YES
UMMC ADULT ICU SEDATION ALGORITHM
Address 3 Critical Areas:
Adult ICU Establish SAS/Pain Score goal 1. Pain Management
Patient SAS = 3 – 4 (most patients) 2. Sedation/Anxiolysis
YES SAS = 2 (severe ARDS/prone pts.) 3. Sleep Enhancement
Mechanical Pain Score < midpoint of scale
Ventilation
Required?
NO Mechanical
ventilation
for > 72 hrs
?
Sedation/analgesia
per goal-
directed therapy NO YES
< 72 hrs > 72 hrs
*Agents of Choice <72 hours: (see below for acute agitation management) *Agents of Choice > 72 hours:
PAIN PAIN
• morphine 2 – 5 mg IV q2h ATC (or infusion @ 1 mg/hr) • morphine 2 – 10 mg IV q2h ATC (or infusion @ 1-5 mg/hr)
• fentanyl 25 – 100 mcg IV q2h ATC (or infusion @ 50 mcg/hr) • fentanyl 50 – 100 mcg IV q2h ATC (or infusion @ 50-250 mcg/hr)
• hydromorphone 0.25 – 1 mg IV q4h ATC • hydromorphone 0.25 – 1 mg IV q4h ATC
SEDATION SEDATION
• lorazepam 2 – 4 mg IV q4h ATC (or infusion @1mg/hr) • lorazepam 2 – 4 mg IV q4h ATC (or infusion @1mg/hr.)
• diazepam 10 mg IV q6h • diazepam 10mg IV q6h ATC
• midazolam infusion @1 mg/hr
SLEEP
• zolpidem 10 – 20 mg po; chloral hydrate 1g PR or PGT
• propofol (see Guidelines for use) initiate @5mcg/kg/min—do not bolus!
SLEEP *Maintain lowest effective treatment dose—Titrate per SAS/Pain Score
• zolpidem 10 – 20 mg po; chloral hydrate 1g PR or PGT
—Bolus dosing preferred for long-term administration
MODIFY THERAPY BASED ON
NO
SAS/PAIN SCALE GOAL YES
ASSESS POTENTIAL CAUSES OF G
AGITATION/OVER-SEDATION (SEE
BELOW) oal
REASSESS SAS/PAIN SCORE
Q4
DOCUMENT SCORES ON
FLOWSHEET
REASSESS SAS/PAIN GOALS
QD
SAS = 6 – 7 SAS = 5,
SAS < goal MAINTAIN LOWEST EFFECTIVE
Pain Score DOSE
> goal AVOID ABRUPT D/C OF TX
Severe Agitation/ Hold therapy or
Delirium: decrease dose by 20%
Monitor for withdrawal
1) If possible, rule out other
causes (see #1 Acute
Agitation box). Acute Agitation:
2) TREAT ICU DELIRIUM USING 1) Determine cause of agitation:
RAPID TRANQUILIZATION:
Hypoxic, neurologic, and metabolic causes must be ruled out initially.
HALOPERIDOL 10 MG IV Q15
Pain: morphine 5mg IV, fentanyl 50mcg IV, hydromorphone 1mg IV q 15 min.
MINUTES UNTIL SAS = 4
(max dosage = 240mg) Anxiety: midazolam 5mg IV or diazepam 10 mg IV q 15 minutes.
3) Divide total effective dose Delirium: haloperidol 10mg IV q 15 minutes.
q6h. Substance withdrawal: see anxiety and tolerance.
4) Wean dose by 20% daily. Sleep deprivation: initiate or increase nightly sleeper dose.
Tolerance: increase doses of pain/sedation medications; consider analgesic
5) Monitor for QT rotation/substitution, especially with long-term and high dose fentanyl.
prolongation and EPS.
2) Repeat bolus dosing until SAS/Pain Score goal reached.
6) Consider monitoring with
Delirium Scale. 3) Reassess SAS/ Pain Score after each bolus administration;
Adjust drip rates to maintain SAS/Pain goals.
4) Repeat #’s 1-3 if goals not met.
(Buck/Habashi/Vanderheyden—11/00) Rev. 3/02, 6/02
