__________________________________________
NURSE SIGNATURE
Date: _________________ Time: _____________
Pharmacy
Scan Time:     ______________
__________________________________________
Name Stamp
Signature
STAMP/PHYSICIAN SIGNATURE/BEEPER #..
Required for countersignature on telephone/verbal orders
Date: _________________ Time: _____________
PO0020
ICU SEDATION ORDERS
73-125 (2/10)

>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>> 

ICU SEDATION PROTOCOL

Check all that apply

Propofol Continuous Infusion protocol

1.   Propofol injection containing 10mg/mL of Propofol in 10% lipid emulsion.
2.   Start infusion at 5-10 mcg/kg/min.
3.   Titrate infusion to goal SAS score , increasing or decreasing the infusion rate to 5-10mcg/kg/min Q5 minutes.
4.   NURSES MAY NOT ADMINISTER BOLUSES.
5.   Monitor BP, pulse, respirations, Sao2 and SAS:
a.   Q5min minutes with each dosage change then
b.   Q1hr until desired SAS achieved
6.   Call House Officer (HO) for:
a.   Hypotension or hemodynamic instability (may require IV fluids or pressors)
b.   Uncontrolled agitation (may require additional analgesic or further intervention) SAS greater than or equal to 5
c.   Dose requirements greater than 50mcg/kg/min

Dexmedetomidine Continuous Infusion Protocol

1.   Before initiating, pt should not have the following contraindications
a.   High grade 2 or 3 Heart Block(HB) (non-pacer protected HB)
b.   Presence of septic syndrome
c.   Severe hypovolemia
d.   Hypotension
e.   Bradycardia
2.   Initiation dose:    infuse 1mcg/kg over 30 minutes.  Assess for bronchospasm and respiratory depression during this initiation time.  Immediately discontinue and call HO if bronchospasm , respiratory depression ,severe hypotension or bradycardia develops.
3.   Infusion:    start at 0.5mcg/kg/hr and increase or decrease rate by 0.1mcg/kg/hr Q15min until desired SAS level is achieved.
DO NOT ADMINISTER ADDITIONAL BOLUSES.
4.   Monitor BP, HR, respiration rate, SaO2 and SAS:
a.   Q5min with each dose adjustment then
b.   Q1hr until desired level of sedation is achieved.
5.   Promptly discontinue and call HO for SBP<80 mmHg, new onset of heart blocks, bronchospasm and HR<45.

Pain Management Protocol

Titrate analgesic dosing to maintain pain score = 3.
1.   Fentanyl Infusion:    start Fentanyl at 50mcg/hr and adjust 25mcg/hr Q20 min prn to MAXIMUM of 300mcg/hr.

Daily Sedation Reduction Protocol

Applies to all patients on continuous infusions.
1.   Daily sedation reduction should be initiated between 0800-noon at the discretion of the nurse.
2.   Reduce sedation infusion rate to ½ current dose.
3.   Assess SAS and pain level every four hours and with drip changes.
4.   If agitation, increased pain level,and/or SAS greater than 5, titrate the infusion back to reach sedation/pain goal.

Neuromuscular Blockade Protocol

All patients must be given sedation in conjunction with a neuromuscular blocking agent (NMBA).
1.   To be implemented in the use of continuous neuromuscular blockade agents.
2.   Initiate cisatracurium (Nimbex) infusion per ICU Sedation Orders.
3.   Place peripheral twitch monitor on ulnar or facial nerve.
Note:   ulnar placement may be less sensitive than facial placement if there is significant peripheral edema.
4. Initiation Dose:    give bolus 0.1mg/kg IV push x1
5. Infusion:
• Begin infusion within 45-60 min of bolus.
• Start infusion at 3mcg/kg/min.
• Titrate infusion to maintain 2 twitches in TOF.
• To titrate up, may give additional bolus of 0.03mg/kg q 40-60 min.
• To titrate down, hold infusion until 2 twitches on TOF or patient movement, and restart at 50% previous dose.
6.  Place BIS monitor and titrate sedation to maintain BIS index 40-60.

RIKER Sedation/Agitation Scale