CICU Pathway for Sedation/Analgesia in the Mechanically Ventilated Patient

ECMO

Medication Infusion Morphine +/- bolus  and  midazolam +/- bolus
NOTE: For neonates, begin with morphine alone, midazolam may not be necessary
Incremental Infusion Change
Morphine 0.01 mg/kg/hr (e.g. increase from 0.02 to 0.03 mg/kg/hr)
Midazolam 0.01 mg/kg/hr (e.g. increase from 0.01 to 0.02 mg/kg/hr)
Assess / TitrationTitration 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 morphine 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 Morphine
≤ 4 Midazolam
If a second PRN dose is required, RN contacts FLOC for incremental change in OR initiation of infusion
NB: Patient to continue on ECMO pathway if remaining intubated AFTER decannulation.
Contact FLOC to discuss increase infusion rate if 3 or more PRNs (dose equivalent to hourly infusion rate) are administered in 6 hours
ECMO Protocol
arrow
Initiate Infusions
Morphine +/- Bolus
and
Midazolam +/- Bolus

Begin infusions if clinically indicated / stable, at the discretion of FLOC

arrow
Assess SBS, Pain Score
every 4 hours and PRN
arrow
arrow
SBS < Goal
Contact FLOC
Consider decrease
infusion rate
SBS at Goal
arrow
arrow
arrow
arrow
SBS > Goal
arrow
arrow
arrow
arrow
Pain Score > 4
Pain Score ≤ 4
1st PRN morphine
Reassess in 10 minutes
1st PRN midazolam
Reassess in 10 minutes
arrow
arrow
Pain Score > 4
SBS not at Goal
2nd PRN morphine
Reassess in 10 minutes
2nd PRN midazolam
Reassess in 10 minutes
arrow
arrow
Contact FLOC to consider:
Increase infusion + PRN doses
If at any point there is concern for inadequate analgesia please discuss with FLOC

Pain Scales

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