Sedation/Analgesia, CICU, Mechanically Ventilated Patient — ECMO — Clinical Pathway: ICU

Sedation/Analgesia in Mechanically Ventilated Patient Clinical Pathway — CICU

ECMO

Medications Opioid (morphine or hydromorphone) +/- bolus and/or dexmedetomidine
Note: For neonates, begin with morphine alone
Incremental Infusion Change
Morphine 0.02 mg/kg/hr (e.g., increase from 0.02 to 0.04 mg/kg/hr)
Hydromorphone 0.001 mg/kg/hr (e.g., increase from 0.003 to 0.004 mg/kg/hr)
Dexmedetomidine 0.25 mcg/kg/hr (e.g., increase from 0.25 to 0.5 mcg/kg/hr)
Midazolam 0.02 mg/kg/hr (e.g., increase from 0.02 to 0.04 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 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 or hydromorphone
≤ 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 non-procedural PRNs (dose equivalent to hourly infusion rate) are administered in 5 hrs
ECMO Protocol
Begin infusions if clinically indicated / stable, at the discretion of FLOC
Assess SBS, Pain Score
every 4 hours and PRN
SBS < Goal or
No PRNs in 24 hours
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 morphine
    or hydromorphone
  • Reassess in 10 minutes
1st PRN midazolam
Reassess in 10 minutes
Pain Score > 4
SBS not at Goal
  • 2nd PRN morphine
    or hydromorphone
  • Reassess in 10 minutes
2nd PRN morphine
Reassess in 10 minutes
Contact FLOC to consider:
  • Increase infusion + PRN doses
  • Initiate additional infusion (dexmedetomidine
    or midazolam) if not currently receiving
  • If 3 or more non-procedural PRNs in 5 hours, increase or initiate the infusion
  • If at any point there is concern for inadequate analgesia please discuss with FLOC
Consider Delirium
CAPD ≥ 9

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