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.