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

Sedation/Analgesia in Mechanically Ventilated Patient Clinical Pathway — CICU

Neonatal Protocol

Medications Opioid (fentanyl 0.5 mcg/kg/hr or hydromorphone 0.003 mg/kg/hr)
Note: patient may not need infusion if stable on intermittent dosing
If fentanyl at 1.5 mcg/kg/hr, consider adding dexmedetomidine (contraindicated if bradycardia, complete heart block)
Dexmedetomidine 0.25 mcg/kg/hr
Ketamine 0.15 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)
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 0.15 to 0.25 mg/kg/hr)
Assess/Titration Use SBS and pain scores (FLACC)
Assess both every 4 hrs, at minimum
Assess 10 minutes after PRN doses, and infusion changes
PRN Doses PRN fentanyl dose matches hourly infusion rate when patient receiving infusion
RN may administer 2 PRN doses based on SBS
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 Ketamine is for short term use. Reassess use following 24 hrs. Do not use for more than 48 hrs.
Neonatal Protocol
Age < 30 Days
Begin infusion if clinically indicated / stable, at the discretion of FLOC
Assess SBS, Pain Score
every 4 hrs and PRN
SBS < Goal or
No PRNs in 24 hrs
Contact FLOC
Consider decrease
infusion rate
SBS at Goal
SBS Above 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 fentanyl or hydromorphone
  • Reassess in 10 minutes
Pain Score ≥ 4
SBS not at Goal
Consider Delirium
CAPD ≥ 9
  • 2nd PRN fentanyl or hydromorphone
  • Reassess in 10 minutes
  • 2nd PRN fentanyl or hydromorphone
  • Reassess in 10 minutes
Contact FLOC to consider:
  • Increase infusion + PRN doses
  • Initiate additional infusion (dexmedetomidine
    or ketamine) 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