Addendum Questionnaire

Flashlight survey patient sedation

/ Survey-ID :
1 Date: ______.______.______/ Time: ______.______o’clock

2. Patient data

Sex:  m  f / Age : / years / ASA :
Height : / cm / Weight : / kg

3. Diagnoses

Admission diagnosis : / ICD 10:
Main diagnosis intensive: / ICD 10:

4. Scoring-systems (if used)

SAPS II / points / APACHE II/III / points
TISS 28 / points (from previous day) / Other.:______/ points

5. Renal replacement therapy

 No /  Yes / Method:

6. Respiration, ventilation

Ventilated since: / ______.______.______/ or / days
 orally intubated /  nasally intubated /  tracheotomized /  NIV
 controlled /  assisted /  CPAP /  spontanous

7.SOFA Score (please check the appropriate box)

PaO2 / FiO2 /  < 400 /  < 300 /  < 200 /  < 100
Platelets (x 103/µL) /  < 150 /  < 100 /  < 50 /  < 20
Bilirubin (mg/dL) /  1.2 – 1.9 /  2.0 – 5.9 /  6.0 – 11.9 /  > 12
Serum creatinine (mg/dL) /  1.2 – 1.9 /  2.0 – 3.4 /  3.5 – 4.9 /  > 5
Glasgow Coma Scale /  sedated 13 - 14 /  10 - 12 /  6 - 9 /  < 6
Hypotension
Agents (µg/kg/min for a minimum of 1 h) /  MAP < 70 /  Dopamine < 5 /  Dopamine > 5
 Epinephrine < 0.1
 Norepin. < 0.1 /  Dopamine >15
 Epineph. > 0.1
 Norepin. >0.1
Urine output (mL/24h) /  < 500 /  < 200

8. Planned duration of ventilation

 Short-term sedation (< 24 h) /  24 - 72 h /  Long-term sedation (> 72 h) /  Weaning

9. For today aimed for Ramsay scale value (see “questionnaire instructions“)

 0 /  1 /  2 /  3 /  4 /  5 /  6

10. At present achieved Ramsay scale value (see “questionnaire instructions“)

 0 /  1 /  2 /  3 /  4 /  5 /  6

11. Extubation intended within

 The next 24 hours /  Between 24 up to 72 hours /  Still unforeseeable

12. Signs of a transitional syndrome /delirium ?

 No /  Yes / Type:

13. Current analgesia and sedation (for bolus please add up the doses of the last 8 hours

Medication / Cont. / Concentration
mg or µg/50 mL / mL / h / Bolus / Total of the last 8 h (in g, mg or µg)
Midazolam /  / ______/ ______/  / ______
Propofol 2% /  / ______/ ______/  / ______
Propofol 1% /  / ______/ ______/  / ______
Methohexital /  / ______/ ______/  / ______
Hydroxybutyric acid /  / ______/ ______/  / ______
Diazepam /  / ______/ ______/  / ______
Lorazepam /  / ______/ ______/  / ______
Flunitrazepam /  / ______/ ______/  / ______
Haloperidol /  / ______/ ______/  / ______
______/  / ______/ ______/  / ______
______/  / ______/ ______/  / ______
Fentanyl /  / ______/ ______/  / ______
Sufentanil /  / ______/ ______/  / ______
Alfentanil /  / ______/ ______/  / ______
Remifentanil /  / ______/ ______/  / ______
Morphine /  / ______/ ______/  / ______
Piritramid /  / ______/ ______/  / ______
Pethidin /  / ______/ ______/  / ______
Buprenorphin /  / ______/ ______/  / ______
Tramadol /  / ______/ ______/  / ______
Metamizol /  / ______/ ______/  / ______
Diclofenac /  / ______/ ______/  / ______
Ketamine /  / ______/ ______/  / ______
Ketamine S /  / ______/ ______/  / ______
Fentanylpatch /  / ______/ ______/  / ______
Morphine /  / ______/ ______/  / ______
Clonidine /  / ______/ ______/  / ______
______/  / ______/ ______/  / ______
______/  / ______/ ______/  / ______
Neuromuscular blockade:
______/  / ______/ ______/  / ______
______/  / ______/ ______/  / ______
 Epidural / Concentration / mL / h / Bolus / bolus requested in 8 hrs.
Ropivacaine /  / ______% / ______/  / ______
Bupivacaine /  / ______% / ______/  / ______
+ Opioid______/  / ______/ ______/  / ______
 PCA / Concentration / Basal rate / bolus requested in 8 hrs.
______/ ______% / ______/ ______
 PCEA / Concentration / Basal rate / Bolus requested in 8 hrs.
Ropivacaine /  / ______% / ______/ ______
Bupivacaine /  / ______% / ______/ ______
+ Opioid______/  / ______/ ______/ ______
Other medication relevant for sedation:

Thank you very much for your cooperation !

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