Vent Separation Guideline/Daily Awakening (Spontaneous Awakening/Spontaneous Breathing Trials-SAT/SBT)

SAT/SBT Protocol

This guideline sets out the timing and cadence of routine/protocolized SAT/SBT followed by extubation, with the goal of daily awakening, spontaneous breathing and extubation in appropriate patients. The timing of SBT start CAN be earlier if the team requests, just as SBT's can be performed at any hour of the day or even in the presence protocol exclusions. 

1) The bedside nurse will do an SAT (spontaneous awakening trial) screen every morning at ICU specific time. For Acute Care Surgery/Trauma, that time is between 0600 and 0700 to be completed by 0700/0715. 

2) Exclusions for SAT will be:

• Seizures

• Alcohol withdrawal (per Alcohol Withdrawal Intubated Protocol if ordered – RASS >0)

• Agitation (as defined by RASS > +1 >)

• Paralytics

• H/o myocardial ischemia in the previous 24 hours

• Patients at risk for increased ICP

• Patients on VV and VA ECMO

  3) If no exclusions, SAT will commence by turning off all sedatives and analgesic drips. Analgesics needed for active pain can be given prn only.
  4) SAT is successful if they open their eyes to verbal stimuli OR tolerate sedative interruption for up to 4 hours without exhibiting failure criteria. If successful, bedside nurse will inform RT for SBT screen.

  5) SAT failure criteria (any of the following):

  • Sustained anxiety, agitation, or pain (as defined by RASS > +1 and / or CPOT > 4), and unresponsive to bolus doses

  • RR >35/min for > 5 min

  • AnSpO2<88%for>5min

  • An acute cardiac dysrhythmia

  • Two or more signs of respiratory distress, including tachycardia, bradycardia, use of accessory muscles, abdominal

    paradox, diaphoresis, or marked dyspnoea
    6) If SAT fails, resume analgesia at half of the previous infusion rate. Do NOT resume IV sedation infusion. If RASS is above goal, use PRN sedation (midazolam) if ordered. If PRN sedation is not ordered, notify provider for orders to manage RASS above goal. SBT Protocol
    1) Exclusion for SBT: Lung transplant patients in the immediate post-op period. If patient is transferred out from the ICU and is subsequently (even during the same admission) readmitted and re-intubated, they would then be eligible for SBT trials.

    2) RT will assess SBT readiness criteria. These are:

    • Passed SAT

    • RASS -2 to +1

    • Sats > 88%

    • FiO2 < 0.5

    • PEEP<6

    • Norepinephrine dose < 0.05 mcg/kg/min (or equivalent pressor/inotrope dose)

    • Spontaneous inspiratory efforts, minute ventilation < 15 L/min

      3) If patient meets all SBT criteria, RT will initiate SBT and inform provider on call for the intensive care unit via Voalte that SBT has been started.

      4) SBT protocol: Pressure support 5, PEEP 5, FiO2 50% or less for 45 mins 5) SBT failure criteria

      • RR > 35/min or <8/min for ≥5 min

      • Sats < 88% for ≥5 min

      • Mental status changes (reduced LOC or RASS +2 or greater)

      • Respiratory distress (use of accessory muscles, facial expressions suggesting stress, severe dyspnea, abdominal

        paradox, diaphoresis)

• Hemodynamic instability (SBP <90 or > 180, HR > 130)
• Acute cardiac arrhythmia
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5) Return to previous supportive care settings after SBT. If dyssynchronous on prior settings, contact provider on call for the intensive care unit.

                6) Decision on extubation to be taken within 45 mins of finishing SBT. (60 minutes stretch target, with                 extubations occurring by 8AM IF that is the decision. 

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