Sedation in the ICCU/ED and the Richmond Agitation Sedation Scale (RASS)

Sedation Why do patient’s need sedation? Sedation Critically ill patients are often subject to a number of unpleasant experiences. The pain and anxiety caused by mechanical ventilation, intravenous lines, continuous noise and disruption, and sleep deprivation, coupled with the stress of their illness, can cause agitation and distress. Agitation has been shown to lead to ventilator dyssynchrony, increased oxygen consumption, and self-extubation. Sedation Sedatives are an important element in the management of critically ill patients. An appropriate level of sedation can ease adverse experiences, facilitate diagnostic and treatment procedures, and protect patients from the hemodynamic consequences of agitation.

Guidelines/Standards for the Use of Sedation in Acute Care The Joint Commission Qualified staff and equipment to monitor, evaluate, and rescue patients receiving sedation, if needed. Defined monitoring standards and assessment tools are identified in policies. Documentation is included in the medical records of all patients receiving sedation. Guidelines provide standards for analgesia, sedation, and anesthesia. Society of Critical Care Medicine Sedation scales help establish sedation goals in individual patients. Sedation of agitated critically ill patients should be started only after providing adequate analgesia and treating reversible physiologic causes. Regular assessment and response to therapy should be documented systematically with the use of validated sedation assessment scales.

Richmond Agitation Sedation Scale (RASS) The Richmond Agitation-Sedation Scale (RASS) was developed by a multidisciplinary team at Virginia Commonwealth University in Richmond, Virginia. It is a ten point scale with levels for assessing anxiety and agitation, one for an alert and calm state and further levels for quality of sedation. RASS can be assessed in 30-60 seconds and does not require equipment. Three sequential steps are used: observation, response to verbal stimulation and response to physical stimulation. A unique feature of RASS is that it uses the duration of eye contact following verbal stimulation as the principal means of titrating sedation.

Richmond Agitation-Sedation Scale (RASS) Score Term Description +4 Combative Overtly combative, violent, immediate danger to staff +3 Very agitated Pulls or removes tube(s) or catheter(s); aggressive +2 Agitated Frequent non-purposeful movements, fights ventilator +1 Restless Anxious but movements not aggressive vigorous Alert and calm Considered normal behavior -1 Drowsy Not fully alert, but has sustained awakening (eye opening/eye contact) to voice (≥ 10 seconds) -2 Light Sedation Briefly awakens with eye contact in response to voice (< 10 seconds) -3 Moderate Sedation Movement or eye opening in response to voice (but no eye contact) -4 Deep Sedation No response to voice, but movement or eye opening in response to physical stimulation -5 Unarousable No response to voice or physical stimulation

Sedation Orders In the ICCU sedation orders are located in MediTech

Sedation Orders, cont. In the ED sedation orders are located in Forms Fast

Sedation used at Community Hospital of San Bernardino Propofol Maximum dose 50 mg/kg/min Versed Maximum dose of 10 mg/hr Ativan Maximum dose of 6mg/hr Precedex Maximum dose of 1.4 mcg/kg/hr

Propofol (Diprivan) Patient must be in ICCU/ED Patient must be intubated and on a mechanical ventilator Use vented tubing to connect IV line (Tubing changed every 12 hours) Use strict aseptic technique Propofol infusion must have dedicated IV line Recommended starting rate: 5-10 mcg/kg/min Titrate to desired effect-physician selects either light or deep sedation and RN will titrate using Richmond Agitation Sedation Scale (RASS) Light Sedation Deep Sedation Adjust infusion rate every 5 minutes based on vital signs and RASS assessment as indicated on order form. DO NOT BOLUS

Propofol (Diprivan), cont. Monitor blood pressure, pulse, respirations, O2 saturation and RASS Every 5 minutes after each rate change, then Every 1 hour when desired level of sedation is achieved Contact physician for any of the following conditions: Hypotension or hemodynamic instability Uncontrolled agitation Excessive sedation (RASS -4) If dose requirements exceed 50 mcg/kg/min Daily neurological assessments (including brief interruption of infusion) Lipid profile on day #3 of therapy, then every 3 days while on propofol infusion Analgesic infusions may be required to address pain since propofol has NO ANALGESIC properties

Versed Patient must be in ICCU/ED Patient must be intubated and on a mechanical ventilator Physician must specify target RASS score (Example: -2 Light sedation or -4 Deep Sedation) Monitor blood pressure, pulse, respirations, O2 saturation and RASS every 15 minutes until goal RASS is achieved, then monitor every hour. Start infusion at 1 mg/hr and titrate in increments of 1 mg every 15 minutes until goal RASS or a maximum dose of 10 mg/hour is reached.

Ativan Patient must be in ICCU/ED Patient must be intubated and on a mechanical ventilator Physician must specify target RASS score (Example: -2 Light sedation or -4 Deep Sedation) Monitor blood pressure, pulse, respirations, O2 saturation and RASS every 15 minutes until goal RASS is achieved, then monitor every hour. Start infusion at 1 mg/hr and titrate in increments of 1 mg every 15 minutes until goal RASS or a maximum dose of 6 mg/hour is reached.

Precedex Patient must be in ICCU/ED Patient must be intubated and on a mechanical ventilator Physician must specify target RASS score (Example: -2 Light sedation or -4 Deep Sedation) Monitor blood pressure, pulse, respirations, O2 saturation and RASS every 15 minutes until goal RASS is achieved, then monitor every hour. Start infusion at 0.2 mcg/kg/hr and titrate in increments of 0.1 mcg/kg every 15 minutes until goal RASS or a maximum dose of 1.4 mcg/kg/hr is reached.

Analgesia If your patient is receiving sedation you may want to ask the physician if he/she would like to order continuous or intermittent analgesia Morphine sulfate is available as a continuous infusion in the ICCU or as a basal PCA in the ED The physician can order a loading dose then a continuous infusion of 1 mg/hr and titrate in increments of 1mg ever 30 minutes until goal pain level or a maximum of 15 mg/hr is reached.

Neuromuscular Blockade Used as an adjunct for continued agitation in patients receiving maximal sedation/analgesia Vecuronium (Norcuron) is used for intermittent bolus dosing Administer 1 mg IV push every 1 hour to attain RASS goal. May increase to 2mg IV push every hour if continued agitation. Physician must specify maximum dose in 24 hours (Not to exceed dose)

Charting-Sedation Flowsheet Your patient was intubated and placed on a versed drip. How do you document the titration of the medication in the electronic medical record? (This process is the same if your patient is on any of the following sedatives: versed, ativan, precedex) First go to the main menu and select PROCESS INTERVENTIONS

Charting-Sedation Flowsheet Next select Add Interv to add the intervention

Charting-Sedation Flowsheet In the Description box type: Sedation Flowsheet (this is used for Versed, Ativan and Precedex drips) and click the F9 key

Charting-Sedation Flowsheet Hit the enter key till the File dialogue box pops up then select YES, this will file the intervention.

Charting-Sedation Flowsheet You are now able to document. Select DI and select the enter key to begin your documentation.

Charting-Sedation Flowsheet This is the first documentation that you are doing, so ensure that the time is correct and click Ok.

Charting-Sedation Flowsheet Complete the documentation. This patient is a RASS of +4 so the RN will continue to titrate and document (every 15 minutes) until goal RASS of -2 is reached. Once goal RASS is reached the RN can document every hour. NOTE: if any changes in the drip rate occur (example: patient becomes restless you will start the Q15 minute charting.

Charting-Propofol Infusion Assessment Your patient was intubated and placed on a propofol drip. How do you document the titration of the medication in the electronic medical record? First go to the main menu and select PROCESS INTERVENTIONS

Charting-Propofol Infusion Assessment Next select Add Interv to add the intervention

Charting-Propofol Infusion Assessment In the Description box type: Propofol Infusion Assessment and click the F9 key

Charting-Propofol Infusion Assessment Hit the enter key till the File dialogue box pops up then select YES, this will file the intervention.

Charting-Propofol Infusion Assessment Complete the documentation. This patient is a RASS of +4 so the RN will continue to titrate and document (every 5 minutes) until goal RASS of -2 (light sedation) is reached. Once goal RASS is reached the RN can document every hour. NOTE: if any changes in the drip rate occur (example: patient becomes restless) you will start the Q5 minute charting. Don’t forget to list the last date ordered and tubing change on each entry.

Pain Assessment Scale in the Critically Ill Patient Pain assessment shall be completed at a minimum of every one hour with vital signs. In the ICCU or the ED when caring for a critically ill patient (either intubated or extubated) the Critical Care Pain Observation tool (CPOT) is the preferred scale. This scale is used for nonverbal or critically ill patients. The CPOT has 4 categories Facial expression Body movements Muscle tension Compliance with the ventilator (intubated patients) OR Vocalization (extubated patients)

Critical Care Pain Observation tool (CPOT)

Thank You