CICU Pathway for Sedation/Analgesia in the Mechanically Ventilated Patient

Infant/Child Protocol

Medication Infusion Fentanyl +/- bolus  and  dexmedetomidine +/- bolus
Midazolam replaces dexmedetomidine if contraindicated due to bradycardia, heart bloc
Incremental Infusion Change
Fentanyl 0.5 mcg/kg/hr (e.g. increase from 1.0 to 1.5 mcg/kg/hr)
Midazolam 0.01 mg/kg/hr (e.g. increase from 0.01 to 0.02 mg/kg/hr)
Dexmedetomidine 0.25 mcg/kg/hr (e.g. increase from 0.25 to 0.5 mcg/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
≤ 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 PRNs (dose equivalent to hourly infusion rate) are administered in 6 hours
Infant/Child Protocol
Age 30 days to 18 years, < 50 kg
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Infusion:
Fentanyl + Dexmedetomidine
or
Fentanyl + Midazolam

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

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Assess SBS, Pain Score
every 4 hours PRN
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SBS < Goal
Contact FLOC
Consider decrease
infusion rate
SBS at Goal
SBS > Goal
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Pain Score > 4
Pain Score ≤ 4
1st PRN fentanyl
Reassess in 10 minutes
1st PRN midazolam
Reassess in 10 minutes
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Pain Score > 4
SBS not at Goal
2nd PRN fentanyl
Reassess in 10 minutes
2nd PRN midazolam
Reassess in 10 minutes
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Contact FLOC to consider:
Increase infusion + PRN doses
Initiate infusion if not currently receiving
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