8. Providing Sedation to the Critically ill Flashcards
(30 cards)
A pt who is agitated (even a pt with a medical, rather than surgical diagnosis) should FIRST receive
an analgesic (analgesia-first sedation) BEFORE receiving anxiolytics.
The degree of sedation (the sedation goal) should be based on
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.
Maintaining _____ of sedation in adult ICU pts is associated with improved clinical outcomes.
light levels.
(improved clinical outcomes: i.e. a shorter duration of mechanical ventilation and a shorter ICU length of stay).
When sedation is provided on an as-needed basis
(a PRN basis), there is less of a possibility of over sedation than there is when sedation is provided with a continuous infusion.
Daily interruptions of continuous infusions of sedation agents allows for
an assessment of further need for the sedation agent and a neurological assessment of the pt.
Nonpharmacological treatment
(massage, music, cold therapy, and relaxation techniques) should be considered BEFORE using an anxiolytic agent, especially for mild anxiety and agitation.
The levels of sedation are:
-Minimal (Light) Sedation
-Moderate Sedation
-Deep Sedation
-General Anesthesia
Minimal (Light) Sedation
Pt responds normally to verbal commands.
Moderate Sedation
The pt responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. the pt is able to maintain a patent airway.
Deep Sedation
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.
General Anesthesia
This is a loss of consciousness during which pts are not arousable, even by painful stimulation.
The level of sedation may exceed the level intended; therefore the RN
needs to be able to identify when this occurs and act accordingly
Assessment of Agitation and Sedation
-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)
Physiological Causes of Agitation in Critically Ill Patients
-Hypoxemia
-Hemodynamic Instability (shock)
-Pain
-Delirium (hyperactive)
-Withdrawal from ETOH, drugs
-Dyspnea
-Immobility
-Sleep deprivation
Pharmacological Causes of Agitation in Critically Ill Patients
-Anesthetics
-Sedatives
-Analgesics
-Steroids
-Bronchodilators
Emotional Causes of Agitation in Critically Ill Patients
-Preexisting anxiety disorders
-Preexisting psychoses
-Dementia
-Fear
-Anger
Environmental Causes of Agitation in Critically Ill Patients
-Noise, alarms
-Lights
-Too cold or warm
-Restraints
-Tubes, lines
-Odors
-Isolation
-Sensory deprivation
-Sensory overload
Use a valid and reliable sedation assessment tool for
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.
Treatment with Select Sedation Agents
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).
Dexmedetomidine
Start Dose:
Titration Time/Dose:
Usual Dose Range:
Nursing Implications:
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.
Ketamine
Start Dose:
Titration Time/Dose:
Usual Dose Range:
Nursing Implications:
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
Lorazepam
Start Dose:
Titration Time/Dose:
Usual Dose Range:
Nursing Implications:
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.
Midazolam
Start Dose:
Titration Time/Dose:
Usual Dose Range:
Nursing Implications:
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.
Propofol
Start Dose:
Titration Time/Dose:
Usual Dose Range:
Nursing Implications:
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)
