Saint Thomas Hospital Protocol. Protocol Title: Terminal Weaning from Ventilator Protocol No.: V-09. Medical Staff departments

Transcription

1 Saint Thomas Hospital Protocol Protocol No.: V-09 Operating Unit(s) Medical Staff departments Important s: Affected: affected:! Hospital! Medicine of Origin: 2/00 " Regional Network! Surgery Reviewed: " Department:! Cardiac Sciences Revised: I. PURPOSE: To allow respiratory care practitioners to wean a patient from a ventilator where death is expected and to allow nurses to give sufficient medication during the weaning process so as to maintain patient comfort, regardless of the impact on vital signs. II. DEPARTMENT(S) PRIMARILY AFFECTED: Nursing; Respiratory Care III. INDICATORS: A. Indicators for Initiation of Protocol A.1. a physician's order for terminal weaning from the ventilator; A.2. completion of the attached order sheet (V-09a); and A.3. assurance that withdrawal complies with Saint Thomas Hospital Operating Unit Policy W-01: Withdrawal of Medical Treatment. B. Indicators for Termination of Protocol B.1. patient's death and notification of physician; or B.2. physician's order. IV. PROTOCOL GUIDELINES AND PROCEDURES: A. Prepare for implementation of protocol by: A.1. assuring withdrawal complies with policy; A.2. maintaining one IV access site for administration of analgesia and sedation; A.3. assembling equipment and medication necessary for comfort and pain/respiratory distress control;

2 Protocol No.: V-09 Page 2 of 5 A.4. determining noninvasive monitoring needs; A.5. discontinuing all monitors that do not contribute to patient comfort as ordered; A.6. discontinuing neuromuscular blocking drugs and allowing time for reversal; and A.7. confirming medication orders prior to beginning midazolam (Versed), lorazepam (Ativan), or morphine sulfate if the patient is currently receiving medication for pain, sedation, or anxiety. B. Gradual Ventilator Withdrawal -- The nurse and respiratory care practitioner (RCP) coordinate their roles so as to assure patient comfort during the weaning process. At each step the patient is evaluated for any signs of pain, respiratory distress, agitation, or anxiety and appropriate action is taken. B.1. If the patient shows any signs of anxiety or agitation, approximately 30 minutes before starting the morphine sulfate drip, the nurse: B.1.a. gives an IV bolus of 1-2 mg midazolam, B.1.b. starts a continuous drip of lorazepam at 0.5 mg/hr., and B.1.c. titrates lorazepam up to 4 mg/hr to control anxiety. B.2. The patient is placed in an upright position, if possible, and the RCP clears the patient's airway of secretions if necessary. B.3. The nurse starts a continuous drip of morphine sulfate at 4 mg/hr. B.4. Approximately 30 minutes after the morphine sulfate as been started, the RCP begins to wean the ventilator by decreasing the SIMV rate in steps of 2-3 breaths per minute at approximately 15-minute intervals. Maintain minimal PEEP (5 cm/h2o) and pressure support (5-10 cm/h2o). B.5. If, at any point during the weaning process, symptoms of pain, respiratory distress, agitation, or anxiety are observed: B.5.a. the nurse gives an IV push of 2-3 mg morphine sulfate every 1-2 minutes, repeating until symptoms are relieved, regardless of the impact on vital signs. Rapid titration of medication to the level required for patient comfort is essential. B.5.b. if morphine titration fails to achieve patient comfort, the RCP increases the ventilator rate until the symptoms are controlled (or, after a patient is extubated, places the patient on oxygen). B.5.c. the nurse increases the continuous drip rate of morphine sulfate by the total of IV push dose. Example: Continuous drip rate set at 4 mg/hr. A decrease in ventilator settings results in respiratory distress. A total of 8 mg. morphine sulfate IV push is needed to relieve symptoms. The continuous drip rate should be increased to 12 mg/hr.

3 Protocol No.: V-09 Page 3 of 5 B.6. When, in the ventilator weaning process, an SIMV of zero is reached, the RCP decreases the PEEP and pressure support levels to achieve spontaneous respirations. B.7. The RCP removes the patient from the ventilator and places him/her on blow-by. B.8. The RCP extubates the patient if ordered by the physician. B.9. The RCP or nurse discontinues the oximeter if ordered by the physician. B.10. The nurse contacts the physician for further orders or to pronounce death when all spontaneous respirations have ceased. C. Immediate Ventilator Withdrawal -- The nurse and respiratory care practitioner (RCP) coordinate their roles so as to assure patient comfort during the weaning process. At each step the patient is evaluated for any signs of pain, respiratory distress, agitation or anxiety and appropriate action is taken. C.1. If the patient shows any signs of anxiety or agitation, approximately 30 minutes before starting the morphine sulfate drip, the nurse: C.1.a. gives an IV bolus of 1-2 mg midazolam, C.1.b. starts a continuous drip of lorazepam at 0.5 mg/hr., and C.1.c. titrates lorazepam up to 4 mg/hr to control anxiety. C.2. The patient is placed in an upright position, if possible, and the RCP clears the patient's airway of secretions if necessary. C.3. The nurse starts a continuous drip of morphine sulfate at 4 mg/hr. C.4. Approximately 30 minutes after the morphine sulfate as been started, the RCP removes the patient from the ventilator and places him/her on blow-by. C.5. If, at any point during the weaning process, symptoms of pain, respiratory distress, agitation, or anxiety are observed: C.5.a. the nurse gives an IV push of 2-3 mg morphine sulfate every 1-2 minutes, repeating until symptoms are relieved, regardless of the impact on vital signs. Rapid titration of medication to the level required for patient comfort is essential. C.5.b. if morphine titration fails to achieve patient comfort, the RCP resumes mechanical ventilation until the symptoms are controlled (or, after a patient is extubated, places the patient on oxygen); C.5.c. the nurse increases the continuous drip rate of morphine sulfate by total of IV push dose. Example: Continuous drip rate set at 4 mg/hr. A decrease in ventilator settings results in respiratory distress. A total of 8 mg morphine sulfate IV push is needed to relieve symptoms. The continuous drip rate should be increased to 12 mg/hr.

4 Protocol No.: V-09 Page 4 of 5 C.6. The RCP extubates the patient if ordered by the physician. C.7. The RCP or nurse discontinues the oximeter if ordered by the physician. C.8. The nurse contacts the physician for further orders or to pronounce death when all spontaneous respirations have ceased. V. DOCUMENTATION: A. The nurse documents the medication delivery on Medication Administration Record and the patient response to the medication in the progress notes as per policy. B. The RCP documents the ventilator changes and the patient response to those changes on the Ventilator Flowsheet as per policy. VI. SIGNATURES (electronic signatures/final approval was received): Approved by: Suzanne White 1/26/00 Senior Vice President, Patient Services/CNO Approved by: Sister Priscilla Grimes 1/26/00 Vice President, Mission Services Approved by: Ann Price, M.D. 1/26/00 Chief Medical Officer Approved by: Seth Cooper, M.D. 1/27/00 President, Medical Staff Approved by: Thomas E. Beeman 1/26/00 President & Chief Executive Officer References (reference material used in preparing this document): Ethical and Religious Directives for Catholic Health Care Facilities (Rev. 1995) Catholic Health Providers Reaffirm Commitment to Compassionate Support for Dying Persons, The Catholic Health Association of the United States, News Release, Sept Weatherill G. "Pharmacologic Symptom Control During the Withdrawal of Life Support: Lessons in Palliative Care." AACN Clinical Issues, May Brody H., Campbell M., Langenon K., Ogle K., "Withdrawing Intensive Life-Sustaining Treatment - Recommendations for Compassionate Clinical Management." New England J Med., Feb Daly J., Thomas D., Dyer M.A., "Procedures Used in Withdrawal of Mechanical Ventilation." Amer. J Critical Care, Sept. 96, Vol 5, No. 5.

5 Protocol No.: V-09 Page 5 of 5 Daly, B., Newlon B., Montenegro MD., Langdon T. "Withdrawal of Mechanical Ventilation" Ethical Principles and Guidelines for Terminal Weaning." Amer. J Critical Care, 1993, Vol. 2, No. 3. Related document(s) (other policies/procedures/protocols related to this document): W-01: Withdrawal of Medical Treatment Policy W-01a: Withdrawal of Medical Treatment Procedure V-09a: Terminal Weaning from Ventilator--Physicians Order Sheet Key Words (words not in this document but used by staff in searching for this document):