Procedural Sedation

1. Procedural Sedation In the Emergency Department

2. Objectives • To understand the reason for procedural (conscious) sedation • To monitor such patients adequately • Understand sedation medications to include usage, dosing and side effects • Document appropriately

3. Definition • Moderate sedation/analgesia (“conscious sedation”) – A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.

4. ENA/ACEP position statement • Defined- A technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patients to tolerate an unpleasant procedure while maintaining cardiorespiratory function. • Meds may include: Etomidate, propofol, ketamine, fentanyl, and midazolam

5. WVBON statement (2010) • Administration of anesthetics i.e ketamine, propofol, etomidate, paralytics is not within RN scope except: • Intubated and ventilated in acute setting • Agent is for specific purposes comfort, stable ventilation and viable airway • Ketamine OK with physician present • Physician must be at the bedside for administration and determine initial infusion dose, RN can titrate on intubated pts.

6. Procedural Sedation • In all circumstances it is expected the RN has appropriate emergency equipment and competent personnel in emergency resuscitation available immediately available to apply this intervention in practice (WVBON, 2010) • Cannot delegate to LPN (WVBON, 2010)

7. Meds • Etomidate • Short acting sedative hypnotic • Dose=0.3 mg/kg • Induction time= 5-10 min. • *Myoclonus

8. IM or IV Dissociative anesthesia Dose = 1-2 mg/kg (IV)/ 4-10mg/kg IM Lasts approx. 30” Glazed eyes & nystagmus Watch for agitated recovery *Increased BP, HR,tonic/clonic,N/V, hypersalivation Ketamine

9. Meds • Versed • Benzo,sedative • 1-2 mg IV • Onset 1.5 min. to 2H • *Hypotension

10. Meds • Fentanyl • Narcotic analgesic • 1-2 mcg/kg • Lasts 30 min. • *Resp. depression

11. Propofol (Diprivan) • Induction agent • Standard dose: 2 mg/kg • Rapid onset, short duration – usually given as an infusion after bolus • Considerations: *Hypotension,apnea

12. Personnel and Training • Minimal # is 2- the operator and the monitor • One must be ACLS certified • Nurses monitoring the patient during sedation must not have other responsibilities that would compromise their ability to adequately monitor pt

13. Ambu bag Suction Crash cart Oxygen Pulse ox Evaluate prior to procedure Equipment

14. Equipment • End Tidal CO2 monitoring (ETCO2) • Bring capnographer to bedside • Age appropriate nasal tubing • Can use nasal 02 in conjunction with CO2 • Normal range – 35-45 mmHg

15. Documentation • Physician Conscious Sedation Pre-Procedure H&P • Diagnostic Therapeutic Procedure Sedation Record • Consent for Anesthesia • Consent for Medical or Surgical Procedures

16. Baseline HR,BP,RR,T,O2 sat,LOC, and responsiveness. Medications Document: Rt,site,time,drug and dose Ongoing Q 5 min. HR,RR,O2 sat. Con’t EKG if hx of heart dz Clinician can judge BP cuff Monitoring

17. OVERSEDATION • Manifested by airway obstruction, decreased O2, inadequate respirations • One person stop duties and monitor Q 5 min. • Defibrillator available • Functioning IV in place

18. Oversedation • Reversal agents: • Narcotic reversal i.e. Fentanyl – Narcan • Benzodiazepine reversal i.e. Versed – Romazicon • Fluids bolus • Oxygen NRB or bag ventilate • Intubate if indicated

19. POST PROCEDURE • ACLS personel • BP and RR Q 15 min • HR and sat Q 15 min • DC criteria; activity, color, respirations, neuro, circulation. Score must be at least 8/10