Category Archives: Goleta420

02Oct/15

Mechanical Ventilation with Sedation

Goleta420

A few weeks ago I had a patient in the ICU who had been intubated and placed on a ventilator. This patient had critical aortic stenosis and was placed on a ventilator following an attempted right internal jugular line placement that resulted in a massive right hemothorax. On the day that I was in the ICU the physician and primary RN decided that they would taper the patient down off the Sublimaze (fentanyl) and Versed (midazolam) being used for analgesia and sedation. The team’s ultimate goal was to see if the patient was ready to be extubated. In addition, the patient was placed on CPAP as a trial. In this particular case it was very important that the patient be monitored for any signs of agitation or distress due to the fact that increased stress would activate the sympathetic nervous system and increase the workload on the heart. Due to the severe aortic stenosis and compromised cardiac function, an increase in workload would be poorly tolerated by the patient. By noon the patient started to respond to stimulation. The patient would open his eyes in response to voices and became agitated during suctioning and turning. The increased heart rate that accompanied the agitation required that the Sublimaze and Versed be initiated once again. Ultimately, the respiratory therapist, nurse, and physician agreed that based on the trial CPAP and spontaneous awakening trial, the patient was not ready to be extubated. Ventilation and sedation are often a necessary treatment for a person with severely compromised cardio-pulmonary function. Nonetheless, these treatments have to be used judiciously with constant reappraisal of the situation in order to minimize the potential short- and long-term consequences of ICU-acquired delirium and weakness. During my next ICU clinical I look forward to investigating the procedures and protocols that are instituted in the hospital units.

02Oct/15

Sedation Vacation

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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:

  1. MICU – FIO2 > 80, Peep > 15
  2. SICU – open abdominal wounds, in which fascia is not closed, unless ordered by a physician, fresh post-op (10-12 hrs.)
  3. 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%.

  1. If after 30 minutes patient is still not overly agitated or delirious decrease the rate again by 50%.
  2. 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

24Sep/15

Pacemakers & Cellphones: Keep Your Distance

Goleta420

It seems like everyone and their brother has a smart phone of some sort these days or at least is exposed to someone who has one. And for patients with pacemakers, this could be a dangerous combination. I look at the medical news on my favorite science-oriented website regularly and a new study from the European Society of Cardiology found that those who have pacemakers should keep their distance from cell phones to avoid unwanted painful shocks or frightening pauses in the function of their device. The study was presented in June to the joint meeting of the European Heart Rhythm Association and the European Society of Cardiology by one of the main authors, Dr. Carsten Lennerz, a cardiology resident in Germany.

Although it does not happen all the time, pacemakers can sometimes mistakenly pick up electromagnetic interference from smartphones and treat them like a cardiac signal, which can cause them to stop working for a brief period of time, according to Lennerz. He recommends that patients should hold their phone on the ear opposite to their pacemaker when talking and not place the phone in a pocket directly above the pacemaker just to be safe.

The authors added that another area of concern for patients with pacemakers is when they are under high voltage power lines. Although is ok for them to walk under power lines, the authors recommend that they do not spend extra time under the power lines, as high electric fields can also tamper with the pacemaker’s normal functioning.

I found it interesting and worrisome that the authors noted that pacemakers themselves do not come with any warnings about these possible problems. My uncle has a pacemaker that has saved his life and next time I see him walking around with his cell phone in his pocket as he often does, I will be sure to warn him about the possible dangers of doing so. In this smartphone inundated world, I wonder how many people with pacemakers have been affected by this problem. This would be an interesting and timely topic to pursue in further research studies.

I would also like to know how long medical experts have known about the interference cell phones and power lines play in the role of the pacemaker. It seems like something that every patient should be warned about but this is the first I have ever heard of the topic. I plan to do more research on this issue since I have a vested interest in it with my uncle’s health at stake.

Here is the link to the article:

http://www.sciencedaily.com/releases/2015/06/150622071207.htm

24Sep/15

Technology, Data and trending

Goleta420

Smart Blood Pressure (SmartBP) BP Tracker

iPhone Screenshot 1iPhone Screenshot 4

This is a free App and what is does is, it keeps track of your blood pressure and allows for convenient storage and trending. The app is straightforward and easy use .This is very helpful if you have hypertension. Especially if you take your blood pressure a couple of times a day. You can keep a log of diet, exercise and medication. You can then plot on your trend graph when you did what. The great thing about this is you can send all the information to your Physician or Clinician. A couple of days before yours scheduled appointment and they can then go over the data and can make decision based on the recorded actual data. Scientist look for trends over time before making a decision as to the effectiveness of an intervention or deciding a different approach. Data is king when making any decision and this app allows you to store and share this data in a professional organized way.