Unique Plan Description: Mechanical Ventilation
Plan Selection Display: Mechanical Ventilation
PlanType: Medical                                 
Version: 8          
Begin Effective Date: 2025-06-10 13:22:00
End Effective Date: 2100-12-31 00:00:00
Last Updated Date: 2025-06-10 13:22:00
Available at all facilities: No

Mechanical Ventilation
Activity
	ICU Progressive Mobility Protocol
		
Diet
	NPO
		T;N
Laboratory
	Blood Gases Arterial (ABG) - MH/WH/JE
		T+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
			Comment: To be done 30 min after intubation
	Blood Gases Arterial (ABG) - FH
		T+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
	Blood Gases VENOUS (VBG)
		T+1;0400, Routine, Q24H, spec type = Blood
		T+1;0400, Routine, spec type = Blood
		T;N+30, Timed, spec type = Blood
			Comment: To be done 30 min after intubation
	Comprehensive Metabolic Panel
		T+1;0400, Routine, Q24H, spec type = Blood
	CBC with Diff
		T+1;0400, Routine, Q24H, spec type = Blood
Diagnostic Tests
	Chest 1 View
		T;N, Stat, Tube Placement F/U
		T+1;0001, Routine, Infiltrate, Portable
		T+1; 0001, Routine, Infiltrate, DAILY, Portable
IV Solutions
	fentaNYL 2500mcg/NS 250mL (MH)
		250 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		2,500 mcg, EVERY BAG, 25 mcg/hr
	fentaNYL 1000 mcg/100 mL Premix IV (JE/WH)
		100 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		1,000 mcg, EVERY BAG, 25 mcg/hr
	fentaNYL 1250mcg/NS 125mL
		125 mL, IV, Routine, T;N
			Comment: Incremental dose increase: 25mcg/hr, incremental dose decrease 25mcg/hr, incremental frequency 30min; Titrate to target pain goal (CPOT 0-3). Max dose of 200mcg/hr.  Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Give 25mcg fentaNYL IV push with an increase in rate of continuous fentanyl infusion. Reorder from pharmacy 1 hr before needed.
		1,250 mcg, EVERY BAG, 25 mcg/hr
Sedation
	dexmedetomidine 400 mcg/NS 100 mL
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate to desired goal OR BIS goal, Notify MD if target RASS OR BIS not met at 0.7mcg/kg/hr. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
	dexmedetomidine 400 mcg/NS 100 mL Premix IV
		400 mcg, EVERY BAG, 0.2 mcg/kg/hr
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.1 mcg/kg/hr, Incremental Decrease: 0.1 mcg/kg/hr, Incremental Freq: 30 mcg/kg/hr, Max Dose: 1.5 mcg/kg/hr
			Comment: Begin at 0.2mcg/kg/hr and titrate desired goal OR BIS goal. Notify MD if target RASS OR BIS not met at 0.7mcg/kg/hr. Hold if HR<50, SBP<100mmHg or MAP<50 and notify MD.
	Diprivan 1000 mg/100 mL vial Premix IV
		1,000 mg, EVERY BAG, 5 mcg/kg/min
		100 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 5 mcg/kg/min, Incremental Decrease: 5 mcg/kg/min, Incremental Freq: 5 min(s), Max Dose: 50 mcg/kg/min
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved. Change bottle and tubing q12hr.
	Triglycerides
		T+3;0400, Routine, Q3D-Lab, spec type = Blood
			Comment: Order if Diprivan ordered
	midazolam 50 mg/NS 50 mL Premix
		50 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.5 mg/hr, Incremental Decrease: 0.5 mg/hr, Incremental Freq: 30 min(s), Max Dose: 4 mg/hr
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved.  Give 1mg Midazolam IV push with an increase in rate of continuous Midazolam infusion.
		50 mg, EVERY BAG, 2 mg/hr
	Versed (MH/JE/WH)
		1 mg, Injection, IV Push, Q2H, PRN agitation
			Comment: agitation-mild (Rass +1 to +2) or with increase in rate of continuous midazolam drip
		2 mg, Injection, IV Push, Q2H, PRN agitation
			Comment: agitation-moderate (Rass +3 to +4)
	midazolam 50 mg/NS 50 mL IV
		50 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.5 mg/hr, Incremental Decrease: 0.5 mg/hr, Incremental Freq: 30 min(s)
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved.  Give 1mg Midazolam IV push with an increase in rate of continuous Midazolam infusion.
		50 mg, EVERY BAG, 2 mg/hr
	Versed (FH)
		1 mg, Injection, IV Push, Q2H, PRN agitation
			Comment: agitation-mild (Rass +1 to +2) or with increase in rate of continuous midazolam drip
		2 mg, Injection, IV Push, Q2H, PRN agitation
			Comment: agitation-moderate (Rass +3 to +4)
Medications
Analgesia
	Tylenol 325 mg/10.15 mL elixir
		650 mg, Elixir, NASOGASTRIC, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild, or CPOT 1-2
	acetaminophen 160 mg/5 mL oral liquid
		650 mg, Elixir, NASOGASTRIC, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild, or CPOT 1-2
	acetaminophen
		650 mg, Suppository, RECTALLY, Q4H, PRN see comment
			Comment: discomfort and/or pain-mild or CPOT 1-2
	oxyCODONE 5 mg/5 mL oral solution
		5 mg 5 mL, Solution, NASOGASTRIC, Q4H, PRN, pain-moderate
			Comment: or CPOT 3-5
		10 mg 10 mL, Solution, NASOGASTRIC, Q4H, PRN, pain-severe
			Comment: or CPOT 6-8
	acetaminophen-hydrocodone 108 mg-2.5 mg/5 mL oral liquid
		10 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-moderate
			Comment: or CPOT 3-5
		20 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-severe
			Comment: or CPOT 6-8
	acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL oral solution
		10 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-moderate
			Comment: or CPOT 3-5
		20 mL, Elixir, NASOGASTRIC, Q4H, PRN pain-severe
			Comment: or CPOT 6-8
	fentaNYL
		25 mcg, Injection, IV Push, Q15MIN, PRN pain-moderate
			Comment: (CPOT 3-5) or with an increase in rate of continuous fentanyl drip. First line treatment: IV Push Fentanyl, after 3 doses within 1 hour and unable to reach target pain goal, notify ordering LIP.  Max IV push dose 200mcg in 1 hour
		50 mcg, Injection, IV Push, Q15MIN, PRN pain-severe
			Comment: (CPOT 6-8) First line treatment: IV Push Fentanyl, after 3 doses within 1 hour and unable to reach target pain goal, notify ordering LIP Max IV push dose 200mcg in 1 hour
Miscellaneous
	pantoprazole IV
		40 mg, Injection, IV Push, DAILY
			Comment: Reconstitute with 10mL normal saline and infuse over 2 minutes.  Does NOT require filtration.
	famotidine
		20 mg, Injection, IV Push, BID
	Dulcolax
		10 mg, Suppository, RECTALLY, Q3D, PRN constipation, T+4;N
			Comment: If no BM despite Miralax and Senna
	MiraLax oral powder for reconstitution
		17 gm, Packet, By Mouth, DAILY
	Senna
		8.8 mg, Syrup, By Mouth, BID, T+2;0900
			Comment: Give if no BM within the past 48 hours
Sedation
	midazolam
		1 mg, Injection, IV Push, Q2H, PRN agitation
			Comment: agitation-mild (Rass +1 to +2) or with increase in rate of continuous midazolam drip
		2 mg, Injection, IV Push, Q2H, PRN agitation
			Comment: agitation-moderate (Rass +3 to +4)
Patient Care

	Restraint non violent, initiate
		T;N
	Enteral Tube
		T;N Per Orogastric Tube (OG) Insert as needed, clamp
		T;N Per Orogastric Tube (OG) Insert as needed
		T;N Per Orogastric Tube (OG) Connect to low continuous suction
		T;N Per Nasogastric Tube (NG) Insert X Ray as needed, clamp
		T;N Per Nasogastric Tube (NG) Insert X Ray as needed
		T;N Per Nasogastric Tube (NG) Connect to low intermittent suction
	Foley Catheter
		T;N, Insert, Critically ill requiring accurate output
Therapies
	Mechanical Ventilator Settings
		
	Mechanical Ventilator Wean Protocol
		
	Perform Spontaneous Awakening Trial
		T;N, DAILY
			Comment: •	If all SAT Safety screening questions are answered NO (no exclusions present), the RN will conclude it is SAFE to perform a SAT and Proceed to awakening trial•	If on Precedex maintain current settings•	If on Fentanyl, turn infusion off.•	If on Fentanyl, if the patient should complain of or demonstrate sign/symptoms of pain while the continuous sedative infusion is off, the RN may administer bolus doses of analgesics as ordered or maintain the continuous analgesic if needed for active pain •	If on Propofol or Versed, turn infusion off. The RN will also hold all sedative PRN pushes.•	If the patient fails the SAT, the RN will attempt PRN doses if able to reach target. If the need to resume the continuous infusion exists, it will be restarted at ½ the previous dose.  RN will repeat SAT and next ordered interval•	If the patient is able to open his/her eyes to verbal stimulation without failure criteria or does not display any of the failure criteria after shutting off sedation, the RN will conclude the patient has passed the SAT and will contact the RT to complete the SBT safety screen
	Spontaneous Awakening Trial Tolerance
		T;N
			Comment: Fail: conditional:1.	Not able to wean continuous sedation off2.	Maintains SAT RASS > + 2 despite interventions3.	SPO2 < 90%4.	RR > 35 BPM > 5 mins5.	New arrhythmias6.	Symptomatic change in HR either increase or decrease7.	Use of accessory muscles8.	Abdominal paradox9.	Diaphoresis10.	Dyspnea11.	Other
	ARDS Protocol
		
	Consult Physical Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
			Comment: Patient on ventilator.
	Consult Occupational Therapy, Evaluate and Treat
		T;N, Reason to See: Evaluate and Treat
			Comment: Patient on ventilator.
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
	End Tidal CO2 (ETCO2) Monitoring
		T;N, Q6H-Sch
			Comment: JE/FH ETCO2 monitoring to be done Q6H. MH continuous monitoring
Respiratory Therapy
	Oxygen Therapy
		T;N
	Pulse Oximetry Spot Check RT
		T;N, BID
	Continuous Pulse Oximetry Monitoring Check
		T;N, BID
Consults/Follow-up

	Consult Dietitian
		T;N, Regarding: Nutrition Assessment, Dietitian Assess and Treat
			Comment: initiate nutrition assessment as appropriate
	Pharmacy Consult
		T;N, Modify current medications for gastric tube administration. Contact provider for direction on medications that are unable to be converted.

Ketamine Infusion Subphase
Vital Signs
	Vital Signs
		T;N, (heart rate, blood pressure, respiratory rate, and oxygen saturation)
			Comment: Prior to Initiation, and then every 15 minutes x 4 after a bolus dose or initiation of infusion, then hourly and prn any dose adjustments (per provider order) while on continuous infusion.
IV Solutions
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		(Choose only 1 indication)(NOTE)*
Pain
	ketamine 200mg/NS 250mL Premix IV
		200 mg, EVERY BAG, 0.05 mg/kg/hr
		250 mL, IV, Routine, T;N
			Comment: Titrate to target pain goal (CPOT 0-3).  Incremental dose increase 0.02 mg/kg/hr. Incremental dose decrease 0.02mg/kg/hr. Incremental frequency q 30 min. Max dose 0.3 mg/kg/hr. Comment: Contact ordering LIP if unable to titrate up or down or if max dose is reached and the desired pain goal is not reached. Reorder from pharmacy 1 hr before needed. Notify provider for excessive oral and/or airway secretions.Stop infusion and notify provider if HR< 50 or >120, or SBP <90mmhg, or for CNS effects (Hallucinations, paranoia, tremors, diplopia, confusion.  After one hour if symptoms resolve, restart infusion at rate prior to symptom onset. If symptoms persist after infusion held for one hour, notify provider for next steps; could consider treatment of CNS Reaction with Midazolam.  * Dosing to IBW
	ketamine IVPB
		0.25 mg/kg, INT, IVPB, Once, STAT
			Comment: IVPB loading dose (max 50mg) once for Pain. Dose using ideal body weight (IBW).
Sedation
		(if unable to tolerate other agents)(NOTE)*
	ketamine 200mg/NS 250mL Premix IV (Sedation)
		250 mL, IV, Routine, Start: T;N, RASS Goal: 0 to -1, Incremental Increase: 0.25 mg/kg/hr, Incremental Decrease: 0.25 mg/kg/hr, Incremental Freq: 30 min(s), Max Dose: 3 mg/kg/hr
			Comment: Notify ordering LIP if unable to titrate up or down or if max dose is reached and the desired RASS sedation goal OR BIS goal is not achieved. Reorder from pharmacy 1 hr before needed.Stop infusion and notify provider if HR< 50 or >120, or SBP <90mmhg, or for CNS effects (Hallucinations, paranoia, tremors, diplopia, confusion.  After one hour if symptoms resolve, restart infusion at rate prior to symptom onset. If symptoms persist after infusion held for one hour, notify provider for next steps; could consider treatment of CNS Reaction with Midazolam. Dosing to IBW
		200 mg, EVERY BAG, 0.5 mg/kg/hr
	ketamine IVPB
		0.5 mg/kg, INT, IVPB, Once, STAT
			Comment: loading dose (max 150mg) once for Sedation followed by infusion. Dose using ideal body weight (IBW)
Medications

	glycopyrrolate
		0.2 mg, Injection, IV Push, Q6H, PRN secretions
			Comment: as needed for hyper-salivation
	midazolam
		1 mg, Injection, IV Push, Q15MIN, PRN see comment
			Comment: prn CNS Emergence Reaction (Hallucinations, paranoia, tremors, diplopia, nystagmus, confusion). After 4 doses (4mg total) notify provider.
Patient Care
	Assess RASS
		T;N, Q15MIN, 4, Dose(s)/Time(s)
		T;N+60, Q1H
			Comment: While on continuous infusion and PRN for any dosage adjustments as directed by provider.
	Pain Assessment
		T;N, Q15MIN, 4, Dose(s)/Time(s)
		T;N+60, Q1H
			Comment: While on continuous infusion and PRN for any dosage adjustments as directed by provider
	Monitor for CNS effects
		T;N, Q15MIN, 4, Dose(s)/Time(s), Monitor for Hallucinations, paranoia, tremors, diplopia, nystagmus and confusion
			Comment: while on continuous infusion and prn any dosage adjustments. If symptoms noted, Stop infusion for one hour and notify provider. Consider treatment of CNS emergence Reaction with Midazolam (per provider order). After one hour if symptoms resolve, restart infusion at rate prior to symptom onset.  If symptoms still persisting after pausing infusion for one hour, continue to hold infusion and notify provider for further direction
		T;N+60, Q1H, Monitor for Hallucinations, paranoia, tremors, diplopia, nystagmus and confusion
			Comment: while on continuous infusion and prn any dosage adjustments. If symptoms noted, Stop infusion for one hour and notify provider. Consider treatment of CNS emergence Reaction with Midazolam (per provider order). After one hour if symptoms resolve, restart infusion at rate prior to symptom onset.  If symptoms still persisting after pausing infusion for one hour, continue to hold infusion and notify provider for further direction
	Notify MD
		If SBP <90 or >180 mmHg, MAP < 65, HR< 50bpm or >120bpm, RASS < -2.
		For excessive oral and/or airway secretions.
Therapies
	Perform Spontaneous Awakening Trial
		T;N, DAILY
			Comment: If on Ketamine, turn infusion off. If the patient should complain of or demonstrate sign/symptoms of pain, the RN may administer bolus doses of analgesics as ordered. If the patient would develop or demonstrate CNS symptoms (Hallucinations, paranoia, tremors, confusion, nystagamus), while the infusion is off, notify the provider for further direction. If the patient fails the SAT and the need to resume the continuous infusion exists, it will be restarted at ½ the previous dose.
Consults/Follow-up
	Pharmacy Consult
		T+1;N, After initiation of Ketamine, review pain and sedation medications for possible adjustments.

*Report Legend:
DEF - This order sentence is the default for the selected order
GOAL - This component is a goal
IND - This component is an indicator
INT - This component is an intervention
IVS - This component is an IV Set
NOTE - This component is a note
Rx - This component is a prescription
SUB - This component is a sub phase