Hi this is Breehan! Because my mom just had a knee replacement, I talked to her about her different medications. She is on Percocet and Tramadol. I was surprised that her doctor did not educate her about not mixing the Percocet and Tramadol too closely together until she actually asked him after I told her that she should not take the maximum amount of each medication all at once, especially because she enjoys a glass of wine in the evening when she tends to take her pain medications to help her sleep. I warned her not to mix the wine and medications and explained why it was a bad idea.

Once my mom was educated about that, she was then confused about whether she could mix Ibuprofen with the opiates and I had to educate her that Ibuprofen and Percocet or Tramadol are ok together but to make sure not to take too much Acetaminophen along with the Percocet if she takes the maximum amount every 4-6 hours as is recommended on the bottle. Once again, I was so dismayed and surprised that my mom’s surgeon did not take the time to give her this important pharmacological education.

The surgeon did succeed at least in telling my mom about the side effects of being on strong opiate pain medication post-op. He encouraged her to take stool softeners for the constipation and not to drive while under the influence of the medications.

I was glad I was present to assist my mom in educating her about her medications and rather appalled that she had not been told what I considered very basic information about them in the post-op period.

I actually have not seen sedation vacation performed in clinicals, but I know Cottage has their own policy and procedure for conducting it. In Cottage, the nurse and Respiratory Therapist collaborate to perform sedation vacation according to the optimal time based on the pt and family’s schedule. In order for the procedure to be performed, the pt must not meet any absolute or relative contraindications. Absolute contraindications includes increased ICP that is exacerbated with awakening or if pt is less than 18 yrs old. Relative contraindications include: PEEP greater than or equal to 10cm H20, PaO2/FiO2 less than or equal to 200, SpO2 less than 90% on FiO2 greater than or equal to 50%. If pt does not meet any contraindications, then all sedation infusions are turned off and pt is assessed according to the Richmond Agitation Sedation Score (RASS). Hospital protocols are then performed according to assessment thereafter.

Standard practice for sedation vacation is the same as Cottage Hospital. Many researchers encourage and promote sedation vacation because of its benefits to the pts (Dunn and Baker, 2011). These include less ICU stays, less chances of developing ICU delirium, and decrease need for ventilator support (Dunn and Baker, 2011). The medications used by Cottage include Lorazepam, Propofol, and Midazolam. If the pt does fail the RASS, then 50% of the previous sedation dose is infused and titrated accordingly. Hospital protocols are followed thereafter.

Reference:

Santa Barbara Cottage Hospital Daily Awakening Trial/Weaning Protocol in Mechanically Ventilated Patients

Dunn, J., Baker, M.W. (2011). Daily Sedation Breaks and Breathing Trials Help Wean Patients from Ventilators Safely: The Authors Give Advice on Developing a Nurse-Implemented Sedation Protocol. American Nurse Today, 6(3). Retrieved from: http://www.medscape.com/viewarticle/741046_6

Sedation Vacation Blog

I did not know much about sedation vacation so it was interesting for me to read the blogs of other students. I also found an article that talks about educating the nurses. This article helped me understand this process and the reasons for it to be performed. Sedation vacation is also called daily sedation interruption and can be beneficial for mechanically ventilated patients (Hogue & Mamula, 2013). Critically ill patients often need continuous IV sedation with analgesia since they may experience pain from mechanical ventilation, suctioning, surgical incisions, catheters, etc. Sedation is required to assess patient’s neurologic status and determine the necessity for further sedation. Hogue and Mamula state that evidence based practice recommends interrupting sedation at least daily in mechanically ventilated patients (2013). Some of the benefits include the ability to accurately titrate sedation, which allows to reduce the time on mechanical ventilation, length of ICU stay, lower risk for ventilator associated pneumonia, etc. (Hogue & Mamula, 2013).

The article also suggests a short quiz on testing your knowledge about the Sedation Vacation. They did not provide the answers, but you guys seem to know so much about this intervention that you can probably figure them out!

1.How long should DSI last?

a.10 minutes

b.20 minutes

c.until patient follows commands

d.until patient exhibits agitation

e.c and d

2.Circle all common benefits of daily sedation interruption.

a.decreased length of time of ventilation

b.decreased length of ICU stay

c.increased sedation

d.decreased other complications, such as ventilator-associated pneumonia and central line-associated bloodstream infection.

e.decreased anxiety

3.Which isn’t a potential adverse reaction to DSI?

a.psychedelic dreams

b.self-extubation

c.pain

d.anxiety

e.rebound agitation

4.DSI is better for acute posttraumatic stress disorder.

a.true

b.false

5.Do you think DSI is important for your patients?

a.yes

b.no

References

Hogue, M., & Mamula, S. (2013). Sedation vacation: Worth the trip. Nursing Critical Care, 8(1), 35-37.

“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.