1. Sedation Protocol Dr Samir Sahu

2. Introduction All patients should be sedated before any procedure & during ventilation to prevent discomfort and pain according to their requirement (patient oriented analgesia & sedation) Try non-pharmacological measures like good compassionate & considerate nursing care, communication & counseling, allaying anxiety, visit by family members, natural daylight etc.

3. Assess all patients for need for analgesia and or sedation.

4. SHORT TERM SEDATION Intubation, Central line insertion, Intercostal drainage, Tracheostomy, Short term ventilation. Agents - Midazolam 2.5mg-5mg IV bolus. SEDATION > 24 hrs – Midazolam boluses or Propofol infusion.

5. PROLONGED SEDATION(Long Term) SEDATION (> 72 hours) ONGOING SEDATION : Lora 1- 4mg IV bolus 10-20 minutes till goal is achieved then every 2-6 hrs If requirment of Lorazepam is more frequent than 2 hrs start Midazolam infusion, increase every 15 minutes till you achieve goal. Reduce infusion rate 10-25% daily OR Propofol 5mcg/Kg/min infusion. Titrate every 5 minutes until goal Convert to Lora after 3 days Dose - Midazolam infusion 0.01-0.3mg/Kg/hr. - Propofol-1-3mg/kg/hr If sedation is not adequate or analgesia is required can use Morphine 2-5mg IV bolus or Fentanyl 25-100mcg IV bolus or Butrum 1-2mg IV bolus

6. MONITOR LEVEL OF SEDATION BY RAMSAY SEDATION SCALE HOURLY SET GOAL FOR SEDATION - Ramsay score - 2-3

7. RAMSAY SEDATION SCORE 1.Anxious and agitated or restless or both 2.Cooperative, Oriented, Tranquil 3.Drowsy, responds to verbal command only 4.Asleep, brisk response to light glabellar tap or loud auditory stimulus 5.Asleep, sluggish response to light glabellar tap or loud auditory stimulus 6.Asleep, no response to light glabellar tap or loud auditory stimulus (Record sedation score hourly)

8. DAILY INTERRUPTION OF SEDATION Stop infusion daily at 7 am. Restart if required by giving bolus & then infusion at 10-25% less then the previous dose If not able to stop sedation daily morning or sedation score is more than 3 then reason has to be stated. Audit compliance of the guideline

9. SUDDEN & URGENT AGITATION Propofol 25-50 mg IV bolus/Midazolam 2.5mg IV in 5-15 minutes till acute event controlled Acute Confusional State - exclude hypoxia, hepatic encephalopathy

10. ANALGESIA Morphine, Fentanyl, Butrum. Patient controlled analgesia. Perioperative use of Epidural analgesia. Haemodynamically unstable - Fentanyl 25- 100mcg every 5 -15 minutes. Haemodynamically stable - Morphine 2.5mg IV every 5-15 min

11. Neuroparalytic Agents NEUROMUSCULAR agents rarely used. They are mostly required for neuro cases and sometimes in ARDS Neurointensive care - neuroparalytic agents along with sedation may be required to reduce ICP & maintained PCO2 between 28-35 mm Hg

12. DELIRIUM Haloperidol