loc & conscious sedation

Ravindar Bethi

AN INTRODUCTION TO

CONSCIOUS SEDATION

MERC

Scales for assessment of

level of consciousness

STIMULUS RESPONSE

Scales for Assessment of level

of consciousness

V Verbal stimuliP Physical stimuli

STIMULUS RESPONSE

Scales for Assessment of level

of consciousness

V Verbally responsiveP Physically responsive

STIMULUS RESPONSE

Scales for Assessment of level

of consciousness

A Awake

V Verbally responsiveP Physically responsive

U UnresponsiveSTIMULUS RESPONSE

Scales for Assessment of level

of consciousness

A Awake

V Verbally responsiveP Physically responsive

U Unresponsive

Abbreviated Coma Scale( ACS )

STIMULUS RESPONSE

• Glasgow coma scale• Ramsay

sedation scale• Riker’s sedation-

agitation scale

DRUG INDUCED DEPRESSION OF CONSCIOUSNESS

Glasgow Coma Scale( GCS )

A

V

P

USTIMULUS RESPONSE

Verbal Response

Motor Response

Eye opening

Response

3

15

5 64PROGNOSIS

Glasgow Coma Scale( GCS )

A

V

P

U

Eye opening

Response

STIMULUS

4

Awake

Verbally

Physically

No Response 1

2

3

4

RESPONSE

Glasgow Coma Scale( GCS )

A

V

P

USTIMULUS

Verbal stimuli

Physical stimuli

RESPONSE

Verbal Response

Motor Response

5 6

Glasgow Coma Scale( GCS )

A

V

P

USTIMULUS

Single Stimulus Repeated Stimulus

Physical stimuli

RESPONSE

Verbal Response

Motor Response

5 6

Glasgow Coma Scale( GCS )

A

V

P

USTIMULUS

Pressure Pain

Single Stimulus Repeated Stimulus

RESPONSE

Verbal Response

Motor Response

5 6

Glasgow Coma Scale( GCS )

A

V

P

U

Verbal Response

Motor Response

STIMULUS

5 6Pressure Pain

Single Stimulus Repeated Stimulus

1 2345

no sound

sounds only

words only

sentences

oriented

RESPONSE

Glasgow Coma Scale( GCS )

A

V

P

U

Motor Response

STIMULUS RESPONSE

6Pressure Pain

Single Stimulus Repeated Stimulus

1 23456

no movement

Glasgow Coma Scale( GCS )

A

V

P

U

Motor Response

STIMULUS RESPONSE

Pressure Pain

Single Stimulus Repeated Stimulus

1 23456

no movement

extension

6

Glasgow Coma Scale( GCS )

A

V

P

U

Motor Response

STIMULUS RESPONSE

Pressure Pain

Single Stimulus Repeated Stimulus

1 23456

no movement

extension

flexion6

Glasgow Coma Scale( GCS )

A

V

P

U

Motor Response

STIMULUS RESPONSE

Pressure Pain

Single Stimulus Repeated Stimulus

1 23456

no movement

extension

flexion

withdrawal

Glasgow Coma Scale( GCS )

A

V

P

U

Motor Response

STIMULUS

Pressure Pain

Single Stimulus Repeated Stimulus

1 23456

no movement

extension

flexion

withdrawal

localisation

RESPONSE

Glasgow Coma Scale( GCS )

A

V

P

USTIMULUS RESPONSE

Pressure Pain

Single Stimulus Repeated Stimulus

1 23456

no movement

extension

flexion

withdrawal

localisation

normal movements

6

Motor Response

Glasgow Coma Scale( GCS )

A

V

P

USTIMULUS RESPONSE

Verbal Response

Motor Response

Eye opening

Response

3

15

5 64

PROGNOSIS

A

V

P

USTIMULUS

Ramsay sedation scale( GCS )

1

2

3

4

5

6

Glabellar tap

Single stimulus Repeated/loud stimulus

Pressure

RAMSAY SEDATION SCALE

1. Anxious and agitated or restless, or both2. Co-operative, oriented, and calm3. Responsive to commands only4. Exhibiting brisk response to loud auditory

stimulus or light glabellar tap5. Exhibiting a sluggish response to loud

auditory stimulus or light glabellar tap6. Unresponsive

RESPONSE

anxiousagitated

CON

SCIO

US

SED

ATIO

N

Riker’s sedation– agitation scale( GCS )

A

V

P

STIMULUS

V

P

U

URESPONSE

Uncontrollable

CONTINUUM OF DEPTH OF SEDATION

V UAV

U

A

PP

CONTINUUM OF DEPTH OF SEDATION

V UAV

U

A

PP

CONTINUUM OF DEPTH OF SEDATION

V UA P

CONTINUUM OF DEPTH OF SEDATION

V UA P

CONTINUUM OF DEPTH OF SEDATION

V UA P

CONTINUUM OF DEPTH OF SEDATION

V UA P

CONTINUUM OF DEPTH OF SEDATION

V UA P

CONTINUUM OF DEPTH OF SEDATION

V UA P

CONTINUUM OF DEPTH OF SEDATION

V UA P

ACLS

PROCEDURAL SEDATION

“A technique of administering sedatives or dissociative agents

with or without analgesics to induce a state that allows the patient

to tolerate unpleasant procedures while maintaining cardiorespiratory function.“

WHAT IS

CONSCIOUS SEDATION ?

“OFFICE BASED ANESTHESIA”

THE TEAM– PROCEDURAL PHYSICIAN– SEDATION PRACTITIONER– REGISTERED NURSE ASSISTANT

PATIENTS CRITERIAASA GRADING

Class I No organic, physiologic, biochemical or psychiatric disturbance. (Normal, healthy patient)

Class II Mild to moderate systemic disturbance; may or may not be related to reason for surgery (Ex: hypertension, diabetes mellitus under control)

Class III Severe systemic disturbance. (Ex: heart disease, poorly controlled HTN, uncontrolled DM)

Class IV Life threatening systemic disturbance(Ex: congestive heart failure, unstable angina pectoris, DKA)

Class V Moribund patient. Little chance for survival. Surgery is the last resort.(Ex: uncontrolled bleeding from ruptured abdominal aortic aneurysm)

PATIENTS CRITERIAMALLAMPATI CLASS

PATIENTS CRITERIAMALLAMPATI CLASS

PATIENTS CRITERIAMALLAMPATI CLASS

PATIENTS CRITERIAMALLAMPATI CLASS

EXCLUSION CRITERIA

PROCEDURES

DESIGNATED PLACES

FACILITIES MUST

MONITORING & EMERGENCY RESUSCITATION EQUIPMENT

• Stethoscope, • ECG, NIBP, Pulse oximeter• Crash cart with defibrillator, • Airway & resuscitation devices,

• Source of Oxygen • Suction source

• IV supplies

DISPLAY OF POSTERS • patient evaluation • dosing of drugs • check lists

FACILITIES MUST

OTHER SUPPLIES & REQUIREMENTS • Means to safely preserve the

narcotic and sedative drugs

• Means for documentation. • Means for intra hospital

communication.

DISPLAY OF POSTERS • patient evaluation • dosing of drugs • check lists

DRUGS

NARCOTICS

ANXIOLYTICS

V

P

U

A

ATROPINE

LOCAL ANESTHETICS

FLUMAZENIL

NALOXONE

DRUGS

NARCOTICS

ANXIOLYTICSFLUMAZENIL

NALOXONE

ANESTHETICS

PRE-PROCEDURE ISSUES

HOSPITAL

NPO PROTOCOLS

DOCUMENTATION

REASSURANCE

VIGILANCE MONITORING

DRUG ADMINISTRATION

INTRA PROCEDURE

RECOVERY AND

DISCHARGE

CONSCIOUS SEDATION COMPARED TO ANESTHESIA

• Less risk patients only• Minor procedure only• Moderate sedation only, with prior analgesia/LA• No OR, no anesthetist except as back support

• Careful selection• Strict preparation• Stringent monitoring• Extreme safety precautions• Meticulous discharge protocols

APPARENTLY EASY BUT

RISK IS RELATIVELY NOT

ACCEPTABLE

DEEP COMA

EMERGENCE

PATHOLOGICAL PROCESS

MEDICAL INTERVENTION

General anesthesia

Conscious sedation

“be meticulous…do no harm”

EXTREME AGITATION

DEEP COMA

AWAKE PATIENT

TAKE HOME MESSAGE• Conscious sedation is safe, reliable, economical• Sound airway management and resuscitation skills in

back up

Anesthetist must know everything about anesthesia and something about everything else

Every body must know something about anesthesia and resuscitation

THANK YOUMERC

V

U

A

Ravindar Bethi

P