Sedation/Analgesia in Mechanically Ventilated Patient Clinical Pathway — CICU
Wean Examples: ≥ 7 Days of Continuous Therapy
Example 1
Patient (10 kg) on therapy for 9 days with fentanyl infusion currently at a rate of 4 mcg/kg/hr and midazolam currently at a rate of 0.2 mg/kg/hr. The following stepwise reduction is recommended at 12 hour intervals with a PRN equal to 1/2 current dose for any withdrawal concerns UNTIL conversion threshold levels are reached. Once threshold levels are met, consider conversion to an enteral option for further weaning if patient condition allows.
| Fentanyl | Midazolam | |||||
|---|---|---|---|---|---|---|
| Step | Infusion Rate | PRN | Step | Infusion Rate | PRN | |
| 1 | 3.2 mcg/kg/hr | 1.6 mcg/kg/hr | 1 | 0.16 mg/kg/hr | 0.08 mg/kg | |
| 2 | 2.4 mcg/kg/hr | 1.2 mcg/kg/hr | 2 | 0.12 mg/kg/hr | 0.06 mg/kg | |
| 3 | Convert to enteral morphine | 3 | Convert to enteral diazepam | |||
Fentanyl 2.4 mcg/kg/hr x 10 kg x 0.18 = 4.32 mg (round to 4.3 mg) enteral morphine to administer every 4 hours
Midazolam 0.12 mg/kg/hr x 10 kg x 1.8 = 2.16 mg (round to 2.2 mg) enteral diazepam to administer every 6 hours
Once patient stable on intermittent enteral therapy (at least 24 hours without any signs or symptoms of withdrawal) wean slowly according to enteral weaning guidelines outlined below.
Example 2
Patient (10 kg) on therapy for 22 days with fentanyl infusion currently at a rate of 5 mcg/kg/hr and midazolam currently at a rate of 0.3 mg/kg/hr. The following stepwise reduction is recommended at 12 to 24 hour intervals with a PRN equal to ~1/2 current dose for any withdrawal concerns UNTIL conversion threshold levels are reached. Once threshold levels are met, consider conversion to an enteral option for further weaning if patient condition allows.
| Fentanyl | Midazolam | |||||
|---|---|---|---|---|---|---|
| Step | Infusion Rate | PRN | Step | Infusion Rate | PRN | |
| 1 | 4.5 mcg/kg/hr | 2.2 mcg/kg/hr | 1 | 0.27 mg/kg/hr | 0.13 mg/kg | |
| 2 | 4 mcg/kg/hr | 2 mcg/kg/hr | 2 | 0.24 mg/kg/hr | 0.12 mg/kg | |
| 3 | 3.5 mcg/kg/hr | 1.7 mcg/kg/hr | 3 | 0.21 mg/kg/hr | 0.1 mg/kg | |
| 4 | 3 mcg/kg/hr | 1.5 mcg/kg/hr | 4 | 0.18 mg/kg/hr | 0.09 mg/kg | |
| 5 | Convert to enteral morphine | 5 | Convert to enteral diazepam | |||
Fentanyl 3 mcg/kg/hr x 10 kg x 0.18 = 5.4 mg enteral morphine to administer every 4 hours
Midazolam 0.18 mg/kg/hr x 10 kg x 1.8 = 3.24 mg (round to 3.2 mg) enteral diazepam to administer every 6 hours
Once patient stable on intermittent enteral therapy (at least 24 hours without any signs or symptoms of withdrawal) wean slowly according to enteral weaning guidelines outlined below.