Sedation/Analgesia, PICU, Mechanically Ventilated Patient — Sedation Initiation — Clinical Pathway

Sedation/Analgesia, Mechanically Ventilated Patient Clinical Pathway — PICU

Sedation Initiation

Medication Infusion – First Line

< 50 kg ≥ 50 kg
  • Fentanyl 0.5-1 mcg/kg/hr
  • or
  • Morphine 0.01-0.02 mg/kg/hr
  • or
  • Hydromorphone 0.003-0.005 mg/kg/hr
  • Opioid choice based on patient-specific factors
  • Fentanyl 25-50 mcg/hr
  • or
  • Morphine 1-2 mg/hr
  • or
  • Hydromorphone 0.1-0.2 mg/hr
  • Opioid choice based on patient-specific factors

Opioid Loading Dose

If SBS is not at goal after continuous infusion initiation, consider loading doses of opioids to achieve steady state before changing infusion rate.

< 50 kg ≥ 50 kg
  • If pain, deliver opioid loading dose:
    • Fentanyl 0.5-1 mcg/kg/dose every 10 minutes PRN up to 2 hours
    • or
    • Morphine 0.01-0.02 mg/kg/dose every 15 minutes
      PRN up to 2 hours
    • or
    • Hydromorphone 0.003-0.005 mg/kg/dose every 15 minutes PRN up to 2 hours
  • If pain, deliver opioid loading dose:
    • Fentanyl 25-50 mcg/dose every 10 minutes PRN up to 2 hours
    • or
    • Morphine 1-2 mg/dose every 15 minutes PRN up to 2 hours
    • or
    • Hydromorphone 0.1-0.2 mg/dose every 15 minutes PRN up to 2 hours

Anxiety or Agitation

< 50 kg ≥ 50 kg
  • Dexmedetomidine 0.25-0.5 mcg/kg/dose over 10 minutes
    • Contraindications: severe bradycardia, complete heart block
  • or
  • Lorazepam 0.05 mg/kg/dose (2 mg max) every
    6 hours PRN
  • Dexmedetomidine 0.25-0.5 mcg/kg/dose (max 25 mcg) over 10 minutes
    • Contraindications: severe bradycardia, complete heart block
  • or
  • Lorazepam 2 mg every 6 hours PRN

Special Scenarios

Propofol Infusion
  • Propofol should not be used in the presence of underlying metabolic disorders or shock state. Use caution in children < 6 months, due to insufficient data and concern for undiagnosed metabolic disorders. Discussion with the pediatric critical care attending should occur prior to initiation.
  • For the purpose of adjunct sedation, propofol can be considered at a maximum dose of 65 mcg/kg/min for up to
    48 hours.
  • If propofol is used for greater than 12 hours, it is recommended to obtain: blood gas with lactate, basic metabolic panel, creatinine kinase, and triglycerides.
  • Monitor labs at every 12 hours and as clinically indicated. In children < 6 months of age, consider monitoring every 6 hours. (See Formulary for Monitoring Recommendations).
  • Monitor for clinical and laboratory signs of propofol infusion syndrome (PRIS) such as:
    • Refractory bradycardia
    • Metabolic acidosis
    • Hypertriglyceridemia
    • Rhabdomyolysis