Sedation/Analgesia, PICU, Mechanically Ventilated Patient — Sedation Maintenance and Escalation — Clinical Pathway: ICU

Sedation/Analgesia, Mechanically Ventilated Patient Clinical Pathway — PICU

Sedation Maintenance and Escalation

Medication Infusion – Second Line

If SBS not at goal and no pain present after administration of anxiolysis rescue medications, consider starting dexmedetomidine continuous infusion.

< 50 kg ≥ 50 kg
  • Dexmedetomidine 0.5 mcg/kg/hr
    • Contraindications: severe bradycardia, complete heart block

Agitation or Anxiety PRN

< 50 kg ≥ 50 kg
  • Dexmedetomidine 0.25-0.5 mcg/kg/dose every
    1 hour PRN
    • Contraindications: severe bradycardia, complete heart block
  • Lorazepam 0.05 mg/kg/dose (max 2 mg) every 6 hours PRN
  • Dexmedetomidine 0.25-0.5 mcg/kg/dose (max 25 mcg) every 1 hour PRN
    • Contraindications: severe bradycardia, complete heart block
  • Lorazepam 2 mg/dose every 6 hours PRN

Dexmedetomidine Infusion Titration Increments

If 2 dexmedetomidine PRNs are administered in 6 hours, consider increasing continuous infusion.

< 50 kg ≥ 50 kg
Dexmedetomidine 0.25 mcg/kg/hr

Opioid PRN

If escalating opioid requirement, consider opioid rotation.

As needed medications (PRN) should be used when SBS is not at goal. The following frequencies
are recommended for most patients:

< 50 kg ≥ 50 kg
  • Fentanyl every 1 hour
  • Morphine every 1 hour
  • Hydromorphone every 1 hour
  • Fentanyl every 1 hour
  • Morphine every 1 hour
  • Hydromorphone every 1 hour

Opioid Infusion Titration Increments

If SBS still not at goal despite PRN doses, continuous infusions may be titrated at the following increment:

< 50 kg ≥ 50 kg
  • Fentanyl 0.3 mcg/kg/hr
  • Morphine 0.02 mg/kg/hr
  • Hydromorphone 0.002 mg/kg/hr
  • Fentanyl 25 mcg/hr
  • Morphine 0.5-1 mg/hr
  • Hydromorphone 0.1-0.2 mg/hr

Medication Infusion – Third Line

  • Midazolam infusion can be considered as a 3rd line infusion if SBS not at goal and no pain present
  • Midazolam infusion can be considered for the following specific situations
    • Neuromuscular blockade infusion
    • Critical illness requiring decreased cerebral metabolic rate
    • Severe anxiety with absolute contraindications for dexmedetomidine
    • Status Epilepticus Pathway
< 50 kg ≥ 50 kg
  • Midazolam 0.02-0.04 mg/kg/hr
  • PRN frequency: every 2 hours
  • Midazolam 1-2 mg/hr
  • PRN frequency: every 2 hours

Midazolam Infusion Titration Increments

If SBS still not at goal and no pain present despite PRN doses, continuous midazolam infusion may be titrated at the following increment:

< 50 kg ≥ 50 kg
Midazolam 0.01-0.02 mg/kg/hr Midazolam 0.5-1 mg/hr