Use of morphine infusions and PRN diazepam for sedation of mechanically ventilated patients

Introduction: Our routine sedation regimen for patients on mechanical ventilation consisted of midazolam infusions and prn morphine. We felt we could provide the same level of comfort using less expensive agents by institution of a sedation guideline. Methods: A 9 person multidisciplinary team consisting of members from the critical care medicine, respiratory, nursing, pharmacy and quality management departments held one hour bimonthly meetings for a year. The team developed a sedation scale and a guideline to initiate, maintain and wean sedation. The guideline uses morphine infusions and prn diazepam as first line management. If the patient has not achieved the desired level of sedation, the dose of the morphine infusion and prn diazepam is increased. In refractory cases scheduled doses of lorazepam with or without midazolam infusions are added. The guideline directs maintenance of these medications based on the desired level of sedation and then weaning of these medications when the desired level of sedation is decreased. Results: The guideline was implemented and tracked for 12 months. There were significant increases in the amount of morphine and diazepam used and significant decreases in the amount of midazolam used with a modest increase in the amount of lorazepam used. The guideline saved $100,000 the first year, based on drug acquisition costs. There was no change in mortality, length of ventilator stay or length of ICU stay during this time period. As a surrogate marker for prolonged wakeup times, the volume of head CTs and EEGs was tracked and no increase was seen during this time period. Conclusions: A sedation guideline using morphine infusions and prn diazepam can be successfully used to sedate mechanically ventilated patients at decreased cost while still maintaining excellent clinical outcomes.