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Moderate Sedation

Annual Review 2009

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ObjectivesAt the end of this review, the learner will be able to:1. State the definition of Moderate Sedation (MS)2. List the patient parameters that must be maintained

that distinguish MS from deep sedation or general anesthesia

3. List the responsibilities of the Registered Nurse in the administration and monitoring of MS

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Note:The following information is based on Kaleida Health policy #CL.4: Moderate Sedation for Operative and

Invasive Procedures (revised 5/05).

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Use of Moderate SedationSome of the procedures that are commonly

performed under moderate sedation include the following:AngiographyBronchoscopySynchronized cardioversionEndoscopyED proceduresEP Studies Lab procedures

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IMPORTANT!!Per policy CL.46.  All female patients age 9 (nine) and older must have a negative pregnancy test unless

menopausal surgically menopausal, or currently pregnant.  Before proceeding with moderate sedation....Is your patient pregnant?

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IMPORTANTThe medications used to cause moderate sedation have been shown to have adverse affects on the fetus!!

All female patients 9-years-old or older, that are not menopausal, MUST HAVE HCG TESTING DONE AND NEGATIVE RESULTS RECEIVED BEFORE THE PROCEDURE IS BEFORE THE PROCEDURE IS STARTED.STARTED.

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Moderate SedationModerate Sedation is a drug induced

depression of consciousness during which:

A. patients respond purposefully to verbal commandsB. patients respond to light tactile stimulationC. cardiovascular function is maintainedD. no interventions are required to maintain a patent airwayE. spontaneous ventilation is adequateF. continual clinical observation of patient’s physiologic

variables is maintained: pulse, O2 saturation, level of consciousness, blood pressure, and respirations.

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Caution!!While the ultimate goal of Moderate Sedation is

minimal depression of consciousness during which the patient maintains his/her own airway, it is easy to produce unconsciousness due to:Increased potency and quicker onset times of newer agents usedInconsistencies in patient response to sedatives and analgesicsUse of multiple sedative and analgesic agents in combination, which increases the level of sedation and complication rate.

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During procedureassess patient for signs of Deep

Sedation, and be ready to handle possible complications.

Deep sedation manifests as:Severely slurred speechUnresponsivenessUnconsciousness

Deep sedation is related to complications of:Cardiopulmonary depressionHypercarbiaDelayed recovery

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Moderate Sedation Review

Part 1: The Procedure

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The Procedure1.     Monitoring:

The Healthcare provider monitoring the patient and documenting during the procedure may not:      perform the procedure      participate in the performance of the procedure      have other responsibilities besides monitoring and documenting the patient during the procedure.

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The Procedure--monitoringDuring procedure, parameters must be monitored every 5 minutes:     respiratory rate    oxygen saturation

(must have audible tone and alarm on oximeter during procedure)

    blood pressure    pulse rate

AND…

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The Procedure—monitoring

    level of sedation, based on sedation scale (See next column)

Sedation ScaleScale Patient Condition 1 Awake, verbalizes, cooperative 2 Drowsy, but awake; may

have eyes open or temporarily closed; can communicate verbally.

3 Eyes closed; mimics sleep behaviorally and physiologically; arousable with minimal or moderate stimuli

4 Sleep; arousable, with moderate to intense stimuli

5 Sleep/non-arousable; loss of protective reflexes temporarily

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ProceduralEquipment: minimal

Must be available in room where procedure is being performed:

    blood pressure monitor and stethoscope    pulse oximeter    oxygen source and delivery system (e.g. nasal cannula)    suction source and suction equipment    bag/mask/valve device (Ambu bag) with reservoir and tubing    IV supplies    Airways, in sizes appropriate to patient age and size    Appropriate reversal agent for medication being administered (e.g., Romazicon®, Narcan®)

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ProceduralEquipment: emergency

  Emergency cart

with defibrillator   Emergency intubation

equipment

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Medication AdministrationMedications should be

given: 1. in an amount

necessary to render the patient calm, cooperative, able to follow commands

2. according to Corporate medication

policies

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Medication administration

IMPORTANT:When additional medication is ordered for sedation after the initial dose has been administered

The cumulative TOTAL dose will be communicated

AUDIBLY to the ordering practitioner

(Example: “I have just given 1mg Versed which makes a total dose of 2 mg given.”)

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DocumentationDuring the procedure all of the following must be

documented on the flowsheet EVERY 5 minutes:Pulse rateO2 saturationBlood pressureRespiratory rate, quality, and effort*Level of sedation*Assessment of patient status after administration of medicationsInterventions, and patient response to interventions.

*Appropriate documentation keys should be used

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Example of documentation grid on MS flowsheet

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Example of documentation keys

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Post-Procedural Observation

To be done every 15 minutes for a minimum of 30 minutes and will include:

1.       Pulse rate2.      O2 saturation

3.      Blood pressure4.      Respiratory rate5.      Level of sedation6.      Effectiveness of pain control

NOTE: Baseline oxygen saturation must be maintained for at least 15

minutes before discharge.

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Remember!The Physician or dentist must be

present in the procedure area until the

patient has returned to:         a sedation level of 2 OR         pre-sedation baseline, if that level was greater than 2

 

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If a reversal agent is used: * post-procedure

observation will be maintained for a minimum of 90 minutes from the time of administration of reversal agent.

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Documentation—post-procedural

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Reportable conditionsDocument and bring to the attention of the physician/dentist:a.      Use of reversal agentb.      Persistent oxygen saturation less than:

  92% in patients over 12 years of age, or as specified by responsible physician/dentist

  94% in patients under 12 years of age or as specified by responsible physician/dentist

c.       Any signs/symptoms of respiratory distress or manual manipulation of airway.d.      Persistent change* in heart rate of + 20% from admission baselinee.       Persistent change* in blood pressure of + 20% from admission baselinef.       Agitation or combativeness

*NOTE: Persistent changes in vital signs or O2 saturation will be reported after two consecutive abnormal readings.

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Discharge Criteria

a.       Discharge of an outpatient from the procedure area will not occur until:

         the patient is awake and has normal vital signs, and has returned to pre-sedation baseline

         the patient or responsible person is provided with verbal and written instructions

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Discharge Criteria-continued

Discharge of an inpatient will not occur until:         a responsible person is given written/verbal report         post-procedure report is given to the unit receiving

the patient with documentation of the name of the

person receiving the report.

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Documentation—discharge criteria