Patient Monitoring and Documentation



|Patient Monitoring and Documentation |

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|Interaction Level 1: patient should be able to communicate presence of pain or anxiety. |

|This should correspond approximately to a VICS interaction score of at or above 24/30. |

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|If the patient is agitated but is unable to communicate presence of pain or anxiety call MD to assess patient for delirium. |

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|Documentation: |

|VICS q4h on ALL patients |

|VICS pre and post intervention to treat pain, agitation/delirium or anxiety |

|Pain Intensity with Numeric Rating Scale (0-10) pre and post intervention to relieve pain |

|In patients who cannot communicate presence of pain, document clearly in the SAD record perceived signs of pain that trigger intervention. |

|Analgesia |

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|Administer 5 MIN prior to procedures that may cause pain (to allow time for drug to act; 80% of peak effect is reached in approx 5 MIN) |

|To relieve pain in patients who communicate need for intervention |

|To treat signs of pain in patients who cannot communicate but pain is suspected given clinical situation. Review signs of inferred pain with|

|MD q4h. |

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|Bolus morphine 0.5 mg, 1 mg, 2mg, 4mg, 6mg Q 5 MIN prn until effect or adverse event seen (e.g. hypotension) |

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|Assessment: |

|Assess patient’s response 5 MIN following each dose. |

|Goal is to reduce patient’s pain intensity rating to |

|3/10 (NOT 0 / 10) or as patient directs |

|If administering analgesia to patients who cannot communicate presence of pain but pain is suspected given clinical situation |

|Review with MD signs of perceived pain that trigger intervention |

|Q4H or earlier if signs are not corrected. |

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|Call MD if infusion considered necessary after 6 hrs of bolus therapy |

|At this time discuss with MD role of: |

|Non-narcotic analgesia: Tylenol or NSAID |

|Whether epidural analgesia is appropriate |

|Peri-procedural sedation |

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|Explain procedure to patient as fully as possible |

|Administer 3 MIN prior to procedure |

|Find minimal effective dose |

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|Bolus midazolam 0.5 mg, 1mg, 2mg, 4 mg, 6 mg IV Q 3 MIN prn |

|Anxiety |

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|Patient must be able to confirm that they are anxious |

|Enquire into source of anxiety and provide reassurance |

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|Lorazepam 0.5 mg to 1mg SL/IV Q4H PRN x 24h |

|Delirium |

|Delirium is characterized by: |

|Inattention & fluctuating interaction WITH EITHER |

|disorientation OR agitation OR withdrawn; hallucinations may be present |

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|Physician should rule out agitation due to: withdrawal from alcohol, sedatives, analgesics or nicotine; or other reversible causes (e.g. |

|suboptimal ventilator settings or metabolic disturbances). |

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|For delirium that is not associated with alcohol or other withdrawal states: |

|Discontinue opioids and benzodiazepines if possible |

|Reassure and re-orientate patient to environment (ensure access to eyeglasses/ hearing aids if applicable) |

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|Use the pre-printed orders “ICU orders for delirium” |

|Physician to order either: |

|Haloperidol 2.5 mg to 10 mg IV Q 20 to 30 MIN prn |

|Dose may also be on a fixed schedule e.g. 1 mg to 5 mg IV/NG bid. |

|If it is ordered on a prn schedule a maximum dose should be specified over a |

|12 hr interval e.g. 40 mg. |

|If maximum dose is reached medical team needs to review and justify continuation |

|OR |

|Methotrimeprazine 5 mg to 25 mg IV Q 20 to 30 MIN prn |

|If ineffective (dosing level 5 reached) or symptoms worsening call MD to reassess |

|reassess with MD if patient received 150 mg in a 12 hr interval |

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|Escalating regimen for Haloperidol and Methotrimeprazine (NOZINAN) |

|Dosing level 1 to 3 can be given 20 mins apart if needed |

|. |

|Dosing Level |

|Haloperidol IV Q 30 MIN (mg) |

|Methotrimeprazine (Nozinan ) |

|IV Q 30 MIN (mg) |

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|1 |

|2.5 |

|5 |

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|2 |

|5 |

|12.5 |

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|3 |

|5 |

|12.5 |

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|4 |

|10 |

|25 |

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|5 |

|10 |

|25 |

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|If at any time agitation is dangerous to patient or caregiver |

|call MD for a midazolam bolus order |

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|Adverse event monitoring |

|Measure QT and RR interval from rhythm strip before first dose of haloperidol |

|Use Table 1 to determine QTc. |

|Measure QT and RR interval from rhythm strip before each dose successive of haloperidol. |

|Discontinue haloperidol if QTc increases by 25% from baseline. |

|Observe and assess patients for any signs of stiffness or parkinsonian-like effect or hypotension |

|( with methotrimeprazine ). |

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|MAINTENANCE REGIMEN |

|For escalating haloperidol or methotrimeprazine regimen, the following applies: |

|If a patient’s target symptoms are corrected call MD to write a maintenance regimen. |

|Add up first 24-hour dose requirement. |

|Give 50% of this dose over the next 24 hours in 4 divided doses i.e. Q6H |

|Reduce maintenance dose by 25% each day if patient’s symptoms remain controlled. |

|Continue prn regimen as needed for breakthrough agitation that is presumed due to delirium. |

|Sedation for physiologic goals |

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|Monitoring |

|Document VICS score q4h |

|Infusion rates must be reassessed q 6h and adjusted accordingly; reduce by 25% if clinical goals are met |

|Medical team must perform daily review and justify continued need for sedation goals |

|Sedation goals |

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|1) (O2 demand during shock state OR |

|2) prevent patient movement OR |

|3) other as specified on order |

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|Midazolam 1 mg, 2 mg, 4mg, 6mg IV Q3 MIN prn |

|Refer to table on infusion titration to determine if an infusion should be started |

|To suppress respiratory drive (that is associated with ( O2 sat) |

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|Morphine 1 mg, 2mg, 4mg, 6mg Q 3 MIN prn |

|With |

|Midazolam 1 mg, 2 mg, 4mg, 6mg IV Q3 MIN prn |

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|If ineffective or if BP falls call MD |

|If effective refer to table on infusion titration to determine if an infusion should be started |

|Sedation and analgesia in patients with elevated ICP |

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|Ensure that Head Injury Protocol has been instituted. |

|Start morphine and midazolam infusions at rate ordered. |

|ICP IS ELEVATED (>20mmHg) ( IS IT RELATED TO NOXIOUS STIMULI? |

|a)YES |b)NO |c) NO |

| | | |

|1) Remove stimulus |>20 for < 5 MIN |>20 for > 5 MIN |

|2) Pre-medicate patient with midazolam |( |( |

|prior to future planned non-painful stimuli| | |

|(use morphine if painful) |NO ACTION |Open drain and leave open x 5 minutes. |

|3) If ordered and ICP remains elevated | |Call MD to determine management |

|despite removal of stimulus follow | |Review head injury protocol |

|guidelines for procedural boluses of | | |

|midazolam to treat this episode of ICP | | |

|elevation | | |

|4) If ICP >20 for > 5 MIN | | |

|( | | |

|Open drain and leave open x 5 minutes. | | |

|Review head injury protocol | | |

| | | |

|5) Do not increase infusion rates based on | | |

|procedural boluses. | | |

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|Sedation and analgesia prior to initiation of neuromuscular blockade |

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|Titrate analgesia to achieve pain relief prior to starting neuromuscular blockade. |

|Ensure patient is deeply sedated so that they are unarousable, with in addition, no physiologic (HR/BP) response to stimuli. |

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|Midazolam bolus 1, 2mg, 4mg, 6 mg IV Q 3 MIN to achieve unarousable state |

|and no response to physiologic stimuli then start midazolam infusion 5 to 10 mg/hr as needed (refer to table on infusion titration). |

|Maintenance protocol for titration of morphine and midazolam infusions |

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|TO DETERMINE INITIAL RATE OF MORPHINE OR MIDAZOLAM INFUSIONS |

|AND SUBSEQUENT RATE INCREASES: |

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|TO START SUBSEQUENT ADJUSTMENT |

|FIRST 6 HOURS: Total amount of drug patient responded to (not including procedural boluses): |

|Initial rate - mg/hr |

|Total bolus doses given in last 6 hours (not including procedural boluses) |

|Rate increase – mg/hr |

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|25mg |

|4 |

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|For physiologic goals, may start an infusion (if ordered) within 6 hours |

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|Titrate to minimal effective dose |

|Infusion rates must be reassessed q 6h |

|Reduce by 25% if clinical goals are met. |

|4) If infusion rate is 1mg/h discontinue infusion and use bolus prn. |

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Vancouver General Hospital ICU

Protocols for sedation, analgesia and delirium

Last revision date: May 2006

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