What is Procedural Sedation?

2. What is Procedural Sedation? • Procedural Sedation also referred to as “moderate sedation/analgesia” or “conscious sedation” …. • “a drug-induced depression of consciousness during which individuals 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. Cardiovascular function is usually maintained.” • Joint Commission, 2001 • Complications of Procedural Sedation can include: • Hypoventilation, allergic or adverse reaction, abnormal cardiac function, deterioration in mental status.

3. Examples of Procedural Sedation • In a Moderate Procedural Sedation the patient’s level of consciousness is altered, though response to verbal commands is still possible. • For a Deep Sedation the patient’s consciousness is altered and cannot be easily aroused, but can respond to purposeful or painful stimulation.

4. Procedural Sedation is DEFINED by Patient’s Level of Conscious • Minimal (Anxiolysis)LOC 2 • Drug induced state, patient responds normally to verbal commands. • Moderate (Procedural Sedation)LOC 1 • Drug induced depression of consciousness, patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. • Deep Sedation (requires special privileges!)LOC 0 • Drug induced depression of consciousness, patient cannot be easily aroused, but respond purposefully following repeated or painful stimulation. (Limited to ED, and Pediatric Sub specialists) • AnesthesiaLOC 0 • Drug induced loss of consciousness, patient is not arousable, even by painful stimulation.

5. Scoring Patient’s Level of Conscious • Procedure & Anesthesia Scoring System (PASS) • Used before giving medication(s), during procedure, during recovery, and before discharge • Consists of 7 categories • Consciousness • Activity • Circulation • Respiration • O2 Sat • Pain • Emetic • All are scored using a point scale of 2, 1, 0

6. PASS Assessment Scale Physiologic Assessment Scoring System • PASS Scoring • Score prior to sedation (all 7 elements) as baseline • Score at the conclusion of procedure • Score prior to discharge Note: Patient must meet pre-sedation PASS Score prior to discharge.

8. WHAT is NOT Procedural Sedation? • Providing for comfort • Preventing predictable anxiety to a procedure or treatment by utilizing narcotics and anxiolytics in dosages appropriate to relieve pain and/or anxiety without altering the LOC • Non-invasive and routine procedures (dressing changes) • Procedure that takes so little time to perform that the fear of the procedure is often worse than the actual process • One type dose medication administration to relieve anticipated pain or anxiety for a particular patient (no titrating dose to “effect”) • Patient in ICU, intubated, and mechanically ventilated (airway is protected)

9. WHAT is NOTProcedural Sedation? • Pain and/or anxiety management that may be performed on all inpatient units • Repetitive procedures (e.g. once daily) and a patient who is on a standard dose, or combination of medication that provides comfort • A change in medication dose that would potentially induce pain and/or anxiety Note:If patients have been on a medication regime in the ICU with Fentanyl/Versed, the physician should be consulted to determine if the choice of narcotics may be changed to an equianalgesic dosage of hydromorphone or morphine sulphate, and the midazolam changed to a non-amnesiac anxiolytic such as lorazepam or valium

10. WHY Provide Procedural Sedation? • Allows patient to tolerate an unpleasant procedure while maintaining consciousness • Patient does not remember majority of procedure, awakens comfortable (depending on medications utilized) • Rapid return to presedation state • Uncomfortable and/or painful procedures can be performed safely utilizing procedural sedation • Patient safety during, and recovering from, sedation is VITAL!

11. WHO can Provide Procedural Sedation? • Physicians must have current sedation privileges. An updated list can be accessed on the SD Credentialing Website: http://cred.zion.ca.kp.org • Residents may perform procedures only when the privileged attending physician is present • RNs with age-specific training in ACLS or PALSmay administer Procedural Sedation and recover the patient • MD will complete the Procedural Sedation Record Physician documentation (Health Connect), including auscultation of heart and lungs and airway assessment • RN will complete the Procedural sedation Record RN documentation (Health Connect)

12. Procedural Sedation SETTING • Emergency Medications, Equipment & Supplies • Crash cart with defibrillator, O2, suction • Reversal agents (naloxone, flumazenil) • Pulse oximeter, blood pressure monitor • Endotracheal tube (ET) CO2 monitoring device • Physical Environment • Emergency power outlets, or flash light • Telephone • Transportation after Sedation • By RN or MD

13. Procedural Sedation Preparation • Consent needs to be obtained by physician for both the procedure and the sedation • Pre-sedation Assessment • Evaluation of Risk (American Society of Anesthesiologists ASA status) • PASS Scores • Sedation plan (medications ordered) • Time Out • Team members discuss any risks • Team members know roles and responsibilities • Patient Safety • Identify patient (2 identifiers), must have arm band • Site/side verified ASA StatusRisk Assessment Class I Healthy patient Class II Mild systemic disease, no functional limitation Class III Severe systemic disease that limits activity (not incapacitating) Class IV Incapacitating systemic disease that is a threat to life (Anesthesia consult) Class E Emergent

14. Presedation Assessment • AMPLE • Allergies – medication, food, latex • Medications – presently taking • Past medical history • Last meal (NPO Guidelines) • Event leading to need for procedure • NPO Guidelines AGESolids & Non-Clear FluidsClear 0-6mo 4 hours 2-3 hours 6mo-3yrs 6 hours 2-3 hours 3yrs + 6-8 hours 2-3 hours

15. Care During Sedation • EnsurePatientSAFETY • RN remains with patient at all times • RN responsibility is to monitor the patient – ensure safety • RN will NOT be expected to assist with the procedure • Maintain level of sedation that allows for continuous patent airway • Monitor patient’s response to medications • Assess vital signs q 15 minutes • Sedation plan (medications ordered) • Document • Use the Procedural Sedation Navigator(Health Connect)

16. Procedural Sedation DocumentationUse the Procedural Sedation Navigator (Health Connect) From the patient’s open record, Click Action  Procedural Sedation on the Main Menu. Procedure Sedation Navigator Appears Four (4) Main Topics Navigate through each section to document your findings…

17. Chloral Hydrate • Chlorpromazine (Thorazine) • Diazepam (Valium) • Fentanyl (Sublimaze) • Hydroxyzine (Vistaril) • Lorazepam (Ativan) • Meperidine (Demerol) • Midazolam (Versed) • Morphine Sulfate • Pentobarbital (Nembutal) • Promethazine (Phenergan) • Alfentanil (Alfenta) • Etomidate (Amidate) • Ketamine (Ketalar) • Methohexital (Brevital) • Propofol (Diprivan) • Thiopental(Sodium Pentothal) Common Sedation Agents Moderate Sedation Agents Deep Sedation Agents Click Deep Sedation Agents for details Procedural Sedation does not include:

18. ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep SedationDosages require adjustment based on patient's clinical conditionAdapted from: Southern CA Regional Drug Information Services

19. ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical conditionAdapted from: Southern CA Regional Drug Information Services

20. ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep SedationDosages require adjustment based on patient's clinical condition

21. ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep SedationDosages require adjustment based on patient's clinical conditionAdapted from: Southern CA Regional Drug Information Services

22. ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical conditionAdapted from: Southern CA Regional Drug Information Services

23. Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mosDosages require adjustment based on patient's clinical condition Consider Adult dosing guidelines for patients greater than 50 kg Adapted from: Southern CA Regional Drug Information Services

24. Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mosDosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg Adapted from: Southern CA Regional Drug Information Services

25. Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mosDosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg

26. Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mosDosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg Adapted from: Southern CA Regional Drug Information Services

27. Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mosDosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg Adapted from: Southern CA Regional Drug Information Services

28. Medication Administration Requirements Clinical Library To find out more information about medications, visit KP’s Clinical Library at http://cl.kp.org. This resource includes information on medication: • Dosages • Routes • Therapeutic range • Pharmacologic classification • Mechanism of action • Safe use of clinical practice guidelines formularies

29. Post Sedation Recovery and Care Ensure PatientSAFETY • RN remains with patient at all times • RN is responsible to monitor the patient – until pt. achieves his/her presedation LOC • If transferring the patient, the RN administering sedatives must accompany the patient, give a complete, concise report to the receiving RN responsible for further patient care • Monitor patient’s vital signs and pulse oximetry q 15 minutes until stable • Reorient patient to time and place • Limit stimuli to the patient (loud noises)

30. Discharge Requirements Patient Must • Be discharged by a physician • Have adequate respiratory function and stable vital signs • Meet their preprocedural LOC, and return to their preprocedural status • Have their pain under control, and site stable without evidence of bleeding • Not be discharged for 20-30 minutes after last medication, longer if reversal agents given • Be discharged to a responsible driver and advised not to drive or use heavy machinery for at least 24 hours • Receive post-procedural written discharge instructions • Verbalize understanding of instructions and education (and/or responsible caregiver)

31. Patient Safety Special Considerations Patient Special Considerations • Elderly patient’s may need more time for monitoring • Ensure a good intact gag reflex especially in children • Evaluate each INDIVIDUAL patient based on a number of considerations, not just meeting these outline criteria • Document time patient leaves the facility

32. PROCEDURAL SEDATION POST TEST

33. Procedural Sedation Post Test • 1. Which treatment is an example of procedural sedation? A. Preventing anxiety prior to treatment without altering the patient’s level of consciousness. B. Providing comfort measures to the patient. C. Performing a simple dressing change. D. Administering medication to alter the level of consciousness prior to a procedure. • 2. A Physician prescribes a one-time dose of Morphine and Ativan to • reduce the patient’s pain and anxiety during a dressing change. • This is considered procedural sedation. A. True B. False

34. Procedural Sedation Post Test • 3. To prepare for procedural sedation, the RN must: • A. Obtain patient consent for both the procedure and the sedation. • B. Confirm auscultation of heart, lungs, and airway assessment was performed by MD • C. Be aware of sedation plan • D. Perform patient identification and a “Time-Out” • E. Perform a baseline PASS assessment. • F. All of the above • 4. To perform procedural sedation, the RN must: • A. Have age-specific resuscitative equipment. • B. Have a physician privileged in Procedural Sedation present in the room. • C. Receive age specific advanced life support certification. • D. Provide a cardiac monitor, O2 monitoring, and ET CO2 monitoring. • E. Follow all of the above.

35. Procedural Sedation Post Test • 5. When performing procedural sedation, it is satisfactory to have the physician be available by pager during the procedure. A. True B. False • 6. The nurse providing moderate sedation should remain with the patient at all times. A. True B. False • 7. Before a procedural sedation patient can be discharged, they need to be observed for a minimum of 30 minutes after the last dose of sedative or analgesic was administered. Longer periods of observation are required if reversal agents are used. A. True B. False

36. Procedural Sedation Post Test • 8. To discharge a patient following procedural sedation, a post-procedural • assessment must be conducted (by a credentialed practitioner privileged in this • procedure), the patient needs to receive written discharge instructions, and a • responsible adult/driver must be identified. A. True B. False • 9. A “time-out” is performed prior to the start of the procedure and typically includes: A. A description of the nature of the procedure, the patient’s condition, details of any abnormal history or condition, and any special patient needs. B. Use of two patient identifiers – patient name and medical record on arm band. C. Verification of the site, both physically and verbally, and if required, marking of the site. D. A review of the expected course of the procedure and recovery. E. All of the above

37. Procedural Sedation Post Test • 10. Development of chest wall rigidity (“wooden chest”) may result in • serious respiratory compromise and is most often seen with the rapid • administration of: A. Fentanyl (Sublimaze) B. Morphine C. Ketamine (Ketalar) D. Flumazenil (Romazicon) • 11. The reversal agent and initial dose preferred for a 300-pound 18 • year-old who has had Diazepam, Midazolam, and Lorazepam • during a procedure is: A. Flumazenil (Romazicon) 0.2 mg, repeat every 1-2 minutes as needed B. Naloxone (Narcan) 0.4 mg, repeat every 2-3 minutes as needed C. Both a and b

38. Procedural Sedation Post Test • 12. During conscious sedation, vital signs and oxygenation status are recorded at least every ______ minutes. A. 1 B. 5 C. 15 • 13. To verify a physician’s privileges to perform procedural sedation: • A. Call the house supervisor • B. Go to the Kaiser Permanente Credentialing web site • C. Call the MD to see if they are privileged • 14. Complications of procedural sedation can include: • A. Abnormal cardiac function and deterioration • B. Hypoventilation and allergic or reverse reaction • C. Hypoventilation, allergic or adverse reaction, abnormal cardiac function, and deterioration in mental status

39. Procedural Sedation Post Test • 15. A 60 year-old male patient with coronary artery disease undergoes a pacemaker implant under IV sedation. During the procedure, the patient’s oxygen saturation decreases to 84%. The patient is snoring and responds to vigorous stimulation. You should: A. Lift the chin and jaw, attempt to provide a better airway, notify the physician immediately after the change in the patient's condition, increase oxygen delivery, call for assistance and consider reversal agents. B. Continue to monitor for further changes; reduce the next dose of sedation medication by half. C. Document the patient's status on the assessment form; notify the MD at the conclusion of the procedure.

40. Procedural Sedation Post Test • 16. After receiving Morphine and Valium for sedation and analgesia, your patient • loses consciousness and becomes dusky in appearance, and the oxygen saturation decreases rapidly from 95% to 75%. What is the appropriate nursing action? A. Ambu bag delivery of oxygen B. Nasal cannula delivery of oxygen C. Be ready to give IV Narcan and Romazicon D. A and C • 17. During a procedure in which you are administering procedural sedation, • respirations suddenly become stridorous and you notice a red rash occurs on the • patient’s hands. The appropriate nursing action is to: A. Intubate B. Do nothing C. Stop the medication and treat per the physician’s order D. Call a code blue

41. Procedural Sedation Post Test • 18. Emergency equipment which must be immediately accessible during IV sedation • includes: A. Emergency cart with defibrillator, cardiac monitor, airways, bag-valve mask, and intubation equipment, including ET CO2 monitor B. Emergency drugs including reversal agents C. Oxygen and suction with tubing D. All of the above • 19. The reversal agent and initial dose preferred for a 44-pound (20-kg) child who has had Morphine during a procedure is: A. Flumazenil (Romazicon) 0.1 mg – 0.2 mg B. Naloxone (Narcan) 0.01 mg/kg C. None of the above

42. Procedural Sedation Post Test • 20. A patient whose PASS score is “1” for consciousness is: A. Presumed to be moderately sedated B. Presumed to be minimally sedated C. Presumed to be deeply sedated