Please continue to use this guideline but be aware that it is in review (16/12/2024).
Please continue to use this guideline but be aware that it is in review (16/12/2024).
Targeted sedation level and daily sedation hold
Record patient baseline:
The bedside nurse must remain with the patient during a sedation hold.
Is the target RASS score achieved?
If no, keep sedation off and reassess every 15 – 30 minutes until target RASS score is achieved
If yes, restart sedation at half original rate and titrate until target RASS score is achieved
RASS is a ten point scale that assesses both degrees of agitation and sedation. When assessing sedation it differentiates between verbal and physical stimulation; it also makes a basic assessment of attention, providing a possible indicator of delirium as it also integrates with the Confusion Assessment Method for the ICU (CAM-ICU) for assessing delirium.
| Score | Term | Description |
|---|---|---|
| +4 | Combative | Overtly combative or violent; immediate danger to staff |
| +3 | Very agitated | Pulls on or removes tube(s) or catheter(s) or has aggressive behavior toward staff |
| +2 | Agitated | Frequent non-purposeful movement or patient–ventilator dysynchrony |
| +1 | Restless | Anxious or apprehensive but movements not aggressive or vigorous |
| 0 | Alert and calm | |
| -1 | Drowsy | Not fully alert, but has sustained (more than 10 seconds) awakening, with eye contact, to voice |
| -2 | Light sedation | Briefly (less than 10 seconds) awakens with eye contact to voice |
| -3 | Moderate sedation | Any movement (but no eye contact) to voice |
| -4 | Deep sedation | No response to voice, but any movement to physical stimulation |
| -5 | Unarousable | No response to voice or physical stimulation |
Does patient have behavior that is consistent with restlessness or agitation (score +1 to +4 using the criteria listed above, under DESCRIPTION)?
In a loud speaking voice state patient's name and direct patient to open eyes and look at speaker. Repeat once if necessary. Can prompt patient to continue looking at speaker.
Physically stimulate patient by shaking shoulder and then rubbing sternum if there is no response to shaking shoulder.
Medical and nursing teams should always strive to use the minimum dose of sedation to achieve the desired effects without compromising patient comfort and safety. It is important to understand that avoiding the complications of sedation is as important as pharmacological sedation itself.
Over-sedation may be responsible for prolongation of artificial ventilation, hypotension and under-perfusion, prolonged recovery and increased need for tracheostomy, delay in weaning from respiratory support, critical illness myopathy and muscle wasting, an increase in delirium, immunosuppression, ileus of the gastro- intestinal tract, thrombosis and DVT, with down regulation of receptors and increased risk of nosocomial pneumonia, leading to worse outcomes for the patient³
Maintenance of a lighter level of sedation is associated with improved clinical outcomes in critically ill patients¹¹
Evaluation of sedation level can be assessed with the use of a sedation scoring tool. Using such tools can reduce the length of ventilation, and the incidence of pain and hospital infections ¹⁰. One such tool is the Richmond Agitation and Sedation Scoring (RASS) tool, which is used in the Critical Care Unit, Frimley Park Hospital.
In order to achieve the optimal level of sedation using the RASS scoring tool, it should be the responsibility the multidisciplinary team to discuss a ‘target’ RASS score, which ideally will maintain the patient in an awake or semi-awake state. A patient who is deeply sedated and needs a lighter level of sedation should have a sedation hold considered.
A sedation hold is defined as a short-term suspension, hold, discontinuation, cessation, or interruption of intravenous sedatives (continuous infusions or fixed dose bolus), and in some cases, analgesic medications. A daily sedation hold is thought to limit accumulation of the drug in the body, promote a more awake state, leading to less psychological trauma, and thereby reduce the duration of mechanical ventilation. ¹
Interrupting continuous sedation with regular daily breaks, together with assessing the level of sedation, allows clinicians and nurses to target the minimal sedation necessary to keep the patient comfortable ⁴ The minority of patients admitted to ICU require a deep sedation and all other patients can usually be managed with little or no sedation while intubated.
Alongside a daily sedation hold or maintenance of a lighter sedation level is the opportunity to undertake a spontaneous breathing trial, to allow the patient to breathe for themself on the ventilator, to facilitate timely removal from mechanical ventilation.
Therefore each ventilated/sedated ICU patient should have a target RASS score and a sedation hold, as required, with exception of those in the exclusion criteria detailed within this guideline.
The guideline applies to all staff in the Critical Care Unit, Frimley Park Hospital, who will be caring for ventilated patients.
All patients should have a target RASS sedation score and be managed by the bedside nurse to maintain their sedation within this target score. Those who are not yet at their target sedation score and are suitable for a sedation hold should have this completed at least once a day. The nurse in charge on the night shift, in discussion with the ICU consultant, will recommend which patients are appropriate for a sedation hold.
Sedation holds should be carried out early in the day (including the end of the night shift where appropriate) and prior to the ICU consultant ward round.
The purpose of this guideline is to ensure all patients are at their target RASS score. An ideal target RASS score for a sedated patient is 0 to -1. If not at this target, sedation should be reduced or stopped via a sedation hold, completed in a timely manner. This will allow for earlier extubation, improved rehabilitation, decrease in delirium and reduced length of stay on ICU.
A reduction of sedation to target RASS score/daily sedation hold should be conducted for all patients who meet the criteria.
All staff caring for a ventilated patient should be familiar with sedation scoring and undertaking a sedation hold of a patient, and the necessary safety parameters required.
Those patients who fall under the following criteria should not automatically be considered for a daily sedation hold without discussion with the ICU consultant in charge:
A sedation hold should be done at least once daily in all patients except those in the exclusion criteria.
The bedside nurse must remain with the patient at all times during a sedation hold due to risk of self extubation, severe agitation causing harm or removal of lines.
Prior to a sedation hold assess patient baseline:
Note the current infusion rates of sedation +/- analgesia
Discuss with the ICU consultant, nurse in charge and/or the ICU physiotherapist to obtain parameters (including target RASS), with a view toward weaning and extubation.
If the patient starts showing signs of any of the following criteria, consider restarting sedation.
Restart the sedation at half the rate prior to sedation hold. Titrate sedation until a target RASS is achieved. Assess the patient’s pain and titrate the analgesia as needed.
Documentation of RASS score should be completed at least once per hour for ventilated patients to ensure the target sedation level is being met
RASS score should be started, or continued on non-ventilated patients until they are deemed wardable (level 0) For non ventilated patients, a RASS score should be assessed every shift, or more frequently dependent on patients need.
For ventilated/sedated patients, if a sedation hold is being done, ensure the physiological changes of the patient are being documented by either changing the parameters on PICIS to allow for more regular updates or by taking snapshots at regular intervals of at least 15 minutes.
The following should also be documented in order to understand whether the patient is making any improvements, should more than one sedation hold be required:
If sedation needs to be restarted, document the following:
| Version: | 1 |
|---|---|
| Role of Policy Lead(s): | Rita Mody |
| Reviewed by: | Dr. M Blackmore; ICU consultant team; Senior Nursing ICU team. |
| Date issued: | 27 November 2017 |
| Review date: | November 2020 |
| Target audience: | All critical care staff managing sedation and sedation holds |