Coordinated Spontaneous Awakening and Breathing Trials ...

Strategies for weaning patients off of mechanical ventilation are often not handled well, as the spontaneous awakening trials (SAT) and spontaneous breathing ... 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Receivingescalatingdosesofsedativeforagitation. Receivingneuromuscularblockers. Evidenceofactivemyocardialischemiainprior24hours. Evidenceofincreasedintracranialpressure. Ifthepatientpassesthesafetyscreen,allsedativesandanalgesicsusedforsedationarestopped.Analgesicsusedforpainarecontinuedasnecessary.Thegoalisthatthepatientcandothreeoutoffoursimpletasksonrequest:opentheireyes,lookattheircaregiver,squeezethehand,orputouttheirtongue3orcangowithoutsedationfor4hoursormorewithoutthefollowing: Sustainedanxiety,agitation,orpain. Respiratoryrateof35breaths/minuteforatleast5minutes. Oxygensaturation(SpO2)oflessthan88%foratleast5minutes. Acutecardiacdysrhythmia. Twoormoresignsofrespiratorydistress: Tachycardia. Bradycardia. Useofaccessorymuscles. Abdominalparadox. Diaphoresis. Markeddyspnea. IfapatientfailstheSAT,sedativesarestartedathalfthepriordosageandtitratedupasneeded. SpontaneousBreathingTrial IfapatientpassestheSAT,thepatientisassessedfortheSBTsafetyscreen.Apatientfailsthesafetyscreenifanyofthefollowingconditionsaremet: Inadequateoxygenation(SpO2<88%oranFiO2of≥50%andapositiveend-expiratorypressure[PEEP]≥8cmH2O). Nospontaneousinspiratoryeffortina5-minuteperiod(Considerationofthesetrespiratoryrateisrecommended). Agitation. Significantuseofvasopressorsorinotropes(patientsmaybeondopamineordobutamineat≤5µg/kg/minornorepinephrine≤2µg/min,butmaynotbereceivinganyvasopressinormilrinone).8 Evidenceofincreasedintracranialpressure. Ifapatientfailsthesafetyscreen,sedativesarestartedathalfthepriordosageandtitratedupasnecessary.ThepatientisthenreassessedforSATthefollowingday.Ifthepatientpassesthesafetyscreen,heorsheundergoestheSBT.Ventilatorysupportisremoved.ThepatientisallowedtobreathethrougheitheraT-tubecircuitofaventilatorycircuitwithcontinuouspositiveairwaypressureof5cmH2Oorpressuresupportventilationoflessthan7cmH2O.Apatientpassesthetrialifheorsheavoidsdevelopinganyofthefollowingfailurecriteriawithin120minutes: Respiratoryrateofeitherfewerthan8breathsperminute(bpm)ormorethan35bpmfor5minutesorlonger. Hypoxemia(SpO2<88%for≥5minutes). Abruptchangeinmentalstatus. Acutecardiacarrhythmia. Twoormoresignsofrespiratorydistress: Tachycardia. Bradycardia. Useofaccessorymuscles. Abdominalparadox. Diaphoresis. Markeddyspnea. IfapatientfailstheSBT,heorsheisreassessedforSATandSBTthefollowingday.IfapatientpassestheSBT,thepatient’sphysiciansarenotifiedforpossibleextubation. Figure1.CoordinatedSATandSBTProtocolSummary   Figure2.CoordinatedSATandSBTProtocolFlowchart References ElyEW,BakerAM,DunaganDP,etal.Effectonthedurationofmechanicalventilationofidentifyingpatientscapableofbreathingspontaneously.NEnglJMed1996Dec;335(25):1864-9.PMID:8948561. Brook AD,AhrensTS,SchaiffR,etal.Effectofanursing-implementedsedationprotocolonthedurationofmechanicalventilation.CritCareMed1999 Dec;27(12):2609-15.PMID:10628598. KressJP,PohlmanAS,O'ConnorMF,etal.Dailyinterruptionofsedativeinfusionsincriticallyillpatientsundergoingmechanicalventilation.NEnglJMed2000May;342(20):1471-7.PMID:10816184. GirardTD,KressJP,FuchsBD,etal.Efficacyandsafetyofapairedsedationandventilatorweaningprotocolformechanicallyventilatedpatientsinintensivecare(awakeningandbreathingcontrolledtrial):Arandomisedcontrolledtrial.Lancet2008Jan;371(9607):126-34.PMID:18191684. Blackwood B,AlderdiceF,BurnsK,etal.Useofweaningprotocolsforreducingdurationofmechanicalventilationincriticallyilladultpatients:Cochranesystematicreviewandmeta-analysis.BMJ2011 Jan;342:c7237.PMID:21233157. QuenotJP,LadoireS,DevoucouxF,etal.Effectofanurse-implementedsedationprotocolontheincidenceofventilator-associatedpneumonia.CritCareMed2007Sep;35(9):2031-6.PMID:17855817. KlompasM,AndersonD,Trick,W,etal.ThePreventabilityofventilator-associatedevents.TheCDCPreventionEpicentersWakeUpandBreatheCollaborative.AmJRespirCritCareMed2015Feb;191(3):292-301.PMID:25369558. ThompsonJ,ElyE.Liberatingpatientsfrommechanicalventilation:whathavewelearnedaboutprotocolizingcare?In:SlutskyA,BrochardL,eds.MechanicalVentilation.Berlin,Germany:Springer-VerlagBerlinHeidelberg;2004:135-51. Publication:16(17)-0018-17-EF RelatedPublications Word,2.23MB PagelastreviewedJanuary2017 PageoriginallycreatedJanuary2017 InternetCitation:CoordinatedSpontaneousAwakeningandBreathingTrialsProtocol.ContentlastreviewedJanuary2017.AgencyforHealthcareResearchandQuality,Rockville,MD. https://www.ahrq.gov/hai/tools/mvp/modules/technical/sat-sbt-protocol.html   BacktoTop