Daily AwakeningsLeanne Current, PharmD, BCPS

January 2014

Reasons for a sedation vacation

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Goal of sedation vacations

• Shorter length of time on the vent• Less ICU delirium

– Delirium associated with prolonged sedation– Delirium associated with benzodiazepines

• Prevent PTSD after hospital discharge• Shorter ICU length of stay• Less morbidity

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Why do we need to have a sedation vacation?

• Tissue accumulation• Change in patient needs

– More tolerable ventilator settings– Better oxygenation (hypoxia=agitation)– No longer in pain – Trached and more comfortable– Delirium better managed

• Change in Renal or liver function• Delayed response to doses and over titration• Half life of medication causes overshooting of goals• Reminder that drips are titratable down just as they are titratable up

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Days1 2

Goal sedation

Appropriateness for a sedation vacation

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Reasons to Avoid Sedation Vacation

• Stopping agent will cause more harm than good• Patient’s ventilator settings do not allow

extubation in the near future• Other medical reasons trump need to minimize

sedation

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Flowsheet Outline

• FiO2 >60• PEEP > 7.5cm• ICP >10• HR >140• MI within 24 hours• Surgery scheduled• ECMO

• Open abdomen• Neurosurgical patient• Active Agitation issues• On NMBA• Active EtOH withdrawal• Active End of life• Physician requested

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What if the patient doesn’t seem appropriate and the MD wants a vacation anyway?

• An MD order trumps all items listed in the flow sheet• If an MD requests a sedation vacation and the patient doesn’t

meet criteria, please stop the line and clarify with the MD– “The patient’s current FiO2 is higher than the protocol

allows for a sedation vacation, do you still want to do a sedation vacation?”

– “The patient’s heart rate is 150bmp. Criteria for a sedation vacation indicates a heart rate less than 140bpm. How should I proceed?”

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Drug Properties for pain and sedation

Treatment of pain

Opiate IV PO IV Onset (min)

Half-life (hours)

Fentanyl 0.1 -- 1-2 2-4

Hydromorphone 1.5 7.5 5-15 2-3

Morphine 10 30 5-10 3-4

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Treatment of pain with IV medications

Opiate Intermittent dosing IV infusion rate Other information

Fentanyl0.35-5 mcg/kg

25-100mcg

0.7-10 mcg/kg/hr

25-250mcg/hr

Most lipophillic, accumulation w/ liver dysfunction

Hydromorphone 0.2-0.6 mg 0.5-3 mg/hrMay be better in patients tolerant to other agents

Morphine 2-4 mg 2-30 mg/hrActive metabolites, histamine release

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Opioid related side effects

• Sedation• Muscle rigidity• Respiratory depression• Decrease GI mucus secretion and increase fluid absorption• Nausea, vomiting• Pruritus • CONSTIPATION

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Adjunctive pain agents

• Local and regional anesthetics• Ketamine • Acetaminophen• NSAIDS• Gabapentin or pregabalin• Carbamazepine• Non-pharmacological management strategies

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Indications for sedation

• Treat agitation • Promptly identify underlying causes

– Delirium, pain, hypoxemia, hypoglycemia, hypotension, alcohol withdrawal

• Titration of sedation to light and arousable • Sedation scales and protocols have reduced the amount of sedation patients

receive and improve outcomes

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Richmond Agitation and Sedation Scale (RASS)

Score Agitation Description

4 Combative Violent, dangerous to staff

3 Very agitated Removes tubes/catheters, aggressive

2 Agitated Frequent non-purposeful movement, fights ventilator

1 Restles Anxious, not aggressive

0 Alert and calm

-1 Drowsy Not fully alert, but has sustained awakening

-2 Light sedation Briefly awakens to voice

-3 Moderate sedation

Movement to voice

-4 Deep sedation No response to voice, but response to physical stimuli

-5 Unarousable No response to voice or physical stimuli

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Benzodiazepines

• Activate GABA-A receptors in the brain• Anxiolytic, amnestic, sedating, hypnotic, and anticonvulsant effects• Potency: Lorazepam > Midazolam > Diazepam • Lipophilicity: Midazolam and Diazepam > Lorazepam • All BDZs are metabolized hepatically• Caution in elderly patients • Lorazepam, oxazepam, and temazepam are renally cleared

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Benzodiazepines

Agent Onset (min)

Half life (hours)

Active metabolites

IV infusion rate

Midazolam 2-3 3-11 Yes 1-7 mg/hr

Lorazepam 15-20 8-15 No 1-10 mg/hr

Diazepam 2-5 20-120 Yes Not used

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Propofol

• Exact mechanism is not known• Binds to GABA-A, glycine, nicotinic, and muscarinic receptors• Sedative, hypnotic, anxiolytic, amnestic, antiemetic, and anticonvulsant• No analgesic properties• Highly lipid soluble• Best for patients who need frequent awakenings • Caution with egg and soybean allergies

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Propofol

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• Adverse effects: hypertriglyceridemia, acute pancreatitis, myoclonus, hypotension

• Propofol infusion syndrome: metabolic acidosis, hypertriglyceridemia, hypotension with vasopressor use, arrhythmias, acute kidney injury, hyperkalemia, rhadbomyolysis

Agent Onset (min) Half life (hours)

Active metabolites

IV infusion rate

Propofol 1-2 3-12 No 5-50 mcg/kg/min

Dexmedetomidine

• Selective alpha 2 receptor agonist• Sedative, sympatholytic, and questionable analgesic properties• Generally patients are more easily arousable with minimal respiratory

depression• Hepatically cleared• Adverse effects: hypotension, bradycardia

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Agent Onset (min)

Half life (hours)

Active metabolites

IV infusion rate

Dexmedetomidine 5-10 1-3 No 0.2-0.7 mcg/kg/min

Awakening time

• Would you expect the patient to wake up fairly quickly based on its drug properties? And what confounding factors may slow clearance causing delayed awakening?

– Propofol– Ativan– Versed– Fentanyl– Dilaudid– Morphine– Dexmedetomidine

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Expectations of Daily awakenings

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What does a sedation vacation mean?

• To stop intravenous pain and sedative agents that are currently causing the patient to not be as alert as baseline

– Propofol, Ativan, Versed– Fentanyl, Dilaudid

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What should I do to prepare for a sedation vacation?

• Evaluate your flowsheet checklist• If patient doesn’t meet requirement, ask for

clarification on multidisciplinary rounds• The most important tool you can have for a sedation

vacation is PRN pain and sedative agents. Why???– If a patient fails vacation and patient isn’t going to be

extubated you will need PRN agents to get them under control and to prevent dose titrations beyond their requirements.

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Utilizing boluses to prevent over sedation

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Goal Sedation

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What about precedex?

• This agent is typically ordered when preparing for extubation

• Purpose of precedex is to allow the pt to remain calm and compliant with the ventilator without lowering respiratory drive

• Allow the patient to prove that he/she needs the agent when the other sedatives are stopped

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How do I handle a sedation vacation when the patient is already on precedex?

• 90 percent of the time, it is appropriate to keep this agent going• If the patient is only on precedex and they are overly drowsy, they may

not require this agent to remain calm for extubation, consider stopping• It is not wrong to pause this agent, in fact, the ideal patient would remain

calm with no agent on board. • If patient has had a h/o agitation and this was the reason for starting the

agent, another appropriate method would be to titrate down to minimal requirements during the “sedation vacation”

• Once the patient is extubated, stop the agent. • If agitation occurs after extubation, clarify with MD what agent to use.

In general we will use other agents after extubation to assist the patient in remaining calm

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The patient failed the trial, how do I proceed

• Is the patient acutely in pain?– Give PRN Pain agent (fentanyl, dilaudid, morphine, norco, etc)

• Is the patient acutely agitated?– Give PRN Sedative agent (ativan, versed)– If patient was on propofol gtt

• What rate to I set my drips at?– Regardless of agitation or not, restart at half the rate!– Utilize PRN pushes to support the patient through the agitation/pain period– If more than one push is required, then titrate up the agent– Let the patient prove they need more agent– Always titrate to calmness, while trying to maintain the highest level of

alertness unless MD order specifies otherwise

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Difficult patient scenarios

What if my patient is fully alert on their sedation?

• Stop the agent and do a sedation vacation.• Let them prove they need the agent to remain calm• The agent may be frivolous at that point…why give

something they do not need?• It is never wrong to ask for clarification, but the majority of

the time your answer will be to stop the agent• Remember, the ideal patient is the one tolerating the

ventilator without any continuous infusion on board. Ideally we would have no gtts and utilize PRN agents to support them through acute pain and agitation

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What if my patient is complaining of pain, should I stop the agent?

• If your pt is alert and complaining of pain, then get a clarification from the MD.

• We do not want to cause pain that would increase respirations and thus negatively impact their ability to be extubated.

• The patient may qualify for a transition to longer acting oral agents to control pain

• If they aren’t alert and unable to verbalize their pain, then stop the agent.

– Let them prove to you they need the pain medication

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Patient specific scenarios

HF is a 60 yoF on a ventilator now for 3 days. Her current regimen is Fentanyl 3mcg/kg/hour and Versed 5mg/hour. She qualifies for a sedation vacation so Sally stops the Versed.

Has she done the correct thing?

What recommendations would you make?34

• HF is a 60 yoF on a ventilator now for 3 days. Her current regimen is Fentanyl 3mcg/kg/hour and Versed 5mg/hour. She qualifies for a sedation vacation. After your brilliant education, Sally stops both the fentanyl and versed. However an hour later the patient starts fighting the ventilator and requires reinitiating the patient’s pain and sedation regimen.

• How should she proceed with reinitiating the pain and sedation on this patient?

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• MM is a 50 yoM on a ventilator for 7 days. He was initiated on precedex 0.5mcg/kg/hour yesterday after his propofol was stopped and he became agitated. He is also on fentanyl at 1mcg/kg/hr. He meets requirements for a sedation vacation.

• What other information do you need before deciding how to proceed?

• If he is in pain how would you proceed?

• If he is drowsy how would you proceed?

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Questions??

• Can you come up with difficult patient scenarios we can address in this session?

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