PHYSICIAN'S ORDERS Mark in for desired orders. If is blank, order is inactive. VENTILATOR SEDATION / ANALGESIC / DELIRIUM ORDER

Transcription

1 Nursing Daily awakenings PHYSICIAN'S ORDERS Mark in for desired orders. If is blank, order is inactive. VENTILATOR SEDATION / ANALGESIC / DELIRIUM ORDER Do not perform daily awakenings: Rationale: Daily weaning trials Do not perform daily weaning trials: Rationale: (for use ONLY with intubated and mechanically ventilated patients) Establish functional pain goal and treat pain first. Note: If unable to establish functional pain goal, functional pain goal is FLACC less than 2. Obtain Richmond Agitation Sedation Scale (RASS) as needed per decision tree. Obtain Confusion Assessment Method for ICU (CAM-ICU) Sedation and Delirium Assessment every 12 hours and as needed for neurological change. If on ventilator, initiate ventilator associated pneumonia prevention care. Medications Analgesics Indication: use to control pain morphine sulfate intermittent dosing: mg IV every hours as needed fentanyl intermittent dosing: mcg IV every hours as needed Choose only one morphine sulfate continuous infusion: 30 mg per 30 ml [1 mg per ml] in normal saline solution Bolus mg followed by mg per hour infusion; increase infusion by 1 mg per hour every 15 minutes until functional pain goal achieved. (Not to exceed 12 mg/hr without physician order) Choose only one (Either Precedex, Ativan, Versed, or Diprivan) fentanyl continuous infusion: fentanyl 1500 mcg in 30 ml normal saline solution [50 mcg per 1 ml] Begin infusion at 50 mcg/hr and increase by 25 mcg every 30 minutes until functional pain goal achieved. (Not to exceed 2 mcg/kg/hour without physician order) Sedation Indication: use to achieve RASS score of 0 to -2 Other: dexmedetomidine (PRECEDEX) infusion 200 mcg per 50 ml in normal saline solution [4 mcg per ml] Note: dexmedetomidine (PRECEDEX) is T an amnestic or analgesic Loading dose 1 mcg per kg over 10 minutes followed by infusion rate of mcg per kg, per hour ( mcg/kg/hour). Notify MD for pulse less than or equal to per minute and hold infusion for 10 minutes. Then reduce rate by 0.3 mcg / kg / hour and restart. Notify MD for systolic blood pressure less than or equal to mmhg and hold infusion for 10 minutes. Then reduce rate by 0.3 mcg / kg / hour and restart. LORazepam (ATIVAN) intermittent mg IV every hours as needed. midazolam (VERSED) intermittent: mg IV every hours as needed. LORazepam (ATIVAN) constant infusion: 30 mg in 30 ml normal saline solution [1 mg per ml] Loading dose mg IV, followed by infusion rate of mg IV per hour. Titrate up by mg per hour to desired sedation score or maximum dose of 0.1 mg/kg/hour. Wean LORazepam (ATIVAN) infusion by 1 mg/hour every 30 minutes if RASS score of negative 4 or negative 5 Prescriber's Signature Scanned to pharmacy / entered into TDS by: Orders verified by: *DT171* TRINITY MOTHER FRANCES HOSPITALS AND CLINICS PHYSICIAN ORDERS VENTILATION SEDATION/ANALGESIC/ DELIRIUM ORDER E.F Rev. 4/11 Pg. 1 of 2

2 Choose only one (Either Precedex, Ativan, Versed, or Diprivan) Sedation (continued): PHYSICIAN'S ORDERS Mark in for desired orders. If is blank, order is inactive. VENTILATOR SEDATION/ ANALGESIC/ DELIRIUM midazolam (VERSED) constant infusion: 30 mg in 30 ml normal saline solution [1 mg per ml] Loading dose mg followed by infusion rate of mg per hour. Titrate up by mg per hour to desired sedation score or maximum dose of 15 mg per hour. Wean by 1 mg/hour every 15 minutes if RASS score is negative 4 or negative 5 propofol (DIPRIVAN) constant infusion: [10 mg per ml] Note: No bolus by RN. Not an analgesic. Begin infusion rate at mcg/kg/minute; may increase by mcg/kg/minute every 10 minutes until ordered RASS scale achieved (Not to exceed 50 mcg/kg/minute without physician order). Wean propofol (DIPRIVAN) by mcg per kg per minute if RASS score of negative 4 or negative 5 LABORATORY: Baseline CK and triglyceride levels. Repeat every 72 hours as long as infusion is going. Delirium Indication: delirium as assessed by positive CAM-ICU haloperidol (HALDOL) intermittent mg IV followed by mg every 20 minutes for total of 5 doses Recommended: years old = 10 mg years old = 5 mg Greater than or equal to 71 years old = 2.5 mg Choose only one If initial cycle of haloperidol (HALDOL) not effective, give LORazepam (ATIVAN) mg IV followed by doubling of initial haloperidol (HALDOL) dose IV every 20 minutes times 5 doses. Note: If scheduled dose of haloperidol (HALDOL) needed after 24 hours, a separate order is required. Baseline EKG on chart prior to administering loading dose. Measure QTc interval. Obtain STAT 12-lead EKG after haloperidol loading dose administered. Measure QTc interval. For QTc interval if greater than or equal to 0.45 seconds or greater than 25% of baseline, discontinue haloperidol (HALDOL) and notify MD. Assess and notify physician for extra pyramidal symptoms, altered temperature and neuroleptic malignant syndrome. 12 lead EKG every hours while on haloperidol (HALDOL) for days. To be read by:. ziprasidone (GEODON): intermittent (Contraindicated Acute MI, decompensated heart failure, Prolonged QTc and Amiodarone) 10 mg IM every 2 hours as needed to maximum dose 40 mg per 24 hours for 3 consecutive days. Baseline EKG on chart prior to first dose. Measure QTc interval. Monitor QTc interval if greater than or equal to 0.45 seconds or greater than 25% baseline discontinue ziprasidone (GEODON) and notify MD. Assess and notify physician for extra pyramidal symptoms, altered temperature and neuroleptic malignant syndrome. 12 lead EKG every hours while on ziprasidone (GEODON) for days. To be read by:. Date: Time: (Required) (Required) Prescriber's Signature Cell/Pager: Scanned to pharmacy / entered into TDS by: Printed Name Orders verified by: *DT171* TRINITY MOTHER FRANCES HOSPITALS AND CLINICS PHYSICIAN ORDERS VENTILATION SEDATION/ANALGESIC/ DELIRIUM ORDER E.F Rev. 4/11 Pg. 2 of 2

3 NURSING Guidelines for Ventilator Analgesia, Sedation, Delirium Management Ventilator Analgesia, Sedation, Delirium NURSING Guidelines - See Decision Tree 1. PAIN ASSESSMENT: Assess, record and establish functional pain goal using adult, pediatric, FLACC as indicated by patient condition. If positive: Attempt non-pharmacologic interventions for pain (positioning, massage, etc.). If needed, obtain physician order for pain management - ANALGESIA - Treat pain FIRST - Treat pain before sedation. Goal: Establish functional pain goal with patient. Information regarding analgesic agents: a. morphine - onset: 5 minutes; peak 20 minutes; t½ life hours; duration 4-5 hours. b. fentanyl (DURAGESIC) - If true allergy to morphine; histamine reaction, hemodynamic instability, and renal failure. (onset: 1-2 minutes; peak 3-5 minutes, t½ life 2-4 hours; duration hour). Reassess pain scores every 15 minutes until desired level of pain relief attained - if agitation continues, assess for agitation/delirium as below. 2. AGITATION/DELIRIUM ASSESSMENT: Rule out other causes of agitation: ie. hypoxia, pain, alcohol withdrawal, electrolyte, sepsis or CNS disturbance, and/ or Delirium. a. If suspected ETOH use, asses with CIWA and notify physician for alcohol withdrawal protocol orders if indicated. Assess RASS and record score, if RASS score is negative 3 to positive 4 (- 3 to + 4) THEN a. Assess and record CAM-ICU score. IF CAM-ICU Positive for delirium, call Physician for delirium management orders. IF CAM-ICU Negative for delirium, call Physician for sedation orders and titrate to RASS SCORE of 0 to negative 2 or 3, unless otherwise ordered by Physician. If patient being treated with neuromuscular blockade, implement Bi-spectral analysis monitoring - BIS score to assess sedation and Train of Four testing to evaluate neuromuscular blockade. Reassess pain and RASS scores every 15 minutes until patient reaches desired level of pain relief and sedation, then every 2 hours and as needed. 3. DAILY AWAKENING - Assess daily for ventilator effort; readiness to wean, CNS, sedation and pain levels every morning at CHANGE OF SHIFT. GOAL: determine minimum dose required for sedation. Decrease dose by one half (½) &/or Turn Off sedation infusion. If one half decrease is not sufficient for evaluation, the infusion can be decreased by one half again until sufficient for evaluation. (Do not turn off epidural infusions or analgesic infusions treating pain, unless unable to arouse patient). Off going and on coming nurse will evaluate patient assessment and CNS status. After the assessment is complete, restart sedation at one half previous dose if needed, continue titration to desired level of minimal sedation. Need physician order and rationale to T perform daily awakening. Information regarding sedation agents Short Term Sedation - LESS THAN 72 HOURS usually use midazolam (VERSED), dexmedetomidine (PRECEDEX) or propofol (DIPRIVAN); Long Term Sedation - 72 HOURS OR GREATER usually use LORazepam (ATIVAN) or midazolam (VERSED). See Decision Tree for Titration/Weaning recommendations for the following drugs: 1. midazolam (VERSED) onset: 1-5 minutes; peak - Rapid; t½ life 1-4 hours; duration 2-4 hours 2. LORazepam (ATIVAN) onset: 5 minutes; peak minutes; t½ life hours; duration 6-8 hours 3. dexmedetomidine (PRECEDEX) onset: 15 minutes; peak - one hour; t½ life ~ 3 hours. May be used during ventilator weaning and post extubation; dexmedetomidine (PRECEDEX) DOES T provide amnesia, (usual infusion of 0.2 to 0.7 mcg/kg/hour). Notify physician for persistent hypotension (Systolic < 90 mmhg or bradycardia). If persistent hypotension or bradycardia, hold for 10 minutes and restart at dose reduced by 0.3 mcg/kg/hour unless otherwise ordered by physician. 4. propofol (DIPRIVAN): MUST BE ON A VENTILATOR SUPPORT INTERMITTENT BOLUS DOSING BY RN; onset seconds; t½ life initial 40 minutes; ½ life terminal 4-7 hours; duration 6-8 hours; Must have MD order to titrate above 50 mcg/kg/minute. Change IV tubing and bottle every 12 hours. Order must be renewed every 72 HOURS. Consider alternative drug for sedation if patient on high dose epinephrine, norepinephrine, routine steroids or receiving propofol (DIPRIVAN) for greater than 72 hours.

4 Richmond Agitation Sedation Scale - RASS Score Term Description Score Term Description + 4 Combative Overly combative, violent, immediate danger to staff. - 1 Drowsy Not fully alert, but has sustained awakening (eye opening/eye contact) to voice (greater than 10 seconds). + 3 Very Agitated Pulls or removes tube(s) or catheter(s); aggressive. - 2 Light sedation Briefly awakens with eye contact to voice (less than 10 seconds). + 2 Agitated Frequent non-purposeful movement, fights ventilator. - 3 Moderate sedation Movement or eye opening to voice (but no eye contact) + 1 Restless Anxious, apprehensive but movements not aggressive or vigorous. - 4 Deep sedation No response to voice, but movement or eye opening to physical stimulation. 0 Alert & Calm - 5 Unarousable No response to voice or physical stimulation. Procedure 1. Observe patient: Is patient alert and calm (score 0)? a. Does patient have behavior that is consistent with restlessness or agitation? Score + 1 to + 4 using criteria listed above. 2. If patient is not alert (score less than 0), in a loud speaking voice, state patient's name and direct patient to open eyes, look at speaker. Repeat once if necessary. a. Can prompt patient to continue looking at speaker. Patient has eye opening and eye contact, which is sustained for more than 10 seconds, Score = - 1 (negative 1). b. Patient has eye opening and eye contact but not sustained for 10 seconds, Score = - 2 (negative 2). c. Patient has any movement in response to voice, excluding eye contact, Score = - 3 (negative 3). 3. If patient does not respond to voice, physically stimulate patient by shaking shoulder and then rub the sternum, if there is no response to shaking shoulder. a. Patient has any movement to physical stimulation, Score = - 4 (negative 4). b. Patient has no response to voice or physical stimulation, Score = - 5 (negative 5). 4. If RASS Score - 3 to + 4 proceed to modified Confusion Assessment Method (CAM-ICU).

5 Confusion Assessment Method in the ICU RASS is above - 4 (- 3 through + 4) 1 Delirium Assessment (CAM - ICU): 1 AND 2 AND (Either 3 OR 4) Acute Onset or Fluctuating Course An acute change from mental status baseline? Or Patient's mental status fluctuating during the past 24 hours. No delirium Proceed to Next Step If RASS is - 4 or Inattention Please read the following ten letters: S A V E A H A A R T Scoring: Error: when patient fails to squeeze on the letter "A" Error: when the patient squeezes on any letter other than "A" No delirium Reassess patient at later time 3 ERRORS Altered Level of Consciousness ("actual" RASS) If RASS is zero, Proceed to next step Patient is Delirious RASS 4 Disorganized Thinking 1. Will a stone float on water? (Or: Will a leaf float on water?) 2. Are there fish in the Sea? (Or: Are there elephants in the Sea?) 3. Does one pound weigh more than two pounds? (Or: Do two pounds weigh more than one?) 4. Can you use a hammer to pound a nail? (Or: Can you use a hammer to cut wood?) 5. Command: Say to patient: "Hold up this many fingers? (Examiner holds two fingers in front of patient) "Now do the same thing with the other hand" (Not repeating the number of fingers). If patient is unable to move both arms for the second part, ask patient "Add one more finger". Patient is Delirious No Delirium

6 NURSING Guidelines for Ventilator Analgesia, Sedation, Delirium Management Decision Tree for Ventilator Sedation Protocol Is the patient restless on Mechanical Ventilation? Does the patient's respiratory status show signs of hypoxia? Does the patient show evidence of pain? (0-10; Pediatric smiley faces, FLACC) Does the patient show signs of or have the potential for alcohol withdrawal? Does the patient show evidence for other potential causes of agitation, such as CNS dysfunction, sepsis (SIRS criteria), electrolyte imbalances or Delirium as evidenced by a positive CAM-ICU? Continue to monitor hourly & more frequently if condition warrants, and reassess for pain & sedation needs. If hypoxia present: assess airway patency, ETT position, proper ventilator function, and need for suctioning. Continuous pulse oximetry is required. Take appropriate measures to resolve respiratory problems. If pain is present, obtain & implement order for pain medication - REMEMBER: Treat pain prior to sedation! Assess with CIWA & implement protocol. If ETOH withdrawal present or potential for withdrawal, assess using CIWA. Notify physician. If other causes present, TIFY physician and institute appropriate physician directed treatment to resolve the problem. Is the patient currently on a sedative infusion? Titrate infusion to RASS score per order. Usually ZERO to Negative 2 (0 to - 2). Obtain physician order for ventilator sedation protocol. Ensure appropriate analgesia prior to sedation. Administer sedation at appropriate rate per protocol. If RASS score of + 1 or higher, titrate infusion up per protocol: LORazepam (ATIVAN) 1 mg every 30 minutes midazolam (VERSED) 1 to 2 mg every minutes propofol (DIPRIVAN) 5 to 10 mcg/kg/minute every 5-10 minutes dexmedetomidine (PRECEDEX) 0.1 mcg/kg/hour at 5 minute intervals Assess RASS sedation level every 15 minutes times 1 hour after initiation of infusion & after each titration. Assess patient's sedation level every 2 hours & as needed while on maintenance drip. Continue titration until patient reaches desired ordered RASS score (usually 0 to - 2) unless otherwise specified by the physician. Then assess sedation level every 2 hours and as needed. Titrate infusion as necessary to maintain desired RASS score. If patient reaches RASS score - 4 or - 5, decrease infusion by appropriate increments per protocol, unless otherwise specified by physician. Assess sedation every 15 minutes times 1 hour after titration, then every 2 hours and as needed. Daily awakening from sedation must be performed at AM shift change. On-coming and off-going nurse to assess CNS function, readiness to wean, and pain & sedation levels. See protocol orders for awakening protocol for weaning and restarting infusion. Neurologic function must be compared to pre-sedation baseline. Notify physician for any variations from baseline. Notify physician for inability to complete daily awakening.