Upcoming Modifications for Sedation and Analgesia As Simple

Upcoming Modifications for Sedation and Analgesia: As Simple as ABCDEF Kaushik Mukherjee MD MSCI FACS Assistant Professor of Surgery Associate Trauma Medical Director Loma Linda University Medical Center

Assess, Prevent, and Manage Pain CPOT BPS CPOT+BPS Sensitivity 76. 5% 62. 7% 80. 4% Specificity 70. 8% 91. 7% 75. 0% • Re-focusing our commitment to pain management • Incorporating feedback from • Patient • Family • Nursing • Correctly assessing when patients have pain and treating it aggressively makes a difference Severgnini et al. Journal of Intensive Care (2016) 4: 68 DOI 10. 1186/s 40560 -016 -0192 -x

IPAD (Initial Pain Assessment Dosing) Intermittent Fentanyl or Hydromorphone IFON (Infusion of Fentanyl or Narcotics) IV Push Works? PO Multimodal Ye s Minimal Pain, Lots of Gain! Enteral Access? No No Fentanyl Infusion • 80% of mechanically ventilated patients to be off drips for pain control within 48 hours IV Multimodal

IPAD • Initial Pain Assessment Dosing • FENTANYL • Give fentanyl (25, 50, 100 mcg to be decided by physician) q 30 minutes PRN CPOT 3 -8 for up to 2 hours • HYDROMORPHONE • Give hydromorphone (0. 1, 0. 2, 0. 4 mg to be decided by physician) q 30 minutes PRN CPOT 3 -8 for up to 2 hours.

IFON • Infusion of Fentanyl Or Narcotics • FENTANYL INFUSION ORDERS (3 OR MORE DOSES DURING IPAD) • Start at 0. 25 mcg/kg/hr. • Titrate by 0. 25 mcg/kg/hr as often as every 20 minutes for CPOT 0 -2 or (specify RDOS) or (specify pain scale) • Wean by 0. 25 mcg/kg/hr as often as every 20 minutes as tolerated. • Maximum dose 3 mcg/kg/hr • INTERMITTENT FENTANYL (0 -2 DOSES DURING IPAD) • Fentanyl (25, 50, 100 mcg to be decided by physician) q 1 hour PRN CPOT 3 -8 • INTERMITTENT HYDROMORPHONE (0 -2 DOSES DURING IPAD) • Hydromorphone (0. 1, 0. 2, 0. 4 mg to be decided by physician) q 1 hour PRN CPOT 3 -8

Acute Multimodal Pain Control Pathway • If PO • If NPO • PO acetaminophen 1000 mg q 6 hrs x 48 hours (for • IV acetaminophen 1000 mg q 6 hrs x 24 hours (for normal liver function) or 1000 mg q 12 hrs x 48 hrs normal liver function) or 1000 mg q 12 hrs (mildly impaired liver function). Renew for an additional 24 hours if still NPO after 24 hours • PO methocarbamol 500 mg q 12 hours x 3 days (if < 70 kg) or 1000 mg q 12 hours x 3 days (if > 70 kg) • IV methocarbamol 500 mg q 12 hours x 3 days (if < 70 kg) or 1000 mg q 12 hours x 3 days (if > 70 kg) • Lidocaine patches to specific pain areas • PO ibuprofen 400 mg TID x 48 hrs (Age < 50, normal renal function, low risk of bleeding) or 200 mg TID x 48 • IV ketorolac 30 mg q 6 hrs x 48 hrs (Age < 50, normal hrs (Age >50 but <65, normal renal function, low risk of bleeding) or 15 mg q 6 hrs of bleeding) x 48 hrs (Age >50 but < 65, normal renal function, low risk of bleeding) • PO oxycodone 5 mg q 6 hrs scheduled x 48 hours, then PRN • IV hydromorphone 0. 2 to 0. 4 mg q 2 hrs PRN breakthrough pain (CPOT 3 -8)

Sedation and Delirium Prevention Sedation (after pain controlled except at MD discretion or if RASS > +1) Acute Delirium Prevention • Dexmetetomidine IV infusion 00. 7 mcg/kg/hr, titrate to RASS -1 to +1 • Lights on and windows open from 0600 -2100 • Propofol IV infusion 0 -50 mcg/kg/hr, titrate to RASS -1 to +1 • If no q 1 hr or q 2 hr orders, cluster cares from 22000400 • Midazolam to be removed from sedation algorithm • Lights off and windows closed from 2100 -0600 • Avoid unnecessary POKEs between 2200 -0400 or cluster them together if they are unavoidable • No baths to be given from 2200 -0400