Assessment Algorithm for Sedated Adult ICU Patients

No
Is patient comfortable and at goal for Sedation and Analgesics?

ICU Sedation Guidelines of Care

This algorithm was created using Microsoft Visio. To modify, double-click on the algorithm and customize as needed using Microsoft Visio.

Yes

Rule out/correct reversible causes Use nonpharmacologic treatment Optimize the environment

Reassess goal daily Titrate and taper therapy to maintain goal Perform awakening trial, if appropriate

See Daily Awakening Protocol

Pain
Is patient in pain? Use pain scale to assess patient Set goal for analgesia

Consider potential causes

TARGET: Non-Verbal Pain Scale: 0 2 Critical Care Pain Observation Tool: 0 - 1

Hemodynamically Stable - FentaNYL - HYDROmorphone - Morphine Hemodynamically Unstable - FentaNYL Renal Impairment - FentaNYL - HYDROmorphone

Signs & Symptoms of Opiate Withdrawal Pupil dilation Vomiting Primary approach for Sweating Diarrhea pain: bolus for pain Lacrimation Hypertension control and then infusion Rhinorrhoea Fever to sustain control. Piloerection Tachypnea Tachycardia Agitation TITRATING OFF INFUSIONS: The potential for opioids withdrawal should be considered for patients receiving high doses or seven (7) days of continuous therapy. Doses should be tapered systematically (i.e. 10-30% per day) to prevent withdrawal symptoms.

- FentaNYL infusion at 25 50 mcg/hr - HYDROmorphone infusion at 0.4 0.8 mg/hr - Morphine infusion at 2 4 mg/hr

Sedation
DRUG SELECTION: Anticipate sedation (< 72 hours) - Midazolam Is patient agitated / anxious? Consider - Propofol Use scale to assess patient potential causes - Dexmedetomidine Set goal for sedation Anticipate sedation (> 72 hours) - LORazepam TARGET: Patient has renal impairment Richmond Agitation Sedation Scale (RASS): 0 to -3 - LORazepam Riker Sedation-Agitation Scale (SAS): 3 to 4 - Propofol SEDATION: Use for RASS greater or equal to 2 levels below what is ordered (e.g., RASS of -2 with an ordered goal of 0) 1.) LORazepam/midazolam continuous infusion: Hold infusion until patient reaches RASS goal, then resume at one-half previous rate. Titrate per written orders. 2.) Propofol continuous infusion: Decrease rate 5-10 mcg/kg/min every 10 minutes until patient reaches RASS goal. Titrate per written orders. 3.) Morphine/HYDROmorphone/fentaNYL continuous infusion: Hold until patient reaches RASS goal, then resume at one-half previous rate. Titrate per written orders.

Delirium

Pharmacologic Treatment for Delirium:

Non-Pharmacologic Treatments for Delirium: Ensure Daily Awakening Trials conducted Continually reorient patient Perform early mobilization Promote effective sleep / awake cycles Perform timely removal of catheters/physical restraints - Ensure the use of eyeglasses, magnifying lenses, and hearing aids - Minimize noise/stimulation at night - Minimize Benzodiazepines for sedation

NPO: Dexmedetomidine 0.2-1.5 mcg/kg/hr (Consider in patients failing spontaneous breathing trials secondary to agitation) Is patient delirious? Consider potential Haloperidol 2.5-5mg IV q 15 min prn + delirium (suggested max 35 mg/ causes Use scale to assess patient day) (Consider decreased dose in hypoactive delirium) PO: Aripiprazole 10-15 mg po daily (Consider when baseline QTc>440 msec) Confusion Assessment Method for the ICU (CAM-ICU) Intensive Care Delirium Screening Checklist (ICDSC) Haloperidol 2.5-5 mg po q6 hr (Caution if baseline QTc >440 msec)
NOTE: Provided dosing ranges are general guidelines and are not intended to supersede clinical judgment of prescriber.

QUEtiapine 50-200 mg po q12 hr (Consider if sedative properties desired) Risperidone 0.5-1 mg po q12 hr (Caution baseline QTc >440 msec)

ICU Sedation Guidelines of Care

ADULT ICU PAIN ORDERS

1. Target pain score _______ (based on pain assessment) 2. For patients pain, select one of the following: FENTANYL CONTINUOUS INFUSION
FentaNYL infusion at _______ mcg/hr (e.g., 2550 mcg/hr) A. FentaNYL bolus at _______ mcg (e.g,. 12.5 mcg) IV every 5 minutes prn pain score 2-3 (mild pain). B. FentaNYL bolus at _______ mcg (e.g., 25 mcg) IV every 5 minutes prn pain score 4-6 (moderate pain). C. FentaNYL bolus at _______ mcg (e.g., 50 mcg) IV every 5 minutes prn pain score 7-8 (severe pain).

Repeat boluses until pain controlled. If the patient requires >2 boluses in an hour, increase rate by _______ mcg/hr (e.g., 12.525 mcg/hr) every hour. Maximum dosage = _______ mcg/hr (e.g., 100200 mcg/hr). Notify physician for oversedation or when target pain score not achieved at maximum dosage.
_________________________________________________________________________________________________

HYDROMORPHONE (DILAUDID ) CONTINUOUS INFUSION

HYDROmorphone infusion at _______ mg/hr (e.g., 0.40.8 mg/hr) A. HYDROmorphone bolus at _______ mg (e.g., 0.2 mg) IV every 10 minutes prn pain score 2-3 (mild pain). B. HYDROmorphone bolus at _______ mg (e.g., 0.4 mg) IV every 10 minutes prn pain score 4-6 (moderate pain). C. HYDROmorphone bolus at _______ mg (e.g., 0.8 mg) IV every 10 minutes prn pain score 7-8 (severe pain).

Repeat boluses until pain controlled. If the patient requires >2 boluses in an hour, increase rate _______ mg/hr (e.g., 0.2 0.4 mg/hr) every hour. Maximum dosage = _______ mg/hr (e.g., 3 mg/hr). Notify physician for oversedation or when target pain score not achieved at maximum dosage.
_________________________________________________________________________________________________

MORPHINE CONTINUOUS INFUSION (Avoid in patients with cardiovascular instability or renal impairment)
Morphine infusion at _______ mg/hr (e.g., 24 mg/hr) A. Morphine bolus at _______ mg (e.g., 1 mg) IV every 10 minutes prn pain score 2-3 (mild pain). B. Morphine bolus at _______ mg (e.g., 2 mg) IV every 10 minutes prn pain score 4-6 (moderate pain). C. Morphine bolus at _______ mg (e.g., 4 mg) IV every 10 minutes prn pain score 7-8 (severe pain).

Repeat boluses until pain controlled. If the patient requires >2 boluses in an hour, increase rate by _______ mg/hr (e.g., 12 mg/hr) every hour. Maximum dosage = _______ mg/hr (e.g., 10 mg/hr). Notify physician for oversedation or when target pain score not achieved at maximum dosage.

Prescriber / PID: _____________________ Date/Time: ________________ Nurse: ______________________ Date/Time: _____________

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ICU Sedation Guidelines of Care

ICU PAIN MANAGEMENT PROTOCOL

SELF-REPORTING PAIN ASSESSMENT SCALE
Wong-Baker FACES Pain Rating Scale* Directions: When the patient is awake, show this card with the faces. Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Point to each face and ask the person to choose the face that best describes how he is feeling. Based on his response, circle the appropriate scale number. NOTE: Although the numbers associated with this scale are 0-5, this number scale numbers should be doubled to a scale of 0-10 in order to apply the standard order set.

Alert Smiling

No humor Serious Face

Furrowed brow Pursed lips Breath holding

Wrinkled nose Raised upper lip Rapid breathing

Slow blink Open mouth

Eyes closed Moaning Crying

No Pain

Can be ignored

Interferes Interferes with with tasks concentration Activity Tolerance Scale

Interferes with basic needs

Bed rest required

0-10 Numeric Pain Scales** (circle one)

*Adapted from: Hockenberry MJ, Wilson D: Wongs essentials of pediatric nursing, ed. 8, St. Louis, 2009, Mosby. Used with permission. Copyright Mosby. **Adapted from: Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline No. 1. AHCPR Publication No. 92-0032: February 1992; Agency for Healthcare Research & Quality, MD; 116-117.

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ICU Sedation Guidelines of Care

NON-VERBAL PAIN SCALE

Directions: Define target pain score using the 10 Point Numerical Rating Scale. Observe the patient per category and, based on your findings, circle the appropriate scale number.

FACIAL EXPRESSION Score 0 1 2 ACTIVITY Score 0 1 Description Lying quietly, normal position Seeking attention through movement or slow cautious movement Description No particular smile or expression Occasional grimace, tearing, frowning, and/or wrinkled forehead Frequent grimacing, tearing, frowning, and/or wrinkled forehead

Restless excessive activity and/or withdrawal reflexes 2 GUARDING Score Description Lying quietly, no positioning of hands over area of body 0 Splitting areas of the body, tense 1 Rigid, stiff 2 PHYSIOLOGIC PARAMETER Score 0 1 Description Stable vital signs Change over past 4 hours in any of the following SBP > 20mmHg or heart rate > 20 bpm Change over past 4 hours in any of the following 2 SBP > 30mmHg or heart rate > 26 bpm RESPIRATORY Score 0 1 2 Description Baseline respiratory rate/oxygen saturation, compliant with ventilator RR > 10 above baseline or 5% decrease in oxygen saturation, mild ventilator asynchrony RR > 20 above baseline or 10% decrease in oxygen saturation, mild ventilator asynchrony Target Pain: 0-1

SCORE:

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ICU Sedation Guidelines of Care

NON-VERBAL PAIN SCALE (CPOT)

Define target pain score using the Non-Verbal Pain Scale (Critical Care Pain Observation Tool or CPOT) when appropriate.
Indicator Facial expression Score Description

Relaxed, neutral Tense

0 1

No muscle tension observed Presence of frowning, brow lowering, orbit tightening and levator contraction or any other change (e.g. opening eyes or tearing during nociceptive procedures) All previous facial movements plus eyelid tightly closed (the patient may present with mouth open or biting the endotracheal tube)

Grimacing

Caroline Arbour, RN, B.Sc., M.Sc.A(c) School of Nursing, McGill University

Body movements
(Puntillo et al., 1997; Devlin et al., 1999)

Absence of movements or normal position Protection Restlessness

Does not move at all (doesnt necessarily mean absence of pain) or normal position (movements not aimed toward the pain site or not made for the purpose of protection) Slow, cautious movements, touching or rubbing the pain site, seeking attention through movements Pulling tube, attempting to sit up, moving limbs/thrashing, not following commands, striking at staff, trying to climb out of bed Alarms not activated, easy ventilation Coughing, alarms may be activated but stop spontaneously Asynchrony: blocking ventilation, alarms frequently activated Talking in normal tone or no sound Sighing, moaning Crying out, sobbing No resistance to passive movements Resistance to passive movements Strong resistance to passive movements, incapacity to complete them Target Pain: 0 - 1 For the rating of the CPOT, the patient should be attributed the highest score observed during the observation period. The patient should be attributed a score for each behavior included in the CPOT and muscle tension should be evaluated last, especially when the patient is at rest because just the stimulation of touch (passive flexion and extension of the arm) may lead to behavioral reactions.

1 2

Compliance with the ventilator (intubated patients)

(Harris et al. 1991. Payen et al., 2001)

Tolerating ventilator or movement Coughing but tolerating Fighting ventilator Talking in normal tone or no sound Sighing, moaning Crying out, sobbing

0 1 2 0 1 2 0 1 2
__ 4.

OR

Vocalization (extubated patients)

(Mateo et Krenzischek, 1992)

Muscle tension

Relaxed

Evaluation by passive flexion and Tense, rigid extension of upper limbs when patient is at rest (Ambuel et al., 1992) Very tense or rigid or when patient is being turned SCORE: Directions for use of the CPOT: 1. The patient must be observed at rest for one minute to obtain a baseline value of the CPOT. 2. The patient should be observed during nociceptive procedures (e.g., turning, endotracheal suctioning, wound dressing) to detect any changes in the patients behaviors to pain. 3. The patient should be evaluated before and at the peak effect of an analgesic agent to assess if the treatment was effective in relieving pain.

5.

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ICU Sedation Guidelines of Care

ADULT ICU SEDATION ORDERS

1. Target sedation score _______ (based on sedation assessment) 2. Perform Daily Awakening Protocol 3. Select from below one of the agents boluses to treat agitation/anxiety. 4. Notify physician if patient has hemodynamic instability or if target sedation score not achieved at maximum dosages.
________________________________________________________________________________________________

BOLUSES FOR BREAKTHROUGH AGITATION/ANXIETY (Recommended for rapid control)

Midazolam _________ mg (e.g., 1 2 mg) IV every 10 minutes prn mild agitation (e.g., RASS +1 to +2) , and Midazolam _________ mg (e.g., 2 5 mg) IV every 10 minutes prn moderate/severe agitation (e.g., RASS +3 to +4) OR

Lorazepam _________ mg (e.g., 0.5) IV every 20 minutes prn mild agitation (e.g., RASS +1 to +2), and Lorazepam _________ mg (e.g., 1 mg) IV every 20 minutes prn moderate/severe agitation (e.g., RASS +3 to +4). ________________________________________________________________________________________________

PROPOFOL (DIPRIVAN ) Infusion (Recommended for sedation <72 hours. Avoid in patients with cardiovascular instability.)
Start propofol IV infusion at _________ mcg/kg/min (e.g., 5-10 mcg/kg/min). Bolus (if checked above) with midazolam as directed or propofol _________ mg (0.03-0.15 mg/kg, max 10-20 mg) for breakthrough agitation Titrate propofol by _________ mcg/kg/min (e.g., 5-10 mcg/kg/min) every 5 minutes until target sedation score achieved. Maximum rate = _________ mcg/kg/min (e.g., 60 mcg/kg/min). Reduce infusion rate by for SBP < _________ mm Hg. Notify physician if patient has hemodynamic instability. Notify physician if target sedation score not achieved at maximum dosages. Oversedation: Wean Propofol by 10 mcg/kg/min every 10 min until sedation score at goal. (Oversedation patient exceeds target sedation scale.) _________________________________________________________________________________________________

MIDAZOLAM (VERSED ) Infusion (Recommended for sedation <72 hours. Not recommended in impaired renal function.
Start midazolam infusion at _________ mg/hr (e.g., 1 3 mg/hr). Bolus (if checked above) with midazolam as directed for breakthrough agitation/anxiety. If the patient requires >2 boluses in an hour, increase rate by _________ mg/hr (e.g., 1 2 mg/hr) every hour. Maximum infusion rate = _________ mg/hr (e.g., 10 mg/hr). Notify physician if target sedation score not achieved at maximum dosages. Oversedation: Hold infusion until sedation score at goal. Restart infusion at previous rate. _________________________________________________________________________________________________

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ICU Sedation Guidelines of Care

LORAZEPAM (ATIVAN ) Infusion (Recommended for sedation >72 hours)

Start LORazepam infusion at _________ mg/hr (e.g., 0.51 mg/hr). Bolus (if checked above) with midazolam OR lorazepam as directed for breakthrough agitation/anxiety. If the patient requires >2 boluses in an hour, increase rate by _________ mg/hr (e.g., 1 2 mg/hr) every hour. Maximum infusion rate = _________ mg/hr (e.g., 10 mg/hr). Notify physician if target sedation score not achieved at maximum dosages. Oversedation: Hold infusion until sedation score at goal. Restart infusion at previous rate. ________________________________________________________________________________________________

PATIENTS FAILING SPONTANEOUS BREATHING TRIALS DUE TO AGITATION: DEXMEDETOMIDINE (PRECEDEX ) (Recommended for short-term use. Avoid in patients with cardiovascular instability.)
Start dexmedetomidine infusion at _________ mcg/kg/hr (e.g., 0.2 0.7 mcg/kg/hr). Bolus (if checked) with midazolam for breakthrough agitation as directed below. Titrate dexmedetomidine by _________ mcg/kg/hr (e.g., 0.1 0.2 mcg/kg/hr) every hour until target sedation score achieved. Maximum rate = _________ mcg/kg/hr (e.g., 1 1.5 mcg/kg/hr). Notify physician if patient has hemodynamic instability or if target sedation score not achieved at maximum dosages.

Prescriber / PID: _____________________ Date/Time: ________________ Nurse: ______________________ Date/Time: _____________

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ICU Sedation Guidelines of Care

RICHMOND AGITATION SEDATION SCALE

Richmond Agitation Sedation Scale (RASS)
Score Description

RASS Target Sedation = 0 to -3

+4 Combative +3 Very Agitated +2 Agitated +1 Restless 0 Alert and Calm -1 Drowsy -2 Light Sedation

Overtly combative, violent, immediate danger to staff Pulls or removes tube(s) or catheter(s); aggressive Frequent non-purposeful movement, fights ventilator Anxious but movements not aggressive vigorous

Not fully alert, but has sustained awakening (>10 seconds) (eye-opening/eye contact) to voice Briefly awakens with eye contact to voice (<10 seconds)

-3 Moderate Sedation Movement or eye opening to voice (but no eye contact) -4 Deep Sedation -5 Unarousable No response to voice, but movement or eye opening to physical stimulation No response to voice or physical stimulation

Procedure for RASS Assessment: The basis of the RASS assessment is to see what amount of stimulation is necessary to evoke a response and evaluate sedation. Observe patient. a. Patient is alert, restless, or agitated. (Score 0 to +4) If not alert, state patients name and say open eyes and look at (speaker). b. Patient awakens with sustained eye opening and eye contact. (Score 1) c. Patient awakens with eye opening and eye contact, but not sustained. (Score 2) d. Patient has any movement in response to voice but no eye contact. (Score 3) When no response to verbal stimulation, physically stimulate patient by shaking shoulder and/or rubbing sternum. e. Patient has any movement to physical stimulation. (Score 4) f. Patient has no response to any stimulation. (Score 5)
Sessler CN, et al. (2002). The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med. Vol. 166. pp. 1338-1344. Ely EW, et al. (2003). Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA ; Vol. 289. pp. 2983-2991

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RIKER SEDATION-AGITATION SCALE (SAS)

Riker Sedation-Agitation Scale (SAS)
Score Term Descriptor

SAS Target Sedation = 3 to 4

7 6 5 4 3 2 1

Dangerous Agitation Very Agitated Agitated Calm and Cooperative Sedated Very Sedated Unarousable

Pulling at ET tube, trying to remove catheters, climbing over bedrail, striking at staff, thrashing side-to-side Requiring restraint and frequent verbal reminding of limits, biting ETT Anxious or physically agitated, calms to verbal instructions Calm, easily arousable, follows commands Difficult to arouse but awakens to verbal stimuli or gentle shaking, follows simple commands but drifts off again Arouses to physical stimuli but does not communicate or follow commands, may move spontaneously Minimal or no response to noxious stimuli, does not communicate or follow commands

Jacobi J, Fraser GL, Coursin DB, et al. (2002). Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. Vol. 30, No. 1

Guidelines for SAS Assessment 1) Agitated patients are scored by their most severe degree of agitation as described 2) If patient is awake or awakens easily to voice (awaken means responds with voice or head shaking to a question or follows commands), that is a SAS 4 (same as calm and appropriate might even be napping). 3) If more stimuli such as shaking is required but patient eventually does awaken, that is SAS 3. 4) If patient arouses to stronger physical stimuli (may be noxious) but never awakens to the point of responding yes/no or following commands, that is a SAS 2. 5) Little or no response to noxious physical stimuli represents SAS 1 This helps separate sedated patients into those you can eventually wake up (SAS 3), those you can't awaken, but can arouse (SAS 2), and those you cant arouse (SAS 1).

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ICU Sedation Guidelines of Care

ADULT ICU DELIRIUM ORDERS

Assess for Delirium using standardized scale (e.g., CAM-ICU or ICDSC)
NOTE: Provided dosing ranges are general guidelines and are not intended to supersede clinical judgment of prescriber.

FOR BREAKTHROUGH AGITATION - check box to select agent(s):

HALOPERIDOL (HALDOL ) BOLUSES
Haloperidol _________ mg (e.g., 2.5-5 mg) IV every 15 min prn agitation/delirium. Maximum daily dose = _________ mg/day (Suggested max total daily dose is 35 mg/day) Monitor for Qtc prolongation ________

MAINTENANCE TREATMENT FOR AGITATION/DELIRIUM - check box to select agent(s):

HALOPERIDOL (HALDOL )
Haloperidol _________ mg (e.g., 2.5-5 mg) PO every _________ hours (e.g., 6 hours). Maximum daily dose (including PRN doses) = _________ mg/day (Suggested max daily dose is 35 mg/day) Monitor for QTc prolongation ________

RISPERIDONE (RISPERDAL ) TABLET OR ORALLY DISINTEGRATING TABLET (ODT)

Risperidone _________ mg (e.g., 1 2 mg) PO every _________ hours (e.g,. 12 hours). Maximum daily recommended dose is 4 mg/day Monitor for QTc prolongation ________

ARIPIPRAZOLE (ABILIFY )
Aripiprazole _________ mg (e.g., 5 10 mg) PO daily OR _________mg (e.g., 9.75 mg) IM daily. Maximum daily recommended dose is 30 mg/day Monitor for QTc prolongation ________

QUETIAPINE (SEROQUEL )
Quetiapine _________ mg (e.g., 50 mg) PO every _________hours (e.g., 12 hours). Maximum daily recommended dose is 200 mg q12h. Monitor for QTc prolongation ________

DEXMEDETOMIDINE (PRECEDEX ) (Consider in patients failing spontaneous breathing trials secondary to agitation)
Loading dose _________ mcg (1 mcg/kg) over 20 min (not recommended due to risk of hypotension).

Start dexmedetomidine infusion at _________ mcg/kg/hr (e.g., 0.2 0.7 mcg/kg/hr). Titrate dexmedetomidine by _________mcg/kg/hr (e.g., 0.1 0.2 mcg/kg/hr) every hour until target sedation score achieved. Maximum rate = _________ mcg/kg/hr (e.g., 1 1.5 mcg/kg/hr). Notify physician if patient has hemodynamic instability or if target sedation score not achieved at maximum dosages.

Prescriber / PID: _____________________ Date/Time: ________________ Nurse: ______________________ Date/Time: _____________

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ICU Sedation Guidelines of Care

CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)

Directions: If patients RASS is above -4 (-3 through +4), refer to the following chart and assess for delirium using the Confusion Assessment Method in the ICU (CAM-ICU) on the next page.

Harvard CAM-ICU Flowsheet (by Houman Amirfarzan, M.D., Wes Ely, M.D.) Copyright 2003, Vanderbilt Medical Center

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CONFUSION ASSESSMENT METHOD FOR THE INTENSIVE CARE UNIT (CAM-ICU)

Table 3: Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) FEATURE 1: Acute Onset or Fluctuating Course
Positive, if answer yes to either 1A or 1B. YES NO

1A: Is the patient different than his/her baseline mental status? OR 1B: Has the patient had any fluctuation in mental status in the past 24 hours as evidenced by fluctuation on a sedation scale (e.g. RASS), GCS, or previous delirium assessment?

FEATURE 2: Inattention

Positive, if either score for 2A or 2B is less than 8

Positive

Negative

First, attempt the Letters (ASE). If patient is able to perform this test and the score is clear, record this score and move to Feature 3. If patient is unable to perform this test or the score is unclear, then perform the Pictures ASE. If you perform both tests, use the ASE Pictures results to score this Feature. Score (out of 10): 2A: AUDITORY (Letter ASE) Record score (enter NT for not tested) Directions: Say to the patient, I am going to read you a series of 10 letters. Whenever you hear the letter A indicate by squeezing my hand. ____ Read letters from the following letter list in a normal tone: SAVEAHAART Scoring: Errors are counted when patient fails to squeeze on the letter A and when the patient squeezes on any letter other than A. 2B: VISUAL (Pictures - ASE) Record score (enter NT for not tested) Score (out of 10): Directions: Use the Picture Packets (A and B) on the next page. ____

FEATURE 3: Disorganized Thinking

Positive, if the combined score isles than 4

Positive

Negative

Combined Score 3A: Yes/No Questions (3A + 3B): (Use either Set A or B, alternate on consecutive days if necessary): ____ (out of 5) Set A Set B 1. Will a stone float on water? 1. Will a leaf float on water? 2. Are there fish in the sea? 2. Are there elephants in the sea? 3. Does one pound weigh more than two pounds? 3. Do two pounds weigh more than one pound? 4. Can you use a hammer to pound a nail? 4. Can you use a hammer to cut wood? (Patient earns 1 point for each correct answer out of 4) 3A Score ____ 3B: Command Say to patient: Hold up this many fingers: (Examiner holds two fingers in front of patient) Now do the same thing with the other hand: (Not repeating the number of fingers). *If patient is unable to move both arms, for the second part of the command ask patient to Add one more finger) (Patient earns 1 point if able to successfully complete the entire command) 3B Score ____

FEATURE 4: Altered level of Consciousness

Positive if the actual RASS score is anything other than 0 (zero)

Positive

Negative

Is the patients current level of consciousness anything other than alert such as vigilant, lethargic, or stupor (e.g., score on Richmond Agitation Sedation Scale other than 0 at time of assessment)? Alert Spontaneously fully aware of environment and interacts appropriately Vigilant Hyper alert Lethargic Drowsy but easily aroused, unaware of some elements in the environment, or not spontaneously interacting appropriately with the interviewer; becomes fully aware and appropriately interactive when prodded minimally Stupor Becomes incompletely aware when prodded strongly; can be aroused only by vigorous and repeated stimuli, and as soon as the stimulus ceases, stuporous subject lapses back into the unresponsive state. (Features 1 and 2 and either Feature 3 or 4): Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved. Overall CAM-ICU:

Positive

Negative

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2B: VISUAL (Pictures - ASE)

Step 1: 5 pictures
Directions: Say to the patient, Mr. or Mrs. _________, I am going to show you pictures of some common objects. Watch carefully and try to remember each picture, because I will ask what pictures you have seen. Then show Step 1 of either Packet A or Packet B, alternating daily if repeat measures are taken. Show the first 5 pictures for 3 seconds each.

Packet A

Packet B

Directions: Say to the patient, Now I am going to show you some more pictures. Some of these you have already seen and some are new. Let me know whether or not you saw the picture before by nodding your head yes (demonstrate) or no (demonstrate). Then show 10 pictures (5 new, 5 repeat) for 3 seconds each (Step 2 of Packet A or B, depending upon which form was used in Step 1 above). Scoring: This test is scored by the number of correct yes or no answers during the second step (out of a possible 10). To improve the visibility for elderly patients, the images are printed on 6x10 buff colored paper and laminated with a matte finish. Note: If a patient wears glasses, make sure he/she has them on when attempting the Visual ASE.

Packet A

Packet B

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INTENSIVE CARE DELIRIUM SCREENING CHECKLIST (ICDSC)

Intensive Care Delirium Screening Checklist 1. Altered level of consciousness. Choose ONE from A-E. Note: May need to reassess patient if recent administration of sedation therapy A. Exaggerated response to normal stimulation SAS = 5, 6, or 7 Score 1 point B. Normal wakefulness SAS = 4 Score 0 point C. Response to mild or moderate stimulation SAS = 3 Score 1 point (follows commands) If LOC related to recent sedation/analgesia, score 0 D. Response only to intense and repeated stimulation (e.g., loud voice and pain) SAS = 2 **Stop assessment E. No response SAS = 1 **Stop assessment 2. Inattention. Score 1 point for any of the following abnormalities: A. Difficulty in following commands OR B. Easily distracted by external stimuli OR C. Difficulty in shifting focus Does the patient follow you with their eyes? 3. Disorientation. Score 1 point for any of the following abnormality: A. Mistake in either time, place, or person Does the patient recognize ICU caregivers who have cared for him/her and not recognize those that have not? What kind of place are you in? (list examples) 4. Hallucinations or Delusions. Score 1 point for either: A. Equivocal evidence of hallucinations or a behavior due to hallucinations (Hallucination = perception of something that is not there with NO stimulus) OR B. Delusions or gross impairment of reality testing (Delusion = false belief that is fixed/unchanging) Any hallucinations over past 24 hrs? Are you afraid of the people or things around you? (fear that is inappropriate to clinical situation) 5. Psychomotor Agitation or Retardation. Score 1 point for either: A. Hyperactivity requiring the use of additional sedative drugs or restraints in order to control potential danger (e.g., pulling IV lines out or hitting staff) OR B. Hypoactive or clinically noticeable psychomotor slowing or retardation Based on documentation and observation over shift by primary caregiver 6. Inappropriate Speech or Mood. Score 1 point for either: A. Inappropriate disorganized or incoherent speech OR B. Inappropriate mood related to events or situation Is the patient apathetic to current clinical situation (i.e., lack of emotion)? Any gross abnormalities in speech or mood? Is patient inappropriately demanding? 7. Sleep/Wake Cycle Disturbance. Score 1 point for either: A. Sleeping less than four hours at night OR B. Waking frequently at night (do not include wakefulness initiated by medical staff or loud environment) OR Based on primary caregiver assessment C. Sleep 4 hours during day 8. Symptom Fluctuation. Score 1 point for: Fluctuation of any of the above items (i.e., 17) over 24 hours (e.g., from one shift to another)
Based on primary caregiver assessment SCORE

TOTAL ICDSC SCORE (Add 1 8)

A total ICDSC score has a 99 percentage sensitivity correlation for a psychiatric diagnosis of delirium Source: Bergeron N et al. (2001). Intensive Care Med. Vol. 27. pp. 869-64 - Revised July 22, 2005

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AGENTS FOR ANALGESIA

Approximate Equivalent Single IV Dose b 1,2 Opioids FentaNYL 100-200 mcg 50-200 mcg/hr 2-5 min 0.5-2 hours $26/day at a rate of 100 mcg/hr $23/day at a rate of 1.6 mg/hr Fastest onset and shortest duration. Typical Infusion Rate b 1,2 Onset to Peak Effect1 Duration1 Average Price/Daya Comments

HYDROmorphone (Dilaudid)

1.5-2 mg

0.2-3 mg/hr

20-30 min

3-4 hours

5-10x more potent than morphine. Avoid in hypotension. Active metabolite accumulates in renal dysfunction. May cause itching due to histamine release (not a true allergy). Decreases preload, which may be beneficial in pulmonary edema.

Morphine

10 mg

2-10 mg/hr

20-30 min

3-4 hours

$20/day at a rate of 10 mg/hr

NSAIDs (Parenteral) Infuse over 30 minutes. Not to exceed 3200 mg/day. Black box warnings: Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk of serious cardiovascular thrombotic events. Risk may increase with duration of use. Contraindicated in setting of CABG. NSAIDs increase the risk of gastrointestinal adverse effects. Max adult dose 120 mg/day (60 mg/d in elderly or weight <50 kg). Do not use for >5 days. Avoid use in renal dysfunction. Monitor for gastrointestinal adverse effects. Black box warning: Nonsteroidal antiinflammatory drugs (NSAIDs) may increase the risk of serious cardiovascular thrombotic events. Contraindicated in setting of CABG.

Ibuprofen (Caldolor)

400-800 mg

IVPB over 30 mg

Not reported

6 hours

$7 per 400mg dose

Ketorolac (Toradol)

15-60 mg

IV push

1-2 hours

4-6 hours

$0.50-0.80 per 15 mg dose

a b

Equivalent prices and doses are approximations and may vary due by institution and due to patient-specific differences in onset and duration of effect. Doses higher than recommended in the chart above may be required. Weight-based doses are reported for the following agents, but use may result in high infusion rates (fentaNYL 0.7-10 mcg/kg/hr, HYDROmorphone 7-15 mcg/kg/hr, morphine 0.07-0.5 mg/kg/hr). Based on clinical experience, more typical infusion rates are included in the table.

References: 1. Crit Care Med. 2008. Vol. 36. pp. 953-963. 2. Crit Care Med. 2002. Vol. 30: pp. 122-123.

ICU Sedation 2009

ICU Sedation Guidelines of Care

AGENTS FOR SEDATION

Drug Typical IV Bolus Dose1 Typical Infusion Rate 1,2 Onset to Peak 1 Duration1 Average a Price/Day Comments Fastest onset and shortest duration. Avoid in hypotension. Dose/rate related hypotension/ bradycardia. Avoid IV push bolus due to increased risk of hypotension (if bolus required and low risk of hypotension, limit dose to 10-20 mg). Monitor triglycerides. Provides 1.1 kcal/mL. Monitor for propofol-related infusion syndrome Fast onset - good for acute agitation/anxiety. Active metabolite accumulates in renal dysfunction. Midazolam 2-3 mg is approximately equivalent to 1 mg LORazepam.
Midazolam is associated with increased incidents of delirium.

Propofol (Diprivan)

0.03-0.15 mg/kg (max 20 mg)

5-80 mcg/kg/min

1-2 min

<20 min

$36/day at a rate of 50 mcg/kg/min

Midazolam (Versed)

1-6 mg

1-10 mg/hr

5-10 min

1.5-2 hours

$70/day at a rate of 8 mg/hr

LORazepam (Ativan)

1-3 mg

1-5 mg/hr

15-20 min6

2-4 hours

$38/day at a rate of 4 mg/hr

Slower onset but longer duration. Risk of propylene glycol toxicity with high doses (anion-gap acidosis, Serum Creatinine, Lactate). Monitor serum osmolality if rate > 6 mg/hour and consider possible PG toxicity if osmol gap >10-15 3-5
LORazepam is associated with increased incidents of delirium.

Dexmedetomidine (Precedex)

1 mcg/kg over 20 min (not recommended)

0.2-1.5 mcg/kg/hr

30 min

2-4 hours

$408/day at a rate of 0.8 mcg/kg/hr

Limited data for use as a 1st line agent. FDA approved for use <24 hrs (studied up to 7 days in literature). FDA approved max dose = 0.7 mcg/kg/hr (studied up to 1.5 mcg/kg/hr). No respiratory depression - consider for patient failing spontaneous breathing trial due to agitation/anxiety. Dose/rate related hypotension and bradycardiabolus not recommended. May cause hyper/hypotension. Consider higher starting dose if used as monotherapy. Expensive.

a b

Equivalent prices and doses are approximations and may vary due by institution and due to patient-specific differences in onset and duration of effect. Midazolam and LORazapem doses higher than recommended in the chart above may be required. Weight-based doses are reported for the following agents, but use may result in high bolus doses and infusion rates (Midazolam bolus 0.02-0.08 mg/kg and infusion 0.04-0.2 mg/kg/hr; LORazepam bolus 0.02-0.06 mg/kg and infusion 0.01-0.1 mg/kg/hr). Based on clinical experience, more typical bolus doses and infusion rates are included in the table.

References: 1. Crit Care Med. (2008). Vol. 36: pp. 953-963. (for all references unless indicated otherwise) 2. Crit Care Med. (2002). Vol. 30: pp. 122-123. 3. Yahwak. Chest. (2003). Vol. 124. pp. 178S. 4. Arroliga. CCM. (2004). Vol. 32: pp. 1709. 5. Barnes. Pharmacotherap. (2006). Vol. 26: pp. 23. 6. Micromedex. LORazepam monograph. (Oct 2009).

ICU Sedation 2009

ICU Sedation Guidelines of Care

AGENTS FOR DELIRIUM

Adverse Effects Antipsychotic Agent Dosage Form Metabolizing Enzyme Equiv. Dosages (approx) (mg) Max Dose (mg/day) QTc Prolongation Potential Dose Related Effect
a

Metabolism

Sedation

Dopaminergic2 Receptor Affinity/ Extrapyramidal Symptoms

b

Anticholinergic Effects

Orthostatic Hypotension

Black Box Warning: Increased mortality seen when used in elderly patients with dementia-related psychosis due to cardiovascular or infectious complications. The use of these agents for delirium in ICU patients has not been tested in large, randomized, placebo-controlled trials. Haloperidol (Haldol) Tab, IV injection T:: 21 hrs Hepatic CYP3A4, 2D6 2 35* Low Low High Low Low
b

* Use heightened caution and be aware that there is a dose related QT interval prolongation and torsades de pointes (TdP) risk when using in excess of >20 mg per day. QUEtiapine (SEROquel)
c

Tab

T:: 6 hrs Hepatic

CYP3A4

125

400

Moderate

Moderate

Low

Moderate

High

Risperidone (Risperdal)

Tab, ODT tab, solution (1 mg/ml)

T:: 3 hrs Hepatic

CYP2D6, 3A4

Moderate

Low

High

Low

Moderate

Aripiprazole (Abilify)

Tab, solution (5mg/ml), IM injection

T:: 75 hrs Hepatic

CYP2D6, 3A4

30

Low

Low

Low

Low

Low

The following agents are NOT recommended for ICU use. Ziprasidone (Geodon)
d

Capsule

T:: 7 hrs Hepatic

CYP3A4, 1A2

40

160

High

Low

High

Low

Moderate

OLANZapine (ZyPREXA)

Tab, ODT tab, IM injection

T:: 30 hrs Hepatic

CYP1A2

20

Low

Moderate

Low

Moderate

Low

a Low: 3-10 msec, Medium: 10-15 msec, High: > 15 msec b Increased with IV formulation c Caution: Bone marrow suppression; blood dyscrasias d Secondary to high risk for QT prolongation e Secondary to high risk for metabolic syndrome

ICU Sedation 2009

ICU Sedation Guidelines of Care

DAILY AWAKENING TRIAL PROTOCOL SHEET (TEMPLATE)

The following protocol sheet contains recommendations from the San Diego Patient Safety Council. Elements may vary based on your patient population and unit needs.

1. Assess for Daily Awakening Exclusions: Increased Intracranial pressure issues Neuromuscular blockade Significant ventilation support required, such as very high PEEP (____), FiO2 (____) CABG immediate post-op Other site specific exclusionary criteria:

2. Perform Daily Awakening Wean / Stop sedation Consider decreasing narcotics infusion by 25-50% 3. Is Patient Awake and Calm? Use sedation scale (SAS 3-4 or RASS 0 to -1)?
- Take opportunity to assess patients pain - Titrate narcotics as needed for pain

If no, Restart Sedation at previous dose (No Rapid Shallow Breathing Index) If yes, proceed to Spontaneous Breathing Trial 4. Assess for Spontaneous Breathing Trial (SBT) (performed by RN and RCP) *** Patient must meet all criteria to proceed to conduct SBT*** Calm and co-operative (SAS score of 3 to 4; RASS 0 to -1) Hemodynamically stable PEEP < 8 FiO2 < 0.60 PH > 7.34 SpO2 > 90% 5. Conduct SBT for 1 Minute Mode CPAP PEEP = 0 Pressure support vent. at least 5 - 10 FIO2 unchanged After 1 minute, calculate Rapid Shallow Breathing Index (RSBI):
RSBI = Respiratory Rate/Tidal Volume in liters <105 = 80% success >105 = 95% failure

SBT Termination Criteria: Respiration Rate >35/minute for >5 minutes SpO2 < 90% for > 2 minutes New Ectopy Heart Rate change 20% from baseline Blood Pressure change 20% from baseline Accessory muscle use Increased anxiety/diaphoresis __________________ Return patients who fail a SBT to their previous ventilator settings and re-screen in 24 hours Discuss with MD prn vs. continuous sedation/pain

If RSBI successful, continue to conduct SBT for up to 2 hours If RSBI failure, return to previous ventilator settings 6. Conduct SBT for up to 2 hours and Continuously Reassess ~~~ Successful Completion SBT ~~~ Discuss Arterial Blood Gases and Extubation Plan with Physician
ICU Sedation 2009