/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/practice-protocols/,

/clinical/cckm-tools/content/delegationpractice-protocols/practice-protocols/name-97447-en.cckm

201706165

page

100

UWHC,UWMF,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Practice Protocols

Pain and Agitation Continuous Infusion Titration – Pediatric – Inpatient [5]

Pain and Agitation Continuous Infusion Titration – Pediatric – Inpatient [5] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Practice Protocols


Practice Protocol Number: 5

Practice Protocol Title:
Pain and Agitation Continuous Infusion Titration – Pediatric – Inpatient

Practice Protocol Applies To:
Mechanically ventilated pediatric intensive care unit (PICU) patients on a continuous infusion of fentanyl,
morphine, dexmedetomidine, or midazolam

Target Patient Population:
Any mechanically ventilated pediatric patient in the PICU requiring continuous infusion analgesia or sedative
medications included in this protocol.

Practice Protocol Champions:
Scott Hagen, MD - Director PICU, Department of Pediatrics
Juan Boriosi, MD - Department of Pediatrics

Practice Protocol Reviewers:
Mohammed Hamzah, MD - Pediatric Critical Care Fellow
Anne Mosely, MSN, MBA, RN - Director Pediatric Nursing and Patient Care Services
Ben Walker, MD - Department of Anesthesia
Deb Soetenga, RN, MS, Clinical Nurse Specialist - PICU
Sue Quamme, RN - Interim Nurse Manager, PICU
Cindy Gaston, PharmD - Drug Policy Analyst
Monica Bogenschutz, PharmD - Clinical Pharmacist
Mike Raschka, PharmD - Clinical Pharmacist
Emma Ross, PharmD - Clinical Pharmacist

Responsible Departments:
Department of Pharmancy
Department of Nursing

Purpose Statement:
To standardize titration of opioid and sedative infusions by Pediatric Intensive Care Unit (PICU) Registered
Nurses (RN) to achieve pain control and target sedation goals. Standardization of analgesia and sedation titration
in mechanically ventilated pediatric patients through a protocol will improve sedation and analgesia treatment,
prevent unintended extubation, decrease exposure to opioids and sedatives, and reduce intubation duration and
PICU length of stay.
1


Who May Carry Out This Practice Protocol:
RNs in the PICU trained on the use of this protocol.

Guidelines for Implementation:
1. The protocol is initiated when the physician enters an order for a continuous opioid or sedative infusion with
administration instructions to initiate and titrate per Pediatric ICU Analgesia/Sedation protocol.

2. Providers will document a sedation goal in the medical record and the goal will be re-evaluated daily on
rounds. Any change in goals will be documented in the medical record.

3. Opioid bolus dosing and infusion titration
3.1. Pain assessment occurs using an appropriate age and cognitive pain scale: numeric rating scale, mild-
moderate-severe, Faces Pain Scale- Revised (FPS-R), Faces-Legs-Agitation-Cry-Consolability - Revised
(FLACC-R). Assessment occurs every 2 hours and after each dose adjustment.
3.2. Potential causes of pain, including mechanical causes (e.g., immobilization, medical devices), are
assessed before dose titration.
3.3. Patients will receive a trial of non-pharmacological therapies in addition to pharmacological therapies
(e.g., music therapy, relaxation techniques, repositioning, heat/cold, patient/family education).
6/3/2015 1

3.4. Non-opioid medications may be used in conjunction with opioid infusions to minimize opioid dosing and
adverse effects and treat neuropathic and / or inflammatory pain.
3.5. Bolus dosing
3.5.1. Bolus doses should be administered pre-emptively prior to painful procedures and painful patient
cares.
3.5.2. Bolus doses will be documented in a separate PRN order, but can be bolused from the continuous
infusion.
3.5.3. During the initiation phase a bolus dose may be given every 15 minutes up to a maximum of 3
doses within the first 2 hours.
3.6. Continuous Infusion – Titration Phase
3.6.1. If pain is not adequately controlled and three bolus doses have been given within 8 hours (other
than prior to painful procedures or cares), then continuous infusion doses will be increased based
on the “Titration Dose Increment” and “Rate of Dose Titration” listed in Table 1.
3.6.2. If the patient is over sedated based on the sedation score goal and not experiencing moderate to
severe pain, then the infusion rate can be decreased by the “Titration Dose Increment” and “Rate of
Dose Titration” in Table 1 if both of the following criteria are met:
 ≤ 3 PRN opioid doses have been given within the last 8 hours (other than bolus doses for painful
procedures or cares)
 The infusion rate has not changed in the previous 4 hours
3.6.3. The lowest effective dose achieving the stated objective will be utilized.
3.7. Continuous Infusion – Wean to extubation phase
3.7.1. If the duration of infusion is < 5 days, then the opioid infusion can be discontinued without further
weaning.
3.7.2. If the duration of infusion is ≥ 5 days, consider using a methadone taper as indicated in the
methadone guideline.

4. Sedative bolus dosing and infusion titration
4.1. A sedation level will be assessed using a validated sedation scale (e.g., State Behavioral Scale) every 2
hours and after each dose titration.
2
(Appendix 2)
4.2. Prior to titration of sedative infusions patients will be assessed for adequate analgesia and other potential
causes of agitation (e.g., hypoxia, hypercarbia, asynchrony with the ventilator, delirium, unfamiliar
environment, pruritis, constipation).
4.3. Patients will receive a trial of non-pharmacological therapies in conjunction with pharmacological agents
(e.g., music and relaxation techniques).
4.4. Bolus dosing
4.4.1. Bolus doses will be documented in a separate PRN order, but may be bolused from the continuous
infusion.
4.4.2. During the initiation phase a bolus dose may be given every 15 minutes up to a maximum of 3
doses within the first 2 hours.
4.5. Continuous infusion – Titration Phase
4.5.1. If a patient is under sedated based on the target sedation score, and three bolus doses have been
given within 8 hours, then the continuous infusion dose will be increased using the “Titration Dose
Increment” and “Rate of Dose Titration” listed in Table 2.
4.5.2. If the patient is over sedated based on the sedation score goal, then the infusion rate can be
decreased by the “Titration Dose Increment” and “Rate of Dose Titration” in Table 2 if both of the
following criteria are met:
 ≤ 3 PRN sedative bolus doses have been given within the last 8 hours
 The infusion rate has not changed in the last 4 hours
4.5.3. The lowest effective dose achieving the stated objective will be utilized.
4.6. Continuous infusion - Wean for extubation phase
4.6.1. If the duration of infusion is < 5 days, then the infusion can be discontinued without further weaning

5. If a patient is receiving neuromuscular blockade and one of the following criteria are met, then give bolus
doses and titrate continuous infusions of opioid and sedative as listed under 3.5, 3.6, 4.4 and 4.5
 Vital signs increase by > 20% with stimulation and other causes for a change in vital signs are
ruled out
 Cerebral regional saturations decrease by ≤ 20%

6/3/2015 2

6. If a patient’s blood pressure is unstable, then increases in the infusion rate may not be implemented

7. If the opioid or sedative reaches the “First Notification Value” as indicated in Table 1 or Table 2, then a
prescribing provider must be notified for additional or alternative treatments or continued titration of the
current agent.

8. If the agent used reaches the “Second Notification Value” indicated in Table 1 or Table 2, then a physician
must be contacted for consideration of additional treatments or alternative agents(s), and must provide
subsequent orders for each dose titration beyond the second notification dose.

9. The nurse documents a progress note in the EMR after notifying the provider of the “First Notifications Value”
and “Second Notification Value.”

10. Nurses will record each dose adjustment in the IV/IV MAR.

11. Nurses will monitor and document pain and sedation assessment with each rate change.



6/3/2015 3

Table 1. Opioid Infusion Dose Titration Table
Medication
Typical Bolus
Dose
Typical Infusion
Dose Range
Typical Initial
Dose
Titration Dose
Increment
Rate of
Dose
Titration
First Notification Value
(notify provider when
dose reached)
Second Notification
Value (notify physician
when dose reached)
Fentanyl
0.5 – 2 mcg/kg
(max 50 mcg)
1 – 5 mcg/kg/h
(max 200 mcg/h)
0.5 mcg/kg/h
(max 50 mcg/h)
0.5 mcg/kg/h
(max 25 mcg/h
4 h
3 mcg/kg/h
(or 100 mcg/h)
5 mcg/kg/h
(or 200 mcg/h)
Morphine
0.05 - 0.1 mg/kg
(max 4 mg)
0.05 – 0.3 mg/kg/h
(max 10 mg/h)
0.05 mg/kg/h
(max 5 mg/h)
0.02 mg/kg/h
(max 1 mg/h)
4 h
0.15 mg/kg/h
(max 6 mg/h)
0.3 mg/kg/h
(max 10 mg/h)



Table 2. Sedative Dose Titration Table
Medication
Bolus
Dose
Typical Infusion
Dose Range
Typical Initial
Dose
Titration Dose
Increment
Rate of
Dose
Titration
First Notification
Value (notify provider
when dose reached)
Second Notification
Value (notify
physician when dose
reached)
Dexmedetomidine NA 0.5 – 1.5 mcg/kg/h 0.5 mcg/kg/h 0.1 mcg/kg/h 4 h 1 mcg/kg/h 1.5 mcg/kg/h
Midazolam
0.025 – 0.05 mg/kg
(max 4 mg)
0.025 – 0.2 mg/kg/h
(max 10 mg/h)
0.025 mg/kg/h
(max 1 mg/h)
0.025 mg/kg/h
(max 1 mg/h)
4 h
0.125 mg/kg/h
(max 4 mg/h)
0.2 mg/kg/h
(max 10 mg/h)
NA – not applicable












6/3/2015 4

References
1.  Deeter KH, King MA, Ridling D, Irby GL, Lynn AM, Zimmerman JJ. Successful implementation of a 
pediatric sedation protocol for mechanically ventilated patients. Crit Care Med 2011;39:683‐688. 
2.  Curley MA, Harris SK, Fraser KA, Johnson RA, Arnold JH. State Behavioral Scale: a sedation assessment 
instrument for infants and young children supported on mechanical ventilation. Pediatr Crit Care Med: 
2006;7:107‐114. 
Collateral Documents/Tools:
Policy 8.76 Pain Management│UWHC Administrative Policy
Policy 8.56 Pediatric Sedation Policy │UWHC Administrative Policy

Approved By:
AFCH Practice Committee – March 2015
Sedation Committee – March 2015
Nursing Practice Council – April 2015
Pharmacy & Therapeutics Committee – April 2015

Effective Date: April 2015

Scheduled for Review: April 2017



Appendix 1. State Behavioral Scale
2


6/3/2015 5