8. Providing Sedation to the Critically ill

Question 1

A pt who is agitated (even a pt with a medical, rather than surgical diagnosis) should FIRST receive

Answer 1

an analgesic (analgesia-first sedation) BEFORE receiving anxiolytics.

Question 2

The degree of sedation (the sedation goal) should be based on

Answer 2

the needs of the pt and should be agreed upon by and communicated to all members of the health care team.
This sedation goal applies to the sedation provided during a procedure and to the sedation provided as part of the therapeutic plan of care.

Question 3

Maintaining _____ of sedation in adult ICU pts is associated with improved clinical outcomes.

Answer 3

light levels.

(improved clinical outcomes: i.e. a shorter duration of mechanical ventilation and a shorter ICU length of stay).

Question 4

When sedation is provided on an as-needed basis

Answer 4

(a PRN basis), there is less of a possibility of over sedation than there is when sedation is provided with a continuous infusion.

Question 5

Daily interruptions of continuous infusions of sedation agents allows for

Answer 5

an assessment of further need for the sedation agent and a neurological assessment of the pt.

Question 6

Nonpharmacological treatment

Answer 6

(massage, music, cold therapy, and relaxation techniques) should be considered BEFORE using an anxiolytic agent, especially for mild anxiety and agitation.

Question 7

The levels of sedation are:

Answer 7

-Minimal (Light) Sedation
-Moderate Sedation
-Deep Sedation
-General Anesthesia

Question 8

Minimal (Light) Sedation

Answer 8

Pt responds normally to verbal commands.

Question 9

Moderate Sedation

Answer 9

The pt responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. the pt is able to maintain a patent airway.

Question 10

Deep Sedation

Answer 10

The pt cannot be easily aroused but responds purposefully to repeated or painful stimulation. The pt may require assistance in maintaining a patent airway. Deep sedation is generally only used during a procedure by providers with specialized privileges or is ongoing for a pt receiving mechanical ventilation.

Question 11

General Anesthesia

Answer 11

This is a loss of consciousness during which pts are not arousable, even by painful stimulation.

Question 12

The level of sedation may exceed the level intended; therefore the RN

Answer 12

needs to be able to identify when this occurs and act accordingly

Question 13

Assessment of Agitation and Sedation

Answer 13

-Rule out hypoxemia, hemodynamic instability, and pain as causes of agitation. If any of these are present, treat accordingly.

-Assess for additional etiologies (table 5-7)

Question 14

Physiological Causes of Agitation in Critically Ill Patients

Answer 14

-Hypoxemia
-Hemodynamic Instability (shock)
-Pain
-Delirium (hyperactive)
-Withdrawal from ETOH, drugs
-Dyspnea
-Immobility
-Sleep deprivation

Question 15

Pharmacological Causes of Agitation in Critically Ill Patients

Answer 15

-Anesthetics
-Sedatives
-Analgesics
-Steroids
-Bronchodilators

Question 16

Emotional Causes of Agitation in Critically Ill Patients

Answer 16

-Preexisting anxiety disorders
-Preexisting psychoses
-Dementia
-Fear
-Anger

Question 17

Environmental Causes of Agitation in Critically Ill Patients

Answer 17

-Noise, alarms
-Lights
-Too cold or warm
-Restraints
-Tubes, lines
-Odors
-Isolation
-Sensory deprivation
-Sensory overload

Question 18

Use a valid and reliable sedation assessment tool for

Answer 18

measuring the quality and depth of sedation before and after treatment.

-The Richmond Agitation-Sedation Scale (RASS) and the Sedation-Agitation Scale (SAS) are valid and reliable sedation assessment tools that are used for adult critical care pts.

Question 19

Treatment with Select Sedation Agents

Answer 19

See Table 5-8 for select sedation agents that are commonly used for an acute/critically ill pt. THE DOSE THAT IS GIVEN MAY VARY DEPENDING UPON UNIT PROTOCOLS.

**Note that memorization of exact dosing is not generally needed for exam. But you need to understand how to manage a pt who requires types of sedation: intermittent, continuous, and procedural (minimal and moderate).

Question 20

Dexmedetomidine

Start Dose:

Titration Time/Dose:

Usual Dose Range:

Nursing Implications:

Answer 20

aka Precedex.

Start dose for Continuous Infusion: Begin at 0.2 - 0.4
mcg/kg/hr, titrate to goal RASS score.

Titration Time/Dose: If goal RASS score is not achieved,
titrate by 0.1 mcg/kg/hr q 15 min.

Usual Dose Range: 0.2 - 1.7 mcg/kg/hr

Nursing Implications:
-Loading dose not recommended due to risk of
hypotension and bradycardia

- Do NOT paralyze pts while they're on 
    dexmedetomidine

 -The pt may not need to be mechanically ventilated 
     while on this medication

-Sedation vacation may not be indicated.

Question 21

Ketamine

Start Dose:

Titration Time/Dose:

Usual Dose Range:

Nursing Implications:

Answer 21

aka Ketalar

Start Dose:
-IV Bolus: 1 - 2 mg/kg IV over 1 min followed by
0.25 - 0.5 mg/kg IV q 5 - 10 min if needed.
-Continuous Infusion: 0.5 - 1 mg/kg/hr

Titration Time/Dose:
-Continuous Infusion: Titrate by 0.25 mg/kg/hr q 30
min; max infusion dose 3 mg/kg/hr for sedation

Usual Dose Range:
-Sedation: 0.5-2 mg/kg/hr
-Refractory Status Epilepticus: 0.5-5 mg/kg/hr

Nursing Implications:
-Give slow IV push over at least 1 minute; faster rates
of administration may cause respiratory depression

-May cause increase in BP and/or HR or
hypersalivation

 -May produce psychosis, including auditory and 
   visual hallucinations; pretreatment with a 
    benzodiazepine reduces incidences of psychosis

Question 22

Lorazepam

Start Dose:

Titration Time/Dose:

Usual Dose Range:

Nursing Implications:

Answer 22

aka Ativan

Start Dose:
-Loading Dose: 1-4 mg IVP q 30 min until goal RASS
score or CIWA score
-Continuous infusion: 1-2 mg/hr

Titration Time/Dose:
-Intermittent Bolus: Titrate by 1-2 mg/hr q 1 hr until
sedation goal is achieved; if RASS score or CIWA
score is not achieved, re-bolus with MIDAZOLAM
2 mg IV q 10 min to a max infusion rate of 10 mg/hr

Usual Dose Range: 1 - 20 mg/hr

Nursing Implications:
-Contact the physician if a rate > 10 mg/hr is needed
-Turn off daily and assess unless a contraindication
exists for sedation vacation; attempt to manage
sedation with PRN dosing with midazolam; if you
need to resume the infusion, resume at half the
previous dose.
-Use a 0.22-micron filter for continuous infusions
-Consider checking the serum osmolarity if > 10 mg/hr
is needed.
-Doses > 20 mg/hr have been associated with
metabolic acidosis and renal insufficiency due to
solvent, propylene glycol.

Question 23

Midazolam

Start Dose:

Titration Time/Dose:

Usual Dose Range:

Nursing Implications:

Answer 23

aka Versed

Start Dose:
-Loading Dose: 1-4 mg IV q 5-15 min until goal level of
sedation is achieved.
-Continuous Infusion: 1-2 mg/hr

Titration Time/Dose:
-Intermittent Bolus: Titrate by 1-2mg/hr every hr until
goal sedation score is achieved; if RASS score or
CIWA score is not achieved, re-bolus 2 mg IV q 10 min
to a max infusion rate of 10 mg/hr.

Usual Dose Range:
1-20 mg/hr

Nursing Implications:
-Contact the MD if a rate >10 mg/hr is needed.

-Turn off daily and assess unless a contraindication
exists for sedation vacation.

-Attempt to manage sedation with PRN dosing with
midazolam; if you need to resume the infusion,
resume at half the previous dose.

Question 24

Propofol

Start Dose:

Titration Time/Dose:

Usual Dose Range:

Nursing Implications:

Answer 24

aka Diprivan

Start Dose:
-Continuous Infusion: 10 mcg/kg/min
-Loading does: Not recommended due to risk of
hypotension

Titration Time/Dose:
-Titrate by 5 mcg/kg/min q 10 min until goal sedation
score is achieved.

Usual Dose Range:
-5-80 mcg/kg/min

-Status Epilepticus:
-Rates up to 150 mcg/kg/min may be appropriate

Nursing Implications:
-Turn off daily and assess unless a contraindication
exists for sedation vacation; attempt to manage
sedation with PRN dosing with midazolam; if you
need to resume the infusion, resume at half the
previous dose.
-Only use for ventilated pts
- Do not paralyze
-No analgesic properties
-Propofol infusion syndrome may occur with
prolonged use or in higher doses.
-Monitor triglycerides at baseline and q 48 hrs during
the infusion.
-Change he tubing every time a bottle is changed OR
at minimum q12 hrs.
-Count as a source of calories (lipids)

Question 25

Benzodiazepine Reversal

Answer 25

with Flumazenil (Romazicon)

-Reverse the effects of benzodiazepines with flumazenil (Romazicon) 0.2 mg IV over 15 seconds for moderate sedation/over 30 seconds for overdosage.

-Repeat doses 0.2 mg at 1-minute intervals, maximum of 4 doses, until pt awakens.

-For resedation, give repeat doses at 20-minute intervals as needed, 0.2 mg per minute to a maximum of 1 mg total, and 3 mg total in 1 hr.

-Onset of action of flumazinil is 1-2 minutes, 30% response within 3 minutes, peak effect in 6-10 minutes.

-Resedation occurs after approximately 1hour; the duration of flumazenil is related to the dose given and the benzodiazepine plasma concentrations.

***Note that the reversal effects of flumazenil may wear off before the effects of the benzodiazepine. Therefore, monitor for a return of sedation and respiratory depression for at least 2 hours and until the pt is stable and resedation is unlikely.

-Use with caution for those with a history of prolonged use. A seizure may occur with reversal.

Question 26

Daily Sedation Withdrawal (Spontaneous Awakening Trial)

Answer 26

An evidence-based strategy for preventing over sedation and its complications is to withhold the sedation for pts who are receiving a CONTINUOUS DRIP in order to perform a neurological assessment and determine whether the continuous sedation drip is still clinically beneficial. The daily spontaneous awakening trial (SAT), or sedation vacation, is best done in conjunction with the daily spontaneous breathing trial (SBT).

Question 27

Suggested guidelines for performing the daily SAT are as follows:

Answer 27

1. Screen the pt prior to the spontaneous awakening trial.
2. Turn off the sedation drip.
3. Monitor the pt for awakening and tolerance to drug withdrawal.
4. Determine whether the sedation drip should be discontinued and replaced with PRN dosing, restarted at half the dose, or returned to the pre-SAT dose.

Question 28

Suggested guidelines for performing the daily SAT are as follows:

1. Screen the pt prior to the spontaneous awakening trial.

Answer 28

-No myocardial ischemia
-No active seizures
-No alcohol withdrawal
-No paralytic drip
-Stable intracranial pressure
-No recent increase in the sedation drip dose to maintain the goal RASS score.

Question 29

Suggested guidelines for performing the daily SAT are as follows:

2. Turn off the sedation drip

Answer 29

If the sedation is propofol, consider weaning down q5min to prevent sudden agitation

Question 30

Suggested guidelines for performing the daily SAT are as follows:

3. Monitor the pt for awakening and tolerance to drug withdrawal.

Answer 30

-Assess the pt’s neurological status, discomfort, and pain.

-Assess the level of sedation/agitation with a sedation tool

-Signs of SAT failure include:
-Dangerous agitation
- Sustained tachypnea, increased work of breathing
-Sustained drop in SpO2 to <90%
-Acute arrhythmia
-Hypotension