaluated for: Changes in mental status, Depth/level of sedation using Richmond Agitation-Sedation Scale (RASS) Discomfort/pain using Numerical (NRS), Visual Analog (VAS), or Behavioral Pain Scale (BPS) Presence of delirium using Confusion Assessment Method for the ICU (CAM-ICU) Need for continuing sedative therapy Readiness for Spontaneous Breathing Trials (SBT). Patient s further needs based on the evaluation above will be managed per established therapy, guidelines and/or protocols. Activation of Protocol: Each ICU will designate a specific time frame for Wake up & Breathe Provider will enter order for sedation hold and SBT per protocol/guideline RN/RT will evaluate patient according to inclusion/exclusion criteria Any RN/RT questions or concerns will be directed to the provider re: patient eligibility. Patient eligibility for sedation weaning and hold and SBT will be confirmed using the exclusion/inclusion criteria. RN and RT will collaborate to facilitate activation of sedation weaning and hold procedure. o RN and RT will coordinate timing of sedation weaning and hold to avoid having multiple patients off sedation at the same time. Active sedation weaning and hold will be initiated accordingly by RN. Spontaneous breathing trial will be conducted by RT. Documentation of sedation hold and spontaneous breathing trial will be reflected in electronic health record (HER).

2 Page 2 of 6 Sedation Hold/Interruption/weaning and Dose Adjustment Ensure that adequate PRN sedative order is available for backup when initiating sedative hold/interruption or weaning 1. Inclusion Criteria Stable patients on continuous sedative infusion who only use occasional-as needed (PRN) sedative/analgesic for nursing care (turns, suctioning, etc) or procedures. Stable hemodynamics: no significant cardiac dysrhythmias, no evidence of active bleeding. FI02.50; peak pressure 35 and PEEP 5 cm H 2 0 Patients on around the clock (ATC) sedative/analgesic who have not required any PRN in the past 12 to 24 hours OR who only need occasional PRN for nursing care or procedures. 2. Exclusion criteria or contraindication to wake-up protocol Patients with APRV ventilation mode Clinical evidence of hypoxia Active treatment for alcohol withdrawal or delirium tremens (DTs) Severe acute respiratory distress syndrome (ARDS), severe acute lung injury (ALI), status asthmaticus Actively dying or CMO/palliative care patient Current treatment of status epilepticus or active seizures Elevated intracranial pressures Concomitant use of neuromuscular blocking agent Patients receiving continuous infusion of lorazepam/midazolam/propofol for >7 days without daily wake up performed previously Presence of severe ventilator dysynchrony/agitation Hemodynamic instability (use of multiple vasoactive agents, myocardial ischemia, cardiac dysrhythmias including uncontrolled tachycardias) 3. Sedation hold or weaning-nursing procedure Continuous infusion of sedative will be held or reduced by some percentage (25-50%) until patient wakes to RASS of -1 to +1 or increased agitation ensues Ensure that adequate PRN sedative order is available for backup when initiating sedative weaning. Weaning of specific sedatives o Propofol: decrease infusion by 5 mg/kg/min every 15 minutes until the patient wakes to RASS of -1 to +1 (responds to command and is cooperative) or o indication for termination of sedation lightening ensures. Midazolam/lorazepam: stop infusion or hold subsequent around the clock (ATC) dose until patient wakes up to RASS of -1 to +1 or indication for termination of sedation lightening ensures. If sedation weaning or hold is tolerated, proceed to SBT and evaluate for re-sedation need. If not tolerated, terminate sedation weaning or hold.

3 Page 3 of 6 4. Indication for termination of sedation weaning or hold Sustained tachycardia or sustained increase or decrease in heart rate >20% of baseline. New onset cardiac dysrhythmias or evidence of myocardial ischemia. Sustained hypertension or sustained increase or decrease in blood pressure >20% of baseline Increasing intracranial pressure. Signs of withdrawal o Sedatives: agitation, anxiety, dysphoria, hallucination, nausea, tremors, muscle cramps, sweating, seizures, etc. Sustained difficulty in ventilating patients, i.e. biting endotracheal tube (ETT), ventilator dyssynchrony. Severe agitation, pain or anxiety (i.e. RASS >+2) SpO2 <92% or 4% decrease from baseline Spontaneous breathing trial Respiratory Therapist (RT) will assess ventilated patients every shift for RSBI, cough, secretions and NIF. RT will perform spontaneous breathing trail (SBT) on eligible patients who tolerate sedation hold/interruption or weaning and meet the inclusion criteria. 1. SBT inclusion Criteria Patient eligibility for SBT will be confirmed using the following criteria: o P/F ratio >200 o PEEP 5 cm H 2 0 o Good cough reflex/manageable secretions o NIF better than -20 cm H 2 0 o RSBI f/vt105 or less or tube compensation (TC) 2. Trial ½-1 hour Zero pressure support except: if ETT < 8 mm then PS 5-8 cm H 2 0 or TC (tube compensation) PEEP not >5 cm H20 except; CHF or fluid overload use zero PEEP or ZEEP RN/RT/Provider will collaborate to determine patient tolerance to SBT which may be aborted due to: o Sustained tachycardia o Increased work of breathing o Evidence of hypoxia/oxygen desaturation o Sustained tachycardia or significant change from baseline o New onset of cardiac dysrhythmia o Hemodynamic instability including hyper or hypotension o Anxiety, diaphoresis, agitation Evaluate patient for extubation if SBT is tolerated or re-sedation if not a candidate for extubation

4 Page 4 of 6 Assessment and documentation 1. Expected nursing documentation on electronic flow sheet Sedation Hold (Include time frame) Yes No Aborted Spontaneous Breathing Trial (Include time frame) Yes No Aborted Time of re-sedation and current rate when applicable Use of PRN sedatives-order should be active during sedation interruption. CAM-ICU status, RASS and or pain score before each PRN bolus use and/or dose titration 2. Expected respiratory documentation Ventilator Weaning Parameter section on flow sheet Outcome summary statement 3. Patient evaluation: Once patient wakes up to desire RASS score (-1 to +1) and is tolerating sedation weaning or hold, continue to evaluate as indicated. Hemodynamics-patient s heart rate, blood pressure, oxygen saturation, and respiratory rate Pain/discomfort using numerical or Behavioral Pain Scale and treat if present. Delirium using modified CAM-ICU and treat if present, Determine need for re-sedated and determine RASS for the day 4. Re-sedation if not a candidate for extubation and/or re-sedation Restart at 50% of previous dose after assessment and no agitation If agitated during or shortly after assessment, give a PRN bolus and restart at 50% of previous dose. If agitation persists with patient needing > 3 PRN doses in 4 hours, increase drip to 75% of previous dose and then to original rate if necessary. New order is required if there is need to exceed the original sedative rate Assess and document RASS and or pain score before each PRN bolus use and/or dose titration Use table below as guide for re-sedation of who did not tolerate sedation interruption.

5 Page 5 of 6 Agent Propofol (decrease dose per guideline) Midazolam, Lorazepam (hold therapy) Dosage Adjustment If patient awaking (RASS score of +1) occurs: Less than 15 minutes, increase to previous rate Between minutes, restart at 75% previous rate of infusion Greater than 30 minutes, restart at 50% of previous rate of infusion If patient awaking (RASS score of +1) occurs: Less than 60 minutes, restart previous rate of infusion Between 1-2 hours, restart at 50% of previous rate of infusion If greater than 2 hours but less than 3 hours, restart at 25% of previous rate If greater than 3 hours, hold infusion until patient wakes up and consider converting to intermittent dose Progressive weaning: Patients not meeting criteria for daily sedation weaning or hold but are not requiring PRN sedatives except occasional-as needed use for nursing care (turns, suctioning, etc) or for procedure will participate in progressive weaning using the table below as a guide. 1. Continuous infusion: Wean according to table below Weaning sedatives DURATION (DAYS) WEANING RATE TARGET D/C (DAYS) Short term 4-6 by 50% initially then 25% every 6 hours till off 2 days Mid-term 7-14 days by 30% initially, then 20% every days hours till off Long term >15 by 20-30% QD x 2 days then 4-7 days days Preadmission opiate weaning to 10-20% QD till off Follow above guidelines to preadmission opioid equivalent dose -Weaning rate should be based on patient assessment Convert to long acting oral or transdermal therapy 2. Around the Clock (ATC) dosing: Hold the next scheduled dose of sedative if patient have not required any PRN dose (except dose for nursing care) in 12 to 24 hour till they wake to RASS score of -1 to +1 (responds to command and is cooperative) or indication for termination of sedation hold/interruption ensues. If well tolerated, decrease dosing frequency to the next interval (q6h to q8h, q8h to q12h, etc.); if not, maintain the same regimen and try again in 24 hours.

6 Page 6 of 6 Transitioning of therapy 1. CI to ATC: Stable patients who have tolerated significant dose reduction through daily hold/interruption or progressive slow wean should be converted to ATC dose equivalent to 24 hour requirement, administered in 4 to 6 doses, followed by daily interruption/weaning as stated above. 2. IV to Oral (PO): Patients on lower CI or IV ATC dose should be converted to oral therapy as soon as adequate oral intake ensured, followed by daily hold/interruption or continuous weaning. 3. Chronic sedative therapy: Patients on long-term therapy prior to admission will be weaned down and converted to their home dose or its equivalent with adequate PRN dosing once acute issues have resolved. Appendix A: Richmond Agitation-Sedation Scale (RASS) Score Term Description +4 Combative Overtly combative or violent; immediate danger to staff +3 Very agitation Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff +2 Agitated Frequent non-purposeful movement or patient-ventilator dyssynchrony +1 Restless Anxious or apprehensive but movements not aggressive or vigorous 0 Alert and calm Calm, awakens easily, follows commands -1 Drowsy Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice -2 Light sedation Briefly (less than 10 seconds) awakens with eye contact to voice -3 Moderate Any movement (but no eye contact) to voice sedation -4 Deep sedation No response to voice, but any movement to physical stimulation -5 Unarousable No response to voice or physical stimulation Key Word Search: Sedation hold/interruption or weaning; spontaneous breathing trial (SBT); wake-up and breathe, NRS, VAS, BPS, CAM-ICU, RASS Issued: 9/2009 Proponent: Critical Care Committee (Sedation Subcommittee-) Replaces: Approved by: Therapeutics Committee 9/21/09, Medical Executive Committee 11/2/09 Reviewed: Revised: June/2011