Daily Spontaneous Awakening Trial (SAT)

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1. Nursing, respiratory therapy, and physicians will collaborate daily for the application and evaluation of the sedation holiday.
2. Daily wake-up applies to all patients unless determined to be clinically inappropriate by the collaborative team.
3. Daily interruption of sedation for neurosurgery patients is to be coordinated with the neurosurgery team.
4. Timing of the daily wake-up will be determined as appropriate for shift resources, Patients most likely to meet weaning parameters for expected extubation should be prioritized to the sedation holiday at 0800.

Exclusion Criteria

1. Active seizures
2. Benzodiazepine use for ETOH withdrawal
3. Escalating sedative dose due to ongoing agitation
4. Patient in cooling/warming phase of Therapeutic Hypothermia
5. Evidence of acute myocardial infarction
6. Increased ICP
7. Unstable airway
8. Use of sedation for comfort/palliative care
9. Use of paralytic medications

 

Process for Daily Wake-Up

1. Turn sedation off
2. Continually monitor for Signs Indicating Need for Re-Sedation
   • Cardiac arrhythmia
   • Sustained anxiety or agitation for 5 minutes or more
   • Sustained respiratory rate >35 breaths per minute
   • SpO₂ <88%
   • Sustained tachycardia
   • Bradycardia
   • Increased use of accessory muscles
   • Inability to ventilate, due to ventilator dysynchrony
3. Assess mental status
   • Use Richmond Agitation Sedation Scale (RASS) [ 244] to assess level of consciousness and psychomotor activity
   • Assess patient’s ability to follow commands at beginning of SAT and throughout
4. Act on patient’s response to SAT
   • If your RASS is a -2 or higher, a daily delirium screening should take place via CAM-ICU [ 243]
   • Coordinate a spontaneous breathing trial with your Respiratory Therapist, if patient meets inclusion criteria (see Spontaneous Breathing Trial Protocol) [ 111]
   • SAT Failed (sustained agitation or sign of physiologic instability)
     • Consider if pain is the cause for sustained agitation
     • Consider if intermittent dosing would meet sedation needs
5. Recommendations following SAT
   • The multidisciplinary team should have a discussion and determine the RASS goal for the patient within the next 24 hours if the patient needs to be re-sedated
   • Consider achieving this goal by using intermittent medications first
   • During episodes of pain and/or agitation, bolus dosing should be utilized before titrating up on a continuous sedative infusion
   • Consider use of antipsychotic medication if CAM-ICU screen positive for delirium
   • Pain management is to include a scheduled oral opioid (oxycodone) dose post-extubation if the patient has been on a continuous opioid infusion and is able to tolerate oral medications
   • If no contraindications consider scheduled dosing of a non-opioid analgesic (acetaminophen or ibuprofen.) Consider contraindications such as a spine or major pelvic injury or GI bleeding