Conscious Sedation

1. Conscious Sedation

2. Sedation and Analgesia • “A state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and/or tactile stimulation”

3. Minimal Sedation • In this drug induced state, the patient may have cognitive function and coordination impaired while ventilatory and cardiovascular functions are not affected • The patient responds normally to verbal command and protective reflexes remain intact

4. Moderate Sedation and Analgesia • The patient develops a drug induced depression of consciousness while responding purposefully to verbal and or light tactile stimulation • Protective reflexes remain intact with adequate spontaneous ventilation. • Cardiovascular function is usually unchanged

5. Deep Sedation/Analgesia • In this drug-induced state, the patient cannot be easily aroused • Response to repeated or painful stimulation is purposeful. • Spontaneous ventilation may be inadequate and the patient may require assistance in maintaining a patent airway. • Cardiovascular function is usually maintained

6. Anesthesia • General or regional anesthesia are included in this category • The drug induced state during general anesthesia produces a state where patients are not arousal and may require ventilation and airway maintenance. • There may be an impairment of cardiovascular function.

7. Sedation and Analgesia • Procedures that invade a body cavity must be performed in the surgical area • Procedures in which sedation and analgesia may be utilized in settings other than surgery include, but are not limited to: chest tubes insertion, central line insertion, cardiac catheterization, TEE, and emergency department procedures.

8. Pre-Procedure • Physician evaluation of the clinically relevant portions of the recommendations outline in policy statements #4 and #5 • Patient education including the use of sedation and analgesic • IV access may be established at the physician’s discretion • Equipment in the room is to include: BVM, wall suction and tubing, nasal cannula, o2 flow meter, cardiac monitor, blood pressure monitor, o2 pulse ox, Narcan, Romazicon(a conscious sedation cart is stored in materials and is available if needed)

9. Equipment to Have Immediately Available • Crash cart • Defibrillator

10. Vital Signs • Obtain a complete set of vital signs BEFORE beginning the procedure • Oxygen saturation • Complete baseline patient assessment using the modified Aldrete Score

11. During the Procedure • Medications and therapeutic interventions must be administered by physician order • Physician signature on sedation and analgesia record authenticates order for medications or may be written on a physician order sheet.

12. Monitor: • O2 saturation and heart rate per pulse oximeter • Blood Pressure • Respiratory Rate • EKG in patients with significant cardiovascular disease or when dysrhythmias are anticipated or detected or at the discretion of the physician or RN • Report changes in patient’s condition ASAP if less then pre-procedure baseline

13. Aldrete Score • The Aldrete score will be recorded as follows • Prior to the procedure • Every 15 minutes until a score of 8 or greater or baseline is achieved, or for a minimum of 2 hours if reversal agents have been used.

14. Post-Procedure • Vital signs are recorded • Prior to procedure • Every 5 minutes x3 following each administration of a sedative/analgesic agent • Then every 15 minutes during the procedure or until base-line is achieved, the patient is stable, or for minimum of 2 hours if a reversal agent was used

15. Recovery Period • If the patient’s Aldete score decreases or is less than the baseline, other complications are assessed and the physician MUST be notified • This includes the o2 sat less than pre-procedure or less than or equal to 90%, dyspnea, apnea or hypoventilation, diaphoresis, inability to arouse the patient, the need to maintain the airway mechanically or other untoward unexpected responses • If the patient’s score has not reached 8 or returned to baseline within 30 minutes of the last administered drug (including reversal agents) the physician MUST be notified and monitoring continued

16. Discharge Criteria • The patient may be returned to their room or appropriate area, resume routine nursing care or discharged home when the following criteria is met: • The modified Aldrete score is greater than 8 or has returned to baseline • The o2 sat is 92% or greater on room air or home o2 or return to baseline • No reversal agents have been utilized. If a reversal was used the patient must be monitored for a MINUMUM of 2 hours post-administration of the reversal regardless of the Aldrete score.

17. Instructions • Any discharge instructions related to the procedure, test, medication given and any restrictions • If returning to a nursing home, report must be called to the appropriate facility and include any previous orders to resume or new orders

18. Intravenous Agents • Benzodiazepines • Used for conscious sedation • Diazepam • long-acting • should be avoided in elderly due to metabolite • Midazolam • 3 to 4 times more potent than diazepam • used for conscious sedation such as for endoscopy, gastroscopy, or bronchoscopy • Flumazenil (Romazicon) is a benzodiazepine reversal agent (antagonist

19. Intravenous Agents Cont • Propofol • used for both induction and maintenance • is rapid-acting and patients have rapid recovery • formulated in fat emulsion; must consider with TPN patients. • Formulation is susceptible to microbial growth and should be discarded 6 hours after opening • adverse effects include hypotension, green urine, and nausea and vomiting

20. Fentanyl

21. Recommend Moderate Sedation Fentanyl Dose • Initial Dose: • < 50 kg: 0.5 mcg/kg • 51-75 kg: 50 mcg • 76 - 100 kg: 75 mcg • > 101 kg: 100 mcg • Maximum Dose per Hour: 2 mcg/kg • Titrate in increments of 25 mcg every 2-3 minutes (12.5 mcg if < 50 kg)

22. Side Effects • Narcotics: • Sedation • respiratory depression • itching (specifically with morphing but can be with all) • constipation (more with chronic use) • Versed: • Sedation • Respiratory depression • Amnesia • Delirium