Procedural Sedation of Adults and Children by Non-anesthetists 2014 Objectives Define minimal, moderate, deep sedation and general anesthesia. List common drugs used in sedation and their side effects. Identify patients that may be at high risk. Describe role of the RN after patient receives procedural sedation. Identify key elements required for pre-sedation, intra- procedure, and post procedure assessment. Objectives Discuss patient education related to specific medications used in procedural sedation. Discuss airway management during procedural sedation. Identify the signs of respiratory depression and airway compromise. Identify emergency situations arising from procedural sedation and the emergency equipment available in your area. Objectives Demonstrate appropriate documentation for those patients receiving procedural sedation, pre, intra and post procedure. Identify criteria for discharge of those patients who have received procedural sedation. The purpose of this learning packet is to provide the healthcare professional with information necessary to provide safe and appropriate care for the adult patient receiving procedural sedation. Policy- Clinical Operations 8.305 Please refer to the Clinical Operations Policy listed above. Go to E-Workplace Policies tab Clinical Ops Manual 8.305 Definition of Procedural Sedation A drug induced state of varying levels of consciousness provided for the means of performing various diagnostic or therapeutic medical procedures with a minimum of anxiety, discomfor or pain. Procedural sedation encompasses a continuum that ranges from light sedation to deep sedation, but should not progress to the level of general anesthesia. Sedation Continuum Five levels of Sedation Light Sedation (anxiolysis) Moderate Sedation/Analgesia “conscious sedation” Dissociative sedation Deep Sedation General Anesthesia Sedation Continuum Minimal Sedation General Anesthesia General Anesthesia Deep Sedation Dissociative Sedation Moderate Sedation Minimal Sedation Minimal/Light Sedation (Anxiolysis) A drug-induced state where pt responds normally to verbal commands. Cognitive function and coordination may be impaired. Ventilatory and cardiovascular functions are unaffected. Moderate Sedation/Analgesia “Conscious Sedation” Depressed level of consciousness where pt can respond to verbal commands either alone or with light tactile stimulation Pt able to maintain a patent airway. Spontaneous ventilation is adequate Cardiovascular function is usually maintained. Dissociative Sedation A trancelike, cataleptic state induced by the dissociative agent ketamine characterized by profound analgesia and amnesia. Patients often will not respond purposefully to repeated or painful stimuli. May require assistance maintaining a patent airway and adequate ventilation. Cardiovascular function is usually maintained Deep Sedation Depression of consciousness where patients cannot be easily aroused but respond purposefully to repeated or painful stimulation. Ability to independently maintain airway and normal ventilation is usually impaired. Healthcare providers will frequently have to provide support to maintain adequate ventilation. Cardiovascular function is usually maintained Deep Sedation continued The MA board of Registration in Nursing prohibits RNs from administering drugs for planned deep sedation. Due to the narrow therapeutic range between sedation and drug induced apnea, deep sedation agents may only be utilized by anesthesiologists, pedi and adult intensivists, and emergency department physicians. See Clin Ops 8.305 appendix B for list of deep sedation drugs General Anesthesia A medication induced depression of consciousness during which patients cannot be aroused, even by repeated or painful stimuli. Ability to maintain independent ventilatory function and patent airway is frequently lost. Positive pressure ventilation and reversal of sedation drugs may be required. Cardiovascular function may be impaired. Local Anesthesia Introduction of local anesthetic agent by injection in subcutaneous tissue, in close proximity to a nerve, or applied topically in such a fashion as to avoid intravascular injection. Local anesthetics possess both excitatory (seizure) and depressant (loss of consciousness) central nervous system effects in sufficient blood levels. Local anesthesia is not considered procedural sedation. Sedation Continuum The risk of complications increase as the level of sedation moves toward deeper sedation. Sedation Continuum Because sedation is a continuum, it is NOT always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Personnel Minimal number of providers involved with the care of a patient receiving procedural sedation should be TWO. 1. The physician (Operator/Sedationist) who performs the diagnostic or therapeutic procedure 2. The individual (MD, RN, PA, NP) who monitors the patient and his/her response to procedural sedation and the procedure. Personnel The person monitoring the patient should have no other responsibilities or tasks that would interfere with monitoring. The Operator/Sedationist or Monitor must be available to the patient from the time the procedure has been completed until the patient has adequately revcovered or has been turned over to personnel performing recovery care. Competencies Individuals who administer procedural sedation should be competent in the following: Airway management Resuscitation measures Medication use and potential side effects and complications ACLS or PALS* training required Cardiac monitoring/dysrhythmia recognition * ACLS and ENPC training may be substituted for PALS Where can planned Deep Sedation be performed? Adult Patients Pediatric Patients MICU,SICU PICU, NICU CVCU Pediatric procedure unit Emergency Department Radiology Pediatric ED Minimum Equipment Needed Supplemental Oxygen Capnograph when pt cannot (Capable of delivering be directly observed is 100% O2 at a rate of 15 strongly recommended liters/min) Specific pharmacological Source of Suction with reversal agents Yankauer suction wand Code cart must be Pulse Oximeter and audible immediately accessible component and alarm Phone number for Code Blood pressure device Blue (4-2345) must be Cardiac and respiratory clearly displayed monitor with alarm Patient Management and Monitoring Patient Risk Factors that require anesthesia consult ASA status III or higher* History of emotional or psychiatric illness History of substance abuse History of major allergy or of anaphylactic reaction Recent meal (emergency procedure) Morbid Obesity History of Sleep Apnea Patient Monitoring and Management Procedural factors: Prolonged procedure Procedure of major complexity New procedure Emergency procedure (full stomach) Miscellaneous factors: Skilled personnel not available Inadequate equipment Pre Procedure Monitoring Patient Identification (CO 2.100) Health History Patient’s symptoms or reason for procedure Procedure being done Allergies (latex, food etc.) Current medications including over the counter and herbals Height and weight NPO status* Presence of denture, loose or broken teeth Medical and surgical history NPO Status Infants (Birth to 6 months)- NPO for solids for 6 hours, breast milk for 4 hours, clear liquids for 3 hours Children > 6 months to adult-NPO for milk or solids for 8 hours, no clear liquids for 3 hours, complete NPO for 2 hours prior to procedure. Patients at high risk for aspiration should be NPO for 8 hours. This includes patients with: Delayed gastric emptying (i.e. diabetes, narcotics, acute abdomen) Increased intra-abdominal pressure (i.e. ascites) Large residual gastric volumes (i.e. obesity) Symptomatic acid reflux disease (i.e. GERD, pregnancy) Pre Procedure Monitoring Physical Examination ASA Physical Status Classification Aldrette Score* Baseline Vitals, including oxygen saturation Airway evaluation Chest and cardiac status General neurological status Pre Procedure Monitoring Patient is instructed to report any problems during the procedure such as pain and difficulty breathing There should be orders for the medications that will be administered during the procedure. IV line is in place and functional Informed Consent The patient/patient representative should be informed of the risks, alternatives to moderate sedation. Documentation should be in the medical record prior to the procedure. Refer to Clinical Ops: Health Care Decisions 9.100 for informed consent specifics Intra-Procedure Monitoring The following should be documented in the medical record: All meds administered including drug, dose, site, time The amount and type of oxygen administered. Unless contraindicated, supplemental O2 should be given to all pts over age 60 or with Hx heart, lung or kidney disease. BP, HR, Resps and pulse oximetry recorded every 5 minutes Intra-Procedure Monitoring Displayed HR and rhythm continuously monitored with adequate alarming and documentation every 5 minutes Level of consciousness and pain must be continuously assessed and documented every 5 minutes. Intra-Procedure Monitoring Patients head position should be checked frequently to ensure a patent airway. If the patient becomes unstable during the procedure, or if the development of deep sedation is suspected, appropriate anesthesia/medical consultation should be sought immediately. Airway Management Staff involved in moderate sedation should possess the following skills/competencies: Recognition of airway obstruction and apnea Reestablishing a patent airway Airway Management Recognizing a patient has an inadequate airway includes: Change in breathing (snoring, loss of snoring) Decreased oxygen saturation Loss of chest expansion Rocking of chest and abdomen Changes in heart rate and/or blood pressure Airway Management Changes in mental status; increased difficulty in arousing Changes in skin color from pink to pale or dusky Changes in head position Any sign of change in the patients general status should initiate an assessment of respiratory status Airway Management Interventions Side lying position, unless contraindicated Stimulation of patient (Stir- up regimen) Head tilt Chin Lift Jaw thrust, Chin Lift Oral/nasal airway Towel roll under shoulders Ventilation with bag-valve-mask Post Procedure Monitoring The patient’s vital signs (BP, P, RR, Oxygen Saturation) should be documented every 15 minutes, for a minimum of thirty (30) minutes following the last administered dose of sedation in non-intensive/non-critical care areas.