Sedation/Analgesia, CICU, Mechanically Ventilated Patient — Duration 8-14 Days — Clinical Pathway: ICU

Sedation/Analgesia in Mechanically Ventilated Patient Clinical Pathway — CICU

Enteral Weaning Plans

8-14 days

  • Initiate opioid and benzodiazepine weans on consecutive days to allow staggered weans. Consider initiating weans on same day for daily weaning in patients with limited exposure (i.e. low cumulative dose) or low risk of withdrawal
  • Calculate 20% of initial opioid and benzodiazepine doses (enteral Day 0) = increment for stepwise dose weaning
  • Wean opioid by 20% of enteral Day 0 dose every 48 hours if staggered or daily if concurrent wean due to low risk or limited exposure
  • Wean benzodiazepine by 20% of enteral Day 0 dose every 48 hours if staggered or daily if concurrent wean due to low risk or limited exposure
  • 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 about 14 days.

Example

10 kg patient with 12 days exposure to fentanyl/midazolam (high doses required), now stable on enteral agents for ≥ 24 hours.

  • Fentanyl IV 3 mcg/kg/hr converted to morphine 5.5mg PO q4h (0.55 mg/kg/dose)
  • Midazolam IV 0.15 mg/kg/hr converted to diazepam 3mg PO q6h (0.3 mg/kg/dose)
    1. Calculate 20% increment for stepwise dose weaning:
      • Morphine PO 5.5 mg/dose (Day 0) x 20% = 1.1 mg/dose
      • Diazepam PO 3 mg/dose (Day 0) x 20% = 0.6 mg/dose
    2. Wean opioid dose (Day 0) every 48 hours by calculated 20% increment if staggered, consider daily wean in patients with limited exposure or low risk for withdrawal
    3. Wean benzodiazepine dose (Day 0) every 48h hours by calculated 20% increment if staggered, consider daily wean in patients with limited exposure or low risk for withdrawal
    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 
14.4 mg PO q4h  
2 2.4 mg PO q6h 
33.3 mg PO q4h  
4 1.8 mg PO q6h 
52.2 mg PO q4h  
6 1.2 mg PO q6h 
71.1 mg PO q4h  
8 0.6 mg PO q6h 
91.1 mg PO q6h  
10 0.6 mg PO q8h 
111.1 mg PO q8h  
12 0.6 mg PO q12h 
131.1 mg PO q12h  
14 Diazepam OFF 
15Morphine OFF