Sedation/Analgesia, PICU, Mechanically Ventilated Patient — Weaning Increments to Reach Conversion Threshold Levels — Clinical Pathway: ICU

Clinical Pathways Home Emergency ICU Inpatient Outpatient Specialty Care Primary Care

Main Pathway
PICU Pathway for Sedation/Analgesia in the Mechanically Ventilated Patient

Patient Likely to be Extubated in the Next 24 Hours

Assess Risk of Withdrawal-associated Adverse Outcomes

If low risk: turn off sedation prior to extubation
Monitor for Signs of Pain, Withdrawal

≥ 5 days of continuous sedation or high risk

Titrate sedation to desired level of wakefulness for extubation

Patient
Intubated
(Titrating)

Patient Extubated

Wean continuous infusions until conversion
thresholds are met

IV Thresholds for Enteral Conversion

Medication	Goal IV Threshold
Fentanyl	2.5 mcg/kg/hr
Morphine	0.1 mg/kg/hr
Hydromorphone	0.015 mg/kg/hr
Midazolam	0.15 mg/kg/hr

NOT Tolerating Enteral Medications
Wean IV Sedation

Tolerating Enteral Medications
Transitioning from IV to PO

Duration 5-9 Days or High Risk < 5 Days
Duration 10-21 Days or High Risk 5-9 Days
Duration > 21 Days or High Risk 10-21 Days

Dexmedetomidine Wean

Opioid Conversion
Benzodiazapine Conversion

Dexmedetomidine Wean

Wean Enteral Sedation

Duration 5-9 Days or High Risk < 5 Days -Enteral
Duration 10-21 Days or High Risk 5-9 Days -Enteral
Duration > 21 Days or High Risk 10-21 Days -Enteral

Monitor Withdrawal Symptoms, (WAT-1 Scale), Pain Scores
Consider Non-Pharmacologic Interventions

Pain Present

Administer opioid or opioid-sparing analgesic as appropriate

WAT Score > 3

Monitor for Over-sedation

Contact FLOC if concerned for over-sedation
Consider decreasing opioid and/or benzodiazepine doses or skipping a scheduled dose

Patient
Extubated
(Weaning)

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.