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Introduction to Conscious Sedation

Dr.Shailendra V.L.Head of ICU & Patient safety Al Bukeriya general hospital

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Primun non nocere“First, Do No Harm”

The guiding principle for health care workers is that, whatever the intervention

or procedure, the patient’s well being is the primary consideration

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Why this course on Conscious sedation?

• Sedation is a continuum and a patient can easily sleep into a deeper level of sedation

• Therefore, the person administering sedation should know how to rescue the patient who slips into a deeper level

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OBJECTIVES• Understand levels of Conscious sedation• Know who can administer sedation• Know what your responsibilities are• Know what equipment is needed• Responsibilities in the procedure room• Know the properties of the medications given for

sedation• Understand synergistic effects of medications• Patient populations who may be at greater risk for

complications

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Hospital-wide Conscious sedation policy

• Describes as to who are privileged to perform conscious sedation

• Designated areas of providing conscious sedation in the hospital

• Equipment & Monitoring (intra & post procedure)

• Discharge criteria • Patient family education on discharge

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These patients and their safety are in our hands

• We must have policy & procedures in place• We must screen the patients• We must have proper equipment• We must monitor them during the procedure• We must be prudent in our sedation and zealous in our

monitoring• We must monitor them post procedure & document• We must discharge them according to discharge criteria • We must provide patient-family education

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What are the responsibilities of sedation nurse?

• Assessment: Vital signs, Level of consciousness and have a good understanding of procedure

• Review patient medical history and medication list, ensure patient is a candidate for procedure

• Ensure immediate availability of emergency equipment & medications

• Educate patient of recovery process and home care• Verify last oral intake• Assure vascular access• Know the properties of medications that will be given

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Pre-procedure sedation nurse responsibilities

• Do “sign-in” on arrival to the procedure room prior to start of sedation

• Connect monitoring equipment to patient• Prepare sedation medication as ordered by

anesthesiologist• Check all the airway & resuscitation

equipment for proper functioning

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Intra-Procedure Sedation Nurse Responsibilities

• Do “time out” just prior to procedure. • Have no other responsibilities other than

monitoring the patient• Administer medicine on the order of

anesthesiologist• Administer Oxygen as ordered• Monitor vital signs & level of consciousness• Document response to medicines, complications,

interventions, etc.

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Post-procedure Sedation Nurse Responsibilities

• Conduct “sign out” at the end of the procedure • Ensure all procedural documentation is

completed• Take patient to recovery room & continue

monitoring • Document patient assessment upon arrival to

recovery room• Give report to nurse assuming patient’s care

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Post-procedure Sedation Nurse Responsibilities

• Document the patient response & vital signs in the appropriate form

• Discharge the patient on the order of anesthesiologist (modified Aldrete’s score)

• Give PFE (patient family education) & record in the chart• Discharge the patient with a responsible adult with

instructions like• not to drive or operate machinery for 24 hours• not to stay alone at home• To report to ER if any problems arise – ER phone number

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What Equipment Do I Need?• Oxygen• Suction• Ambu-bag adult & pediatric • Airways all sizes • Laryngoscope – all size blades• Endotracheal tubes • Crash cart with AED• Sedation medications• Reversal agents• Monitoring devices

– Pulse oximeter– Non-invasive blood pressure– ECG monitor– End-tidal CO2 monitor

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Medications used for Sedation

• Midazolam• Fentanyl • Pethidine• Propofol• Ketamine• Thiopentone• Reversal agents:– Flumazenil (benzodiazepin reverasal)– Naloxone (opiate reversal)

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Synergistic effects• When Midazolam is given along with Fentanyl

there is synergistic effect noted– Excessive respiratory depression – Resulting in hypoxemia

• Great care should be exercised when 2 drugs are used in combination

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Patient Factors Affecting Response to Sedation

Morbidity Organ System Abnormalities

Difficult airways Sleep apnea; obesity; short neck; reduced mouth opening; large tongue; anatomical abnormalities

Risk of aspiration Acute upper gastrointestinal bleeding; gastric outlet obstruction; delayed gastric emptying; achalasia

Reduced tolerance / paradoxical reactions to standard sedative

Tobacco, alcohol, or substance abuse; previous adverse experience with sedation; neuropsychiatric disorders; allergies; drug reactions

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Sedation can be risky with certain patient populations

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Thank you

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Continuum of Depth of SedationMinimal Sedation

(“Anxiolysis”)

Moderate Sedation / Analgesia

(“Conscious Sedate”)

Deep Sedation / Analgesia

General Anesthesia

Responsiveness Norman response to verbal stimulation

Purposeful* response to verbal or tactile stimulation

Purposeful* response following repeated or painful stimuli

Unarouseable, even with painful stimulation

Airway Unaffected No intervention required

Intervention may be required

Intervention often required

Spontaneous Ventilation

Unaffected Adequate May be inadequate Frequently inadequate

Cardiovascular Function

Unaffected Usually maintained Usually maintained May be impaired