Procedural Sedation Lutheran Medical Center

1. Procedural SedationLutheran Medical Center v.2011-12

2. Note: Press F11 to maximize 1. Definitions along the Sedation Continuum • Specific differences:Proceduraland Deep • Response? • Airway intervention required? • Ventilation? • Cardiovascular function? To verbal or tactile stimulation Following repeated or painful stimulation No Maybe Adequate May be inadequate Usually maintained Usually maintained for both

3. 2. Verification of Provider Credentials (prior to EVERY procedure even if the physician performed the procedure yesterday) • Call Medical Staff Services or the Hospital Supervisor if you cannot obtain this information • Login to the Portal (my.exempla.org) • Open the DeliveringCare tab • Choose the Privileges link • Choose appropriate hospital from the dropdown list • Enter searchcriteria • Click Submit • Click the provider’sname to see: • Privileges granted • Suspension status • Other information For more details concerning requirements for specific privileges: • Click the MedicalStaff tab • Choose Privileges Sheets link in the top right corner of the page • Open the appropriate list to see further definitions of the privileges granted

4. 3a. Prerequisites tasks for the licensed independent practitioner (LIP) • History • Baseline Physical Examination • Upper Airway Assessment • ASA Score • Plan of Care – rationale for procedure and sedation plan • Informed Consent • COR status • Re-assessment – immediately before the administration of sedation • Discharge criteria

5. Solids & Non-Clear Liquids* Clear Liquids** 8 hours4 hours 6 hours3 hours 6 hours2 hours 4 hours2 hours Age More than 8 years 3 - 8 years 6 months to 3 years Less than 6 months 3b. NPO Status Recommendations - Elective and Emergent Procedures * Non-clear liquid = breast milk, formula ** Clear liquids = water, clear juices, black coffee and tea (no milk) • NPO status for emergentandurgent procedures is determined by: • patient’s status • procedural risk and type • degree of sedation anticipated

6. Acts under the direction of a credentialed Medical Staff Member Reviews/completes pre-procedure & post-procedure assessment Administers medications for sedation/analgesia Monitors patient Completes required documentation Ensures patient/family education 4a. RN Responsibilities:

7. Acts under the direction of a credentialed Medical Staff Member Completes required documentation Ensures patient/family education 4a. Respiratory Therapist Responsibilities:

8. Acts within hospital approved Scope of Practice Has successfully completed: Current Basic Life Support (BCLS) Procedural Sedation Clinical Competency Nursing Adult and Pediatric  RNS Departmental Competencies as required If Applicable, has successfully completed: Advanced Cardiac Life Support (ACLS) Neonatal Resuscitation Program (NRP) Pediatric Advanced Life Support (PALS) 4b. RN Qualifications / Requirements

9. Acts within hospital approved Scope of Practice Has successfully completed: Current Basic Life Support (BCLS) Procedural Sedation Clinical Competency Departmental Competencies as required If Applicable, has successfully completed: Advanced Cardiac Life Support (ACLS) 4b. Respiratory Therapist Qualifications / Requirements

10. Oxygen a positive pressure system that is capable of administering > 90% Oxygen at a 15 liter per minute flow rate for > than one hour (2 E cylinders) Face mask and/or nasal prongs Pulse oximeter Intravenous equipment Blood pressure equipment Bag valve mask (ambu) 5. Needed supplies and equipment • Oral/Nasal airway • Defibrillator & Cardiac monitor • Suction equipment • Emergency Medications • Atropine and reversal agents (i.e. Narcan and Flumazenil) • Advanced airway management equipment • laryngoscope handles and blades • endotracheal tubes and stylets On COR Cart

11. 6. Monitoring requirements The decision to monitor the cardiac rhythm is based on: Clinical indicators, history of significant cardiac disease, likelihood that procedure might result in rhythm changes, physician’s discretion.

12. Exhibiting signs of deep sedation, purposeful response only to repeated or painful stimuli Rass score of –4 or –5 O2 Sat <92% during or > 30 min after last dose of medication BP increase or decrease by 20% from baseline Arrhythmias Apnea Any change in respiratory or circulatory parameter Abnormal assessment findings and when to notify a LIP When patient is:

13. Combination of sedatives and analgesics increase the risk of respiratory depression and apnea Medications should be administered: one at a time in incremental doses with sufficient time to evaluate (generally over 2 minutes and wait 2-5 minutes to evaluate) Titrate narcotics to obtain pain relief and sedatives to decrease anxiety General principles in administration of Sedatives & Analgesics

14. 8a. Age Specific Considerations for medication • Medication dosage by weight • Preferred routes PO or IV • Knowledge of age specific vital sign normals/abnormals is essential • Oxygen desaturation occurs faster • Faster drug clearance due to increased renal/hepatic blood flow • Increased body fat therefore increased storage • Increased susceptibility to airway obstruction. • (S/S of respiratory distress includes cyanosis, grunting, retractions, • and nasal flaring.) • Available airway equipment must be appropriate size • Sniff position for infants • Increased sensitivity to medications, adjust dosage appropriately • Lessoxygen reserve • Decreaseddrugmetabolism from decreased renal and hepatic flow • Slowercirculationtime of medications • Decreasedmuscle tone (stiff neck) • Increased musculoskeletal disorders

15. Diminished drug clearance 8b. Disease Considerations for medication • Poor venous access • Inaccurate blood pressure • Hypertension • Difficult airway management • Respiratory insufficiency, diaphragm pushed up by abdomen • Positioning difficulties • Storage of medication in adipose tissue • Co-morbidity: diabetes resulting in circulatory disorders

16. 8c. Usual dosage for medication • Initial doses IV over 2 minutes unless indicated Benzodiazepines Narcotics Other Refer to policy for repeat doses and other vital information

17. 8d. Considerations & precautions for meds ConsiderationsPrecautions • Major side effects and respiratory depression hypotension (averted if drug administered slowly) • Lorazepam injection must be diluted with = amount of diluent before IV use • Reduce dosage if used with narcotics • Reversal agent is flumazenil • Lorazepam may have longer onset of action up to 10 minutes Benzodiazepines • Will potentiate effects of benodiazepines • May need increased dose of naloxone to reverse CNS/resp. effects of fentanyl • Caution use in patients with asthma and/or COPD Narcotics

18. 8d. Considerations & precautions for meds (continued) ConsiderationsPrecautions • Contraindicated in patients with elevated intracranial pressure, uncontrolled hypertension, aneurysms, thyrotoxicosis, CHF, angina • Caution in patients with coronary artery disease, tachycardia • Observe for sedation for a minimum of one to two hours • Monitor blood pressure, heart rate, respiratory rate. • Close cardiac monitoring for patients with history of hypotension or cardiac decompensation Ketamine

19. ONLY for ED and ICU use 8c. Usually dosage for medications specific to the ED and ICU • Initial doses IV Refer to policy for repeat doses and other vital information 9. RN administration MUST be under direct supervision of credentialed physician and RT or 2nd physician not involved in the procedure. MUST be monitoring airway.

20. ONLY for ED and ICU use 8d. Considerations & precautions for medications specific to the ED & ICU ConsiderationsPrecautions • RN administration restricted to ED and ICU • Monitor blood pressure, heart rate, respiratory rate • Caution in patients with serious asthma, hypotension, myoclonus, and nausea/vomiting Etomidate

21. Propofol is used in the GI Lab as well as the ED and ICU 8c. Usually dosage for medications specific to the ED, ICU and GI Lab • Initial doses IV Refer to policy for repeat doses and other vital information MUST be administered only by an anesthesiologist.

22. 10. Identify appropriate interventions if pt. progresses to deep sedation 11. Describe REVERSAL agents, their actions and criteria for use • Initial doses IV over 15 seconds Benzodiazepine Antagonist Narcotic Antagonist Refer to policy for repeat doses and other vital information

23. 10. Identify appropriate interventions if pt. progresses to deep sedation11. Describe REVERSAL agents, their actions and criteria for use ConsiderationsPrecautions • Caution in patients addicted to benzodiazepines • Caution in patients with history of seizures • Caution in patients with history of panic attacks • Observe for re-sedation for a minimum of one to two hours FLUMZAENIL Benzodiazepine Antagonist • Caution use in patients addicted to narcotics • May need higher doses with fentanyl • May not reverse cardiovascular effects of narcotics • Naloxone associated non-cardiogenic pulmonary edema has been reported throughout dose range • Observe for re-narcotization for a minimum of one to two hours • Titrate to avoid excessive reduction in analgesia Narcotic Antagonist NALOXONE

24. Monitor pulse oximeter continuously Stimulate patient to breathe Position head appropriately Chin lift and jaw thrust Administer supplemental oxygen Administer reversal agents Oral or nasal airway Suction airway if needed Ventilate manually with bag valve mask device Airway obstruction 12. Potential complications related to the procedure Complication Treatment

25. Oxygen Medications as ordered and indicated If patient develops shortness of breath or chest pain, obtain EKG Bradycardia (caused by hypoxemia, vagal stimulation) 12. Potential complications related to the procedure Complication Treatment

26. Notify MD of tachycardia Administer pain medication as ordered by MD performing procedure Administer O2 as needed Administer IV fluids as ordered by MD Tachycardia (caused by pain, anxiety, hypoxemia, hypovolemia) 12. Potential complications related to the procedure Complication Treatment

27. Notify MD of dysrhythmias Administer medication as ordered by MD Look for underlying causes such as hypoxemia and hypovolemia and report to MD Other dysrhythmias Atrial dysrythmias, PVC’s (caused by hypoxemia & hypovolemia ) 12. Potential complications related to the procedure Complication Treatment

28. As indicated and ordered: Administer reversal medications Administer fluids Administer vasopressors Hypotension (caused by pre-existing condition, response to medications, hypovolemia ) 12. Potential complications related to the procedure Complication Treatment

29. As indicated and ordered: Administer additional sedation Administer analgesia Administer patient medications for hypertension Hypertension (caused by pre-existing conditions, pain, stress) 12. Potential complications related to the procedure Complication Treatment

30. Stability of vital signs = BP and Pulse within 20 points for 3 consecutive observations (in the absence of significant hypertension or hypotension. ) SPO2 meets or exceeds oxygen saturation guidelines(greater than 90 % on room air or with supplemental oxygen or within baseline measurements) Body temperature at or greater than 96.8 degrees Patient orientation to name, place and day or to similar orientation present pre-procedure Patient able to move all four extremities on command or in a manner similar to that present pre-procedure Absence, control or MD awareness of: Pain, nausea and vomiting, wound drainage and bleeding Airway patency and respiratory function must be adequate and appropriate for discharge 13. Criteria for discharging a patient

31. Fluids balanced, taking into account previous NPO status and underlying conditions Physician if needed and desired contacted prior to discharge Vital signs remain stable after oxygen has been removed for 15 to 20 minutes Patient will remain at least 20 minutes after IV analgesic, providing other discharge criteria have been met Final nursing assessment and evaluation of patient condition will be performed and documented Primary nurse will inform unit nurse, if applicable, in an organized report of patient condition and procedural experience Patients not meeting pre-determined discharge criteria requires a specific physician order for discharge (Nurses notes will explain criteria not met and interventions) 13. Criteria for discharging a patient (continued)

32. Discharge to Patient Care Unit Vital signs monitored every 15 minutes after procedure until: Patient has met specified criteria  or per physician order  Transfer order written by physician  13. Criteria for discharging a patient (continued)

33. Discharge from Hospital When criteria for discharging a patient has been met Control of pain acceptable to the patient Control of nausea Ambulation in a manner consistent with the procedure and previous ability Arrangements for safe transportation from the facility Patient and responsible adult should verbalize an understanding of instructions Patients should be evaluated for the need for provision of additional resources to contact if any problems arise Patients are to be discharged per a physician’s order A copy of the post procedure discharge instructions should accompany the patient home It is recommended that the patient have a responsible adult with them for 24 hours post procedure 13. Criteria for discharging a patient

34. An H&P mustbe in the patient chart prior to the procedure AnH&P Update must be completed if the original H&P was done prior to patient admission Appropriate Informed Consent for the procedure must be in the patient chart Emergent procedures must contain appropriate physician documentation 14. Documentation ELECTIVEPROCEDURE H&P

35. Amount of medication used, including dosage, route, and times given Notation if supplemental oxygen was given Monitors employed Oxygensaturation and vitalsigns at required intervals Any complication and subsequent management Levelofconsciousness and generalappearance Any restraints or protective devices used Use of reversalagents Response to the procedure Condition of any dressings,procedure sites, or drainage Orders for transfer/discharge Dischargeinstructions given if discharged from facility 14. Documentation DURING TREATMENT & POST-PROCEDURE RECOVERY

36. Select appropriate areas for your department and complete Doc Flow Sheets 14. Documentation DURING TREATMENT & POST-PROCEDURE RECOVERY

37. For charting vitals, select specific Intra-Procedural Doc Flow sheet for your area 14. Documentation DURING TREATMENT & POST-PROCEDURE RECOVERY

38. Complete Vital Signs/Pain flow sheet, charting medications administered in the MAR 14. Documentation DURING TREATMENT & POST-PROCEDURE RECOVERY

39. Conclusion • You have completed the training content for this lesson. You should now be able to: • Differentiate between procedural and deep sedation • Demonstrate correct timing and process of verification of provider credentials • Identify prerequisites tasks for the licensed independent practitioner (LIP) • Describe RN/RT prerequisite tasks • Describe needed supplies and equipment • Identify monitoring requirements • Recognize abnormal assessment findings and know when to notify a LIP • Describe usually dosage and age specific considerations for medication • Identify appropriate staff who must be in the room and who can supervise a RN administering medications • Identify appropriate interventions if patient progresses to deep sedation • Describe reversal agents, their actions and criteria for use • List potential complications • Describe criteria for discharging a patient • Describe essential elements to document in the patient’s medical record • Evaluate the procedure by completing the procedure review form

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