Sedation/Analgesia, CICU, Mechanically Ventilated Patient — Greater Than 14 Days — Clinical Pathway: ICU

Sedation/Analgesia in Mechanically Ventilated Patient Clinical Pathway — CICU

Enteral Weaning Plans

> 14 days

  • Initiate opioid and benzodiazepine weans on consecutive days to allow staggered wean
    • (e.g., wean morphine on day 1 and then wean diazepam on day 2, etc.)
  • Calculate 10% of initial enteral opioid and benzodiazepine doses (enteral Day 0) prior to initiation of weaning protocol. (This will be the increment for stepwise dose weaning.)
  • Wean opioid by 10% of enteral Day 0 dose every 48 hours.
  • Wean benzodiazepine by 10% of enteral Day 0 dose every 48 hours.
  • Once ≤ the lowest starting dose is reached, alternate spacing opioid and benzodiazepine frequencies in a daily stepwise fashion until off (see below)
    • (i.e. q4h → q6h → q8h → q12h → OFF)

Lowest Starting Doses for PO Agents

MedicationLowest starting dose (< 50 kg)
mg/kg PO		Lowest starting dose (≥ 50 kg)
mg PO
Opioids
Morphine0.15 mg/kg/dose PO7.5 mg PO
Hydromorphone0.03 mg/kg/dose PO2 mg PO
Benzodiazepines
Diazepam0. 05 mg/kg/dose PO2.5 mg PO
Lorazepam0. 05 mg/kg/dose PO2.5 mg PO

Total wean should take approximately 21 days.

Example

10 kg patient with 21 days exposure to fentanyl/midazolam, now stable on enteral agents for ≥ 24 hours.

  • Fentanyl IV 3mcg/kg/hr converted to morphine 5.5 mg PO q4h (0.55mg/kg/dose)
  • Midazolam IV 0.15mg/kg/hr converted to diazepam 3 mg PO q6h (0.3mg/kg/dose)
    1. Calculate 10% increment for stepwise dose weaning:
      • Morphine PO 5.5mg/dose (Day 0) x 10% = 0.6mg/dose
      • Diazepam PO 3mg/dose (Day 0) x 10% = 0.3mg/dose
    2. Wean opioid dose (Day 0) every 48 hours by calculated 10% increment
    3. Wean benzodiazepine dose (Day 0) every 48h hours by calculated 10% increment
    4. Determine lowest starting enteral dose for opioid and benzodiazepine
      • Morphine 0.15 mg/kg/dose = 1.5 mg/dose
      • Diazepam 0.05 mg/kg/dose = 0.5 mg/dose
    5. Once the patient's dose is approximately at the lowest starting dose, space opioid and benzodiazepine frequencies in a daily stepwise fashion (see example chart below)
StepMorphineDiazepamDate Wean Step Completed
Current dose (Day 0)5.5 mg PO q4h3 mg PO q6h 
14.9 mg PO q4h  
2 2.7 mg PO q6h 
34.3 mg PO q4h  
4 2.4 mg PO q6h 
53.7 mg PO q4h  
6 2.1 mg PO q6h 
73.1 mg PO q4h  
8 1.8 mg PO q6h 
92.5 mg PO q4h  
10 1.5 mg PO q6h 
111.9 mg PO q4h  
12 1.2 mg PO q6h 
131.3 mg PO q4h  
14 0.9 mg PO q6h 
151.3 mg PO q6h  
16 0.6 mg PO q6h 
171.3 mg PO q8h  
18 0.6 mg PO q8h 
191.3 mg PO q12h  
20 0.6 mg PO q12h 
21Morphine OFF  
22 Diazepam OFF