Sedation withdrawal
Strategies for weaning sedation and analgesia
Decrease the dose of the opioid and or benzodiazepine as soon as the drugs are not physiologically indicated.
Gradual tapering (of all sedative / analgesic agents) instead of abrupt discontinuation when the agent has been used for 5-7 days.
If the patient is tolerating enteral feed then all intravenous agents should be converted to the appropriate oral agents before patient discharge from the PICU.
Upon converting from IV to PO the calculated total dose for the specific agent should be given for 24-48 hr before any attempt at weaning is made.
Patient should be continuously assessed for withdrawal with the aid of the Finnegan scoring scale.
If patient develops withdrawal signs during weaning off opioid and benzodiazepine consider starting clonidine (0.2-2 micrograms/kg/hr IV or 3-5 micrograms/kg/dose q 6 hr PO).
Once opioid and benzodiazepine have been weaned off initiate clonidine wean.
Wean chloral hydrate and alimemazine by reducing the frequency of administration.
Oral morphine is the preferred drug to substitute for IV morphine or fentanyl.
Oral lorazepam is the preferred drug to substitute for IV midazolam
Conversion from IV morphine to ng or oral
1 mg morphine IV = 1 mg morphine NG
- Calculate the total daily dose of IV morphine
If the intention of the change is to start weaning then consider lowering the dose by 20-50% from the calculated one
- Dose (mg) x wt (kg) x 24 hr / 1000 = dose (mg) /24 hr
- Morphine is given 4 hourly
- Dose (mg)/24 hr / 6 = Dose (mg) q 4 hr
- Decrease the IV morphine by
- 50 % after the 1st dose
- Stop after the 2nd dose
- 50 % after the 1st dose
- Continue to wean the oral dose by reducing the frequency from 4 to 6 hourly
- Then reduce the dose in steps of 10-20% of the dose from which weaning is started
- This can be done daily or each dose depending
- Length of sedation
- Withdrawal symptoms
- Use of other sedatives
- Length of sedation
- If excessive sedation occurs, one dose is withheld and the total daily dose decreased by 10-20 %.
All patients discharged from PICU still receiving sedation should have a clear written plan of weaning in the discharge summary and the note prior to leaving the unit.
Conversion from IV midazolam to ng or oral lorazepam
1 mg Midazolam IV = 0.5 mg lorazepam PO
- Calculate the total daily dose of IV midazolam
- If the intention of the change is to start weaning then consider lowering the dose by 20-50 % from the calculated one
- Dose (mg) x wt (kg) x 24 hr / 1000 = dose (mg) /24 hr
- Lorazepam is given 8 hourly
- Dose (mg)/24 hr / 3 = Dose (mg) q 8 hr
- Decrease the IV midazolam by
- 50 % after the 1st dose
- stop after the 2nd dose
- 50 % after the 1st dose
- If excessive sedation occurs, one dose is withheld and the total daily dose decreased by 10-20 % of the dose at which weaning was started.
- Taper the lorazepam dose by 10-20 %, once patient on a minimal dose (1 mg) reduce the frequency to q 8 hr, q 12 hr, then to off.
- This can be done daily or with every dose depending
- Length of sedation
- Withdrawal symptoms
- Use of other sedatives
- Length of sedation
All patients discharged from PICU still receiving sedation should have a clear written plan of weaning in the discharge summary and the note prior to leaving the unit.
Conversion from IV clonidine to ng or oral
1 mg IV clonidine = 1 mg NG clonidine
- Calculate the total daily dose of IV clonidine
- If the intention of the change is to start weaning then consider lowering the dose by 20-50 % from the calculated one
- Dose (microgramsg) x wt (kg) x 24 hr = dose (micrograms) /24 hr
- Clonidine is given 6 hourly
- Dose (microgramsg)/24 hr / 4 = Dose (micrograms) q 6 hr
- Decrease the IV clonidine by
- 50 % after the 1st dose
- stop after the 2nd dose
- 50 % after the 1st dose
- Taper the clonidine dose by 15-20 %, once patient on a minimal dose reduce the frequency to q 8 hr, q 12 hr, then to off.
- This can be done QD or QOD depending
- Length of sedation
- Withdrawal symptoms
- Use of other sedatives
- Length of sedation
All patients discharged from PICU still receiving sedation should have a clear written plan of weaning in the discharge summary and the note prior to leaving the unit.