INTERMITTENT DOSING

Intermittent dosing of analgesics and anxiolytics, as opposed to continuous dosing, has been shown to reduce the duration of mechanical ventilation and intermittent dosing of analgesics and anxiolytics should be instituted prior to continuous dosing. Although many sedative agents are utilized for their short duration of action (e.g. midazolam), administration as a continuous infusion will often result in a prolonged duration of action and effect due to fat storage an accumulation of active metabolites. It is recommended that intermitted sedation be used whenever feasible. For patients who require dosing more frequently than every 1-2 hours, continuous dosing titrated to effect can be used; however, continuous infusions should be converted to intermittent dosing as early as possible.

SEDATION VACATIONS

Daily interruptions of sedation (“sedation vacations”) have repeatedly demonstrated reduction in the duration of mechanical ventilation as well as the incidence of ventilator-associated pneumonia.21 Intermittent dosing and daily sedation holidays prevent the accumulation of active metabolites, which may impede patient assessment for prolonged periods of time.25,28

- Continuous infusions should be stopped daily to obtain a reliable physical examination, including neurologic assessment, and to perform a spontaneous breathing trial in ventilated patients.
- Sedation goals should be assessed every day following sedation holidays and every effort should be made to reduce infusion doses.

CONTRAINDICATIONS TO THE DAILY SEDATION HOLIDAY:

- Intractable intracranial hypertension.
- Hemodynamic instability.
- Inability to adequately oxygenate or ventilate mechanically ventilated patients.

See Appendix H for a sample order set including medication options and dosing.

See Table 1 in Appendix A for suggested management algorithms.