Sedation/Analgesia in Mechanically Ventilated Patient Clinical Pathway — CICU

Infant/Child Protocol

Medications Opioid (fentanyl 0.5 mcg/kg/hr or hydromorphone 0.003 mg/kg/hr) and dexmedetomidine 0.25 mcg/kg/hr
Midazolam 0.02 mg/kg/hr replaces dexmedetomidine if contraindicated due to bradycardia, heart block
Ketamine 0.25 mg/kg/hr
Note: Short term for 24-48 hrs to allow early extubation
Incremental Infusion Change
Fentanyl 0.5 mcg/kg/hr (e.g., increase from 1 to 1.5 mcg/kg/hr)
Hydromorphone 0.001 mg/kg/hr (e.g., increase from 0.003 to 0.004 mg/kg/hr)
Midazolam 0.02 mg/kg/hr (e.g., increase from 0.02 to 0.04 mg/kg/hr)
Dexmedetomidine 0.25 mcg/kg/hr (e.g., increase from 0.25 to 0.5 mcg/kg/hr)
Ketamine 0.1 mg/kg/hr (e.g., increase from 0.25 to 0.35 mg/kg/hr)
Assess/Titration Use SBS and pain scores (FLACC, FACES, Numbers)
Assess both every 4 hrs, at minimum
Assess 10 minutes after PRN doses, and infusion changes
PRN Doses PRN dose matches hourly infusion dose for fentanyl and midazolam when patient receiving infusion
RN may administer 2 PRN doses based on SBS
Selection of PRN agent is based on pain score
Pain score > 4 fentanyl or hydromorphone
≤ 4 midazolam
If a second PRN dose is required, RN contacts FLOC for incremental change in OR initiation of infusion
Contact FLOC to discuss increase infusion rate if 3 or more non-procedural PRNs (dose equivalent to hourly infusion rate) are administered in 5 hrs
Suggestions Non-postoperative patients may not need fentanyl
For delirium wean off ketamine and midazolam
Ketamine is for short term use; Reassess use following 24 hrs and do not use for more than 48 hrs
Infant/Child Protocol
Age 30 days to 18 years, < 50 kg
Begin infusions if clinically indicated / stable, at the discretion of FLOC
Assess SBS, Pain Score
every 4 hrs PRN
SBS < Goal or
No PRNs in 24 hrs
Contact FLOC
Consider decrease
infusion rate
SBS at Goal
SBS > Goal
Consider
non-pharmacologic interventions
See Job Aid
Pain Score > 4
Pain Score ≤ 4
  • 1st PRN fentanyl or hydromorphone
  • Reassess in 10 minutes
1st PRN midazolam
Reassess in 10 minutes
Pain Score > 4
SBS not at Goal
  • 2nd PRN fentanyl or hydromorphone
  • Reassess in 10 minutes
2nd PRN midazolam
Reassess in 10 minutes
Consider Delirium
CAPD ≥ 9
Contact FLOC to consider:
  • Increase infusion + PRN doses
  • Initiate infusion if not currently receiving
  • If 3 or more non-procedural PRNs in 5 hrs, increase or initiate the infusion
  • If at any point there is concern for inadequate analgesia please discuss with FLOC

Pain Scales

Review Pain Scales

FLACC Term NB to 7 yrs
FACES ≥ 3 yrs, able to self-report
Numeric Rating Scale > 5 yrs
SBS
Pediatric patients on mechanical ventilation
Response to stimuli, 6 point scale