Slide 1

Dr. Ghaleb NasrallahHead OR & AN Dept.Chairman of CS & pain manag. committee

CONSCIOUS SEDATION(CS)Definitionsedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis during a potentially painful or frightening procedureDefinition cont.For minor not painful procedures, to release anxiety and frightening.In mild to moderate painful procedures , analgesia in its majority depends on LA given by the surgeon, and minimum iv sed-analgesia (given by qualified conscious sedation staff) to maintain the Patient, sedated,but awake, cooperative, breathing spontaneous, hemodynamically stable ,respond to verbal or tactile stimulation.The Aim To train a nonanesthesia staff to give safe sedation

for minor procedures , (ASA 1-2 ) patients in

specific places to outside the Operating Room .

Minimal Sedation(anxiolysis)Moderate Sedation/ AnalgesiaDeep Sedation/AnalgesiaGeneral Anesthesia

ResponsivenessNormal response to speechPurposeful response to speech or touchPurposeful response to repeated or painful stimulationNo response, even to painAirwayUnaffectedRemains openMay need help to maintain airwayOften needs help to maintain airwayBreathingUnaffectedAdequateMay not be adequateOften require ventilatory supportHeart FunctionUnaffectedUsually maintainedUsually maintainedMay be impairedDepth of SedationScaleDescription1Anxious and agitated or restless, or both2Cooperative, oriented, and tranquil3Response to commands only4Brisk response to light glabellar tap or loud auditory stimulus5Sluggish response to light glabellar tap or loud auditory stimulus6No response to light glabellar tap or loud auditory stimulusThe Ramsay ScalePre-Sedation AssessmentThe patients ASA status should be determined.

The ASA describe five physical status classes:

ASA class I patients are healthy with no medical problems.ASA class II patients have a mild,well-controlled disease(e.g. HTN)ASA class III patients have multiple medical problems or a moderately-controlled disease. (e.g. CHF compensated)ASA class IV (decompensated)ASA class V patients are moribund

Patients in ASA classes I and II can be given moderate sedation. Medical consultation is suggested for class III patients. Patients in ASA classes IV and V should not be given moderate sedation by a non anesthesia provider.

ASA classes and CS Procedures ExamplesProcedures such as all types of endoscopy, lumbar puncture, and cardioversionWound care: suturing, dressing changes, incision and drainage of abscesses, burn debridementMinor surgical procedures: dental, podiatric, plastic, ophthalmic; vasectomyPlacement of implanted devices, catheters, and tubesBone marrow aspirationReduction and immobilization of fracturesRemoval of implanted devices and tubesProcedures for which the patient is anxious but must remain as motionless as possible, such as magnetic resonance imaging and computed tomography scan (not usually painful but may occasionally require sedation)

1. Ingestion of large food or fluid volumes2. Physical class III - IV or greater3. Lack of support staff, drugs, monitoring or equipment4. Lack of experience/credentialing on part of clinician5. Patient not ready ,no consent

ContraindicationExcluded casesfor non anesthesiologistChildren (except for pediatrician and very well trained staff)Full stomach Obese patientsHeavy smokersEmergency casesLiver or kidney diseaseRespiratory compromiseAcute narrow angle glaucomaCardiovascular disease Uncontrolled diabetes Young children, infants, neonatesFrail, debilitated elderlyPossible or confirmed pregnancy, nursing mothers

Optimal conscious sedation/analgesia is achieved when the patient

maintains consciousnessindependently maintains his/her airwayretains protective reflexes (swallow and gag)responds to physical and verbal commandsis not anxious or afraidexperiences acceptable pain reliefhas minimal changes in vital signsis cooperative during the procedurehas mild amnesia for the procedurerecovers to preprocedure status safely and promptly

ASA Revised NPO Guidelines for Sedation2 hours prior to sedation: nothing by mouthUp to 2 hours prior to sedation: clear liquidsUp to 4 hours prior to sedation: infants may have breast milkUp to 6 hours prior to sedation: may have nonhuman milk and infant formula

Up to 8 hours prior to procedure: may have solid foodMedications: gastric stimulants, drugs that block gastric acid secretion, and antacids may be ordered pre-procedure in patients with risk of aspiration.

DRUGS DOSAGES FOR CONSCIOUS SEDATION

MAY BE USED IN PAIN MANAGEMENT IN ER OR OTHER DEPARTMENTS BY TRAINED STAFF ,EMERGENCY DRUGES &EQUIPMENT , VITAL SIGNS MONITORING TO BE AVAILABLE AND CHECKED

drugsdosesPropofol amp0.25-0.50 mg/kg IVKetamine vial1-2 mg/kg IV ,IMEtomidate amp0.3-0.5mg/kg IVMidazolam amp0.02-0.1mg/kg IV , IMFentanyl amp0.3-0.5 microgram/kg IVPethidine amp0.3-0.7mg/kg IV IMMorphine amp 0.07-0.15mg/kg IV ,IMSTANDARDS(ST.1-ST.12)ST.1Conscious Sedation in the hospital has policies and guidelines approved by the Head of Anesthesia, the nurse manager, and the appropriate department heads.

ST.2Conscious sedation is performed only in areas identified in policy and the following equipment is available to provide safe care:

2.1 Wall suction or suction equipment.2.2 Oxygen.3.3 Pulse Oximetry.3.4 Automated blood pressure monitor or means of taking BP3.5 ECG Monitor

ST.2ST.3There is a crash cart with defibrillator, medications, IV access, and intubation equipment that is appropriate to the age of the patient available where sedation/analgesia is being performed.

ST.4There is a list of all medications used in

conscious sedation and includes the route

administered along with dosage appropriate

to the age groups available where conscious

sedation is performed.

ST.5Staff who participate in caring for

patients receiving conscious sedation have the following certifications:

5.1 Physicians who perform conscious sedation are certified as appropriate in BCLS, ACLS,PALS, NALS and have privileges granted to perform conscious sedation.

5.2 Nurses who assist with sedation/analgesia are certified in BCLS, and preferably ACLS or PALS, according to the age of the patient.

ST.5ST.6

Conscious sedation is only used for patients having short diagnostic or therapeutic procedures.

ST.7 Preparation before the conscious sedation procedure includes the following:

7.1Availability of crash cart with defibrillator, medications, IV access and intubation and other equipment that is appropriate to the age of the patient where sedation/analgesia is being performed. ST.77.2 Informed consent is obtained after the physician educates the patient regarding the risk and benefits of the sedation/analgesia and the consent is signed by the patient, guardian, or next of kin if the patient is unable to sign.

ST.77.3 An IV is inserted and venous access is maintained in case of emergency.

ST.8

The physician obtains a history and

physical examination within the first

4 hours of admission and checks:

8.1 The history of medication allergy.8.2 Any history of systemic illness or major organ impairment that might be risky for the patient.

ST.8ST.9The physician performs a physical exam and checks:9.1 Vital signs.9.2 Age and weight.9.3 ECG findings.

ST.10During the procedure, the following is required:

10.1 The physician performs a physical exam.10.2 One registered nurse who is certified with BCLS and preferably ACLS or PALS is at the patient side constantly and continuously monitors the patient.

ST.1010.3 One physician is physically present and close by the patient.

10.4 The IV is maintained and kept patent in case of emergency.

10.5 The patient is continuously monitored for level of consciousness, vital signs, oxygen saturation and skin color and this is documented by the physician an nurse.

ST.10ST.11After the procedure, the following is required:

11.1 The physician documents the status of the patient post procedure and includes vital signs, level of consciousness, and ECG findings.

ST.1111.2 The nurse documents the status of the patient post procedure and includes vital signs, level of consciousness, and ECG findings.

ST.1111.3 The physician writes a discharge order or transfers the patient back to the unit with follow up instructions for the nurses (vital signs, oxygen saturation, etc.)

ST.11ST.12The nurse carries out the physicians orders andmonitors the patient post procedure:

12.1 Assessment/Re-assessment of vital signs, Oxygen saturation, level of consciousness, pain, tolerating fluids, and voiding.

ST.1212.2 The nurse provides education and discharge instruction to the patient and family that includes follow up and emergency number to call, if needed.

ST.12

Discharge criteria must be approved in writing by the responsible physician

Patient is as alert and orient as baselinePresence of protective reflexes (swallow and gag)Stable V. S consistent with baseline for 30 min. after last drug doseSpo2 on room air >95% or at baseline for 30 min. after last drug doseCardiac rhythm consistent with baselineBP and heart rate within 20 points of baseline or within normal limitsNo feverPain rating < or = to baselineWhen applicable, no visible site drainage or excessive swellingPatient is able to ambulate as well as prior to procedureResponsible adult is present to drive patient home & remain with him

Summary

Conscious sedation is a safe practice in a setting withProper patient selectionProper preoperative assessmentProper preparation(Familiarity with Ready& Functioning Equipment &Medications)Proper monitoring Adequate IV accessExperienced personnel(doctor and nurse)Recovery room( staff monitoring-discharge criteria)

For your attentionQuestions?