Sedation Vacation

Sedation vacation is a term used in the critical care field and refers to patients that are sedated and on a ventilator . The sedative is titrated down in order to perform Neuro checks and assess for the possibility of extubating. The sedation vacation is necessary to reduce ventilator acquired pneumonia, delirium from the sedatives and a shorten ICU stays. This however does not mean that all the patients in the critical care units receive a sedation vacations. The patient has to meet certain criteria. Criteria like being Hemodynamically stable, shows no agitation on current sedative regiment, Fio2 is less than 50% and Peep is less than 10%, the sedation is not used to control status epilepticus or symptoms of alcohol withdrawal. Patient must also not be on a Blakemore tube for the control of bleeding varices. If a patient does not meet these criteria then the patient is not eligible yet for a sedation vacation. But as with all and any medical procedure there is a Policy for that which is basically describing how and when to perform this sedation vacation. The following is a Policy and Procedure form The Jefferson University Hospital


	Index No:	I-10
	Effective Date:

NURSING CRITICAL CARE PROCEDURES

Category:	General Critical Care
Title:	DAILY LIGHTENING OF SEDATION

Purpose

Daily lightening of sedation, “Sedation Vacations”, and assessing the patient’s readiness to extubate is an integral part of the Ventilator Bundle and has been correlated with reduction in the rate of ventilator-acquired pneumonia. This procedure is generally initiated after 48 hours of continuous sedation.

Kress et al. demonstrated that daily interruption of continuous sedation decreased the length of time patients spend on the ventilator and in the ICU and diminished the number of diagnostic tests performed to evaluate why a patient was not waking up once sedatives had been discontinued.

This protocol involves daily 50% dose reduction, and furthermore decreasing the sedation of the continuous drug infusion (including opiates) and monitoring the patient until he or she starts to show signs of awakening or agitation. At this time the patient is assessed for readiness to wean. The patient can also be assessed neurologically at this time.

The continuous sedation infusions can be titrated at the discretion of the bedside nurse to achieve a Ramsay sedation score of 2 to 3. In comparison with routine management, the daily cessation of drug infusions significantly reduced time on the ventilator in the ICU and provided a valuable window of opportunity for assessment of the patient’s neurologic function.

Steps in Procedure	Points to be emphasized
Eligibility for Daily Sedation Vacation evaluated every morning at 7:30 AM on all mechanically ventilated patients receiving IV sedation (Propofol, Benzodiazepines, Narcotics and/or Precedex) after 48 hours of continuous sedation. Exceptions to Daily Sedation Vacation include patients who are on paralytics, on medication for chronic pain or on sedation for comfort care. Other unit specific exceptions: MICU – FIO2 > 80, Peep > 15 SICU – open abdominal wounds, in which fascia is not closed, unless ordered by a physician, fresh post-op (10-12 hrs.) NICU – elevated ICP (ordered as per Physician), on sedation for anti-seizure purposes	Decrease sedation until patient awake and agitated. Assess patient’s readiness to wean. Respiratory therapists are available in the ICU at this time for active weaning. A Spontaneous Breathing Trial (SBT) will be done on patients who meet the criteria. If successful, after 30 minutes patient will be extubated. (Refer to Spontaneous Breathing Trials for details). This process should occur during morning rounds (between 8AM and 11 AM) and patients should be extubated in a timely fashion after passing the SBT. During the Sedation Vacation it is recommended that a neurological exam be completed at this time to assess the patient on continuous sedation for an acute change in mental status or focal neurological deficits. Patients not sedated as deeply will have an increased potential for self extubation. Increased monitoring may be warranted to ensure patient safety. Patients may have an increased potential for pain and anxiety associated with lightening sedation.

Procedure for Daily Sedation Vacation:
Fentanyl 1. If the patient is not exhibiting significant pain, decrease the Fentanyl drip by 50%. 2. If after 30 minutes patient is still not overly agitated,delirious, or in significant pain, decrease fentanyl by 50% again. 3. If patient becomes agitated, delirious, or develops significant pain give a 50 microgram bolus of Fentanyl and restart the drip titrating the rate as necessary to obtain a Ramsay score of 2-3. Morphine 1. If the patient is not exhibiting significant pain, decrease the Morphine drip by 50%. 2. If after 30 minutes patient is still not overly agitated, delirious, or in significant pain, decrease Morphine by 50% again. 3. If patient becomes agitated, delirious, or develops significant pain give a 4 mg bolus of Morphine and restart the drip titrating the rate as necessary to obtain a Ramsay score of 2-3. Hydromorphone 1. If the patient is not exhibiting significant pain, decrease the Hydromorphone drip by 50%. 2. If after 30 minutes patient is still not overly agitated, delirious, or in significant pain, decrease Hydromorphone by 50% again. 3. If patient becomes agitated, delirious, or develops significant pain give a 0.5 mg bolus of Hydromorphone and restart the drip titrating the rate as necessary to obtain a Ramsay score of 2-3.
Propofol 1. If patient has significant pain make sure patient has a form of medication ordered for routine pain relief. 2. Reduce Propofol rate by 50%. 3. If after 30 minutes patient is still not overly agitated or delirious decrease the rate again by 50%. 4. If patient becomes agitated or delirious after reducing the drip resume infusion of Propofol and titrate to a level that results in a
Lorazepam or Midazolam 1. If patient has significant pain make sure patient has a form of medication ordered for routine pain relief. 2. Decrease the Lorazepam (Ativan^®) or Midazolam (Versed^®) drip by 50%. If after 30 minutes patient is still not overly agitated or delirious decrease the rate again by 50%. If patient becomes agitated or delirious and needs to return to IV drip, administer 2 mg bolus of Lorazepam or Midazolam and restart the drip. Titrate the rate up or down as necessary to obtain a Ramsay score of 2-3 Dexmedetomidin 1. If the patient is not exhibiting significant pain, decrease the dexmedetomidine drip by 50%. 2. If after 30 minutes patient is still not overly agitated, delirious, or in significant pain, decrease dexmedetomidine by 50% again. 3. If patient becomes agitated, delirious or develops significant pain, load with 1 mcg/kg dexmedetomidine and restart the drip titrating the rate as necessary to obtain a Ramsay score of 2-3.
Repeat Sedation Vacation at least Daily

Documentation

Nursing:

1. Critical Care Flowsheet/JeffChart – document wean attempt, ventilator settings, and success or failure of procedure. Document patient’s response to SBT.

2. ABG results

3. Document neurological assessment and response to decreased sedation.

Respiratory:

1. Respiratory Flowsheet – document wean ventilator settings and response to attempt to wean.

2. Document assessment findings and patient response that indicated success or failure of wean.

References

Kress JP, Pohlman AS, O’Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. New England Journal of Medicine. May 18 2000;342(20):1471-1477.

Original Issue Date:	8/8/2007
Revision Date(s):	1/25/08
Review Date(s):

Responsibility for maintenance of policy:	Content Expert, Amy Callahan, RN, CRNP, ANCC
	(Signature on File)

(Signature on File)

Approved by: Sharon Millinghausen, RN MSN Vice President

References

Jefferson University Hospital Sedation Vacation protocal retrieved from

http://hospitals.jefferson.edu/

Strategies for Sedation Vacation in the MICU retrieved from

http://www.aacn.org/wd/ntispeakermats/PosterPresentations/00042670/00042670.swf

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