“Sedation vacation” is an interesting topic, one which I had not considered before it was recently brought up in class. I have spent two shifts in the SICU and witnessed patients on intubation and sedation, but unfortunately, in my clinical rotations I have not had the opportunity to see it during the course of a patient’s stay. It was a strong impression…seeing patients unconscious and not breathing on their own. From what I understand, many of these patients could be on ventilation and sedated indefinitely, so close monitoring and attention is important to better understand when they can be advanced to being weaned off of sedation, if possible.
Since this topic of sedation vacation was assigned after my opportunity to speak to the staff regarding the hospital protocols, I decided to take a closer look at hospital approved reading under Cottage Hospital’s “Nursing Resources”. I decided to focus my reading on the top three recommended articles available at Cottage to see what I could learn of interest…
I found that sedation vacation is also referred to as Daytime Awakening Trial (DAT), and has only recently been looked at for protocol creation in the last ten years. Interestingly, there is still limited research as to whether or not a primary nurse team or a collaborative team (respiratory therapist, physician, nurse and pharmacist) are more effective than the other. There is general agreement, however, that a dedicated ventilator bundle rounding team (VBR) in addition to the primary nurse team, is the most effective combination (Mendez et al. 2013).
Despite who performs the “bundle” of assessments, what is in agreement are the parameters checked for patients on sedation. Generally, the assessment occurs in the early morning (between 0500-0900), and five areas are performed and assessed as a bundle: sedation vacation, spontaneous breathing trial (SBT), head of the bed ≥30º, prophylaxis of deep vein thrombosis, and prophylaxis of peptic ulcer disease (PUD). For ongoing assessment of sedation, the Richmond Agitation and Sedation Scale was used.
Upon closer reading, I noticed that ventilator-associated pneumonia is of great concern, as it is considered the second most common hospital acquired infection in the United States and is responsible for 25% of the infections that occur in intensive care units (Vallés, 2007). In response to this phenomenon, additional practices added to the bundle may include protocols for mouth care and hand washing, head-of-bed alarms and subglottic suctioning in addition to the DAT bundle protocol.
According to the articles, the patients who were found to be the most ready for sedation weaning included those with the following parameters: hemodynamic stability, minute ventilation less than 15 L/min, not hypoxic (PaO2 > 60 mm Hg, oxygen saturation > 92%, fraction of inspired oxygen <50%, positive end-expiratory pressure <5 cm H2O), minimal secretions, rapid shallow breathing index less than 120, and respiratory rate less than 38/min.
So, although I was not able to directly apply this week’s learning objective, sedation vacation, directly to my clinical experience, I am now more enlightened and feel that I understand and am better able to assist and collaborate in the new bundle protocols. Despite this assignment coming after my SICU shifts, I feel that I am now more informed on the generally accepted protocol and bundle for sedated patients and will apply what I learned for future patients’ cases.
One last comment I would like to share, is that in the cases where the patients were sedated, I witnessed the nurses speak to them as though they were alert, hearing and comprehending. This was of course most important when performing the neuro checks, but also showed great compassion and respect. I was impressed and think they deserve some recognition for their professionalism and humanity.
REFERENCES
Makic, M., Rauen, C., Jones, K., & Fisk, A. (2015). Continuing To Challenge Practice To Be Evidence Based. Critical Care Nurse, 35(2), 39-50.
Mendez, M., Lazar, M., Digiovine, B., Schuldt, S., Behrendt, R., Peters, M., & Jennings, J. (2013). Dedicated Multidisciplinary Ventilator Bundle Team and Compliance with Sedation Vacation. American Journal of Critical Care, 22(1), 54-60.
ICU Sedation Guidelines of Care. (2009, December 1). Retrieved October 3, 2015, from http://www.carefusion.com/pdf/The_Center/2009-ICU-sedation-toolkit-disclaimer-updated-may-30-2014.pdf
Sedwick, M., Lance-Smith, M., Reeder, S., & Nardi, J. (2012). Using Evidence-Based Practice to Prevent Ventilator-Associated Pneumonia. Critical Care Nurse, 32(4), 41-51.
Vallés, J., Pobo, A., García-Esquirol, O., Mariscal, D., Real, J., & Fernández, R. (2007). Excess ICU mortality attributable to ventilator-associated pneumonia: The role of early vs late onset. Intensive Care Med Intensive Care Medicine, 33(8), 1363-1368.
