Conscious Sedation

Sedation and AnalgesiaO “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”

Minimal SedationO In this drug induced state, the

patient may have cognitive function and coordination impaired while ventilatory and cardiovascular functions are not affected

O The patient responds normally to verbal command and protective reflexes remain intact

Moderate Sedation and Analgesia

O The patient develops a drug induced depression of consciousness while responding purposefully to verbal and or light tactile stimulation

O Protective reflexes remain intact with adequate spontaneous ventilation.

O Cardiovascular function is usually unchanged

Deep Sedation/Analgesia

O In this drug-induced state, the patient cannot be easily aroused

O Response to repeated or painful stimulation is purposeful.

O Spontaneous ventilation may be inadequate and the patient may require assistance in maintaining a patent airway.

O Cardiovascular function is usually maintained

AnesthesiaO General or regional anesthesia are

included in this categoryO The drug induced state during

general anesthesia produces a state where patients are not arousal and may require ventilation and airway maintenance.

O There may be an impairment of cardiovascular function.

Sedation and AnalgesiaO Procedures that invade a body cavity

must be performed in the surgical area

O 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.

Pre-ProcedureO Physician evaluation of the clinically relevant

portions of the recommendations outline in policy statements #4 and #5

O Patient education including the use of sedation and analgesic

O IV access may be established at the physician’s discretion

O 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)

Equipment to Have Immediately Available

O Crash cartO Defibrillator

Vital SignsO Obtain a complete set of vital signs

BEFORE beginning the procedureO Oxygen saturation O Complete baseline patient

assessment using the modified Aldrete Score

During the ProcedureO Medications and therapeutic

interventions must be administered by physician order

O Physician signature on sedation and analgesia record authenticates order for medications or may be written on a physician order sheet.

Monitor:O O2 saturation and heart rate per pulse

oximeterO Blood PressureO Respiratory RateO EKG in patients with significant

cardiovascular disease or when dysrhythmias are anticipated or detected or at the discretion of the physician or RN

O Report changes in patient’s condition ASAP if less then pre-procedure baseline

Aldrete ScoreO The Aldrete score will be recorded as

followsO Prior to the procedureO 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.

Post-ProcedureO Vital signs are recorded

O Prior to procedureO Every 5 minutes x3 following each

administration of a sedative/analgesic agent

O 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

Recovery PeriodO If the patient’s Aldete score decreases or is less than

the baseline, other complications are assessed and the physician MUST be notified

O 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

O 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

Discharge CriteriaO The patient may be returned to their room or

appropriate area, resume routine nursing care or discharged home when the following criteria is met:O The modified Aldrete score is greater than 8 or

has returned to baselineO The o2 sat is 92% or greater on room air or

home o2 or return to baselineO 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.

InstructionsO Any discharge instructions related to

the procedure, test, medication given and any restrictions

O If returning to a nursing home, report must be called to the appropriate facility and include any previous orders to resume or new orders

Intravenous AgentsO Benzodiazepines

O Used for conscious sedationO Diazepam

O long-actingO should be avoided in elderly due to metabolite

O MidazolamO 3 to 4 times more potent than diazepamO used for conscious sedation such as for

endoscopy, gastroscopy, or bronchoscopyO Flumazenil (Romazicon) is a

benzodiazepine reversal agent (antagonist

Intravenous Agents Cont

O PropofolO used for both induction and maintenanceO is rapid-acting and patients have rapid

recoveryO formulated in fat emulsion; must consider

with TPN patients.O Formulation is susceptible to microbial

growth and should be discarded 6 hours after opening

O adverse effects include hypotension, green urine, and nausea and vomiting

Fentanyl

Recommend Moderate Sedation Fentanyl Dose

O Initial Dose: O < 50 kg: 0.5 mcg/kgO 51-75 kg: 50 mcgO 76 - 100 kg: 75 mcgO > 101 kg: 100 mcgO Maximum Dose per Hour: 2 mcg/kgO Titrate in increments of 25 mcg

every 2-3 minutes (12.5 mcg if < 50 kg)

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