Sedation and Monitoring During Endoscopy

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Sedation and Monitoring During Endoscopy

• James W. Simmons

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Purpose of Sedation

• Allow patients to tolerate unpleasant procedures
  and relieve anxiety
• Expedite procedures that require an uncooperative
  patient to not move

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Types of Sedation

• Minimal Sedation Anxiolysis patient responds
  normally to verbal commands. Cognitive function
  may be impaired but ventilatory and
  cardiovascular functions are not affected

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Types of Sedation

• Moderate Sedation(Conscious Sedation) patients
  respond purposefully to verbal commands, either
  alone or accompanied by light tactile
  stimulation. No interventions required to
  maintain a patent airway and spontaneous
  ventilation is adequate. Cardiovascular function
  is usually maintained

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Types of Sedation

• Deep Sedation Patients cannot be easily aroused
  but can respond to repeated or painful
  stimulation. Ability to maintain ventilatory
  function may be impaired. May require assistance
  maintaining airway. Spontaneous ventilation may
  be inadequate. Cardiovascular function is
  usually maintained

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Types of Sedation

• General Anesthesia Patients are not arousable.
  Ability to maintain ventilatory function is
  usually impaired. Often require assistance in
  maintaining a patent airway. Positive pressure
  ventilation may be required. Cardiovascular
  function may be impaired.

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Types of Sedation

• Sedation is a continuum
• Providers should be able to rescue patients from
  a deeper level of sedation than was originally
  intended
• Ex If you administer moderate sedation you
  should be able to rescue someone from deep
  sedation

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Patient Evaluation

• There is some suggestive evidence that some
  pre-existing medical conditions may be related to
  adverse outcomes in patients who receive moderate
  or deep sedation
• Risks of complications are related to underlying
  conditions and the procedure being performed
• Experts agree that a preprocedure evaluation(HP)
  increases the liklihood of satisfactory sedation
  and decreases the likelihood of adverse outcomes

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Patient Evaluation

• Recommended history items
• Abnormalities of major organ systems
• Previous adverse outcome with sedation/anesthesia
• Drug allergies
• Current medications and potential interactions
• Time and nature of last PO intake
• H/O tobacco, Etoh, and substance abuse

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Patient Evaluation

• Recommended physical items
• Cardiovascular heart and lungs
• Airway
• Habitus obesity, esp face and neck
• Head Neck short neck, limited motion,
  tracheal deviation
• Mouth small opening(lt3cm), edentulous,
  loose/bad teeth, no visible uvula, high arched
  palate
• Jaw micrognathia, retrognathia, trismus,
  malocclusion
• Mallampati Classification

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Mallampati Classification

• Class I-soft palate, fauces, uvula, tonsillar
  pillars
• Class II-soft palate, fauces, uvula
• Class III-soft palate, base of uvula
• Class IV-soft palate, no uvula

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ASA Classification

• 1. Healthy
• 2. Mild systemic disease(DM, HTN)
• 3. Severe systemic disease that limits activity
  (angina, COPD, uncontrolled asthma)
• 4. Incapacitating disease that is a constant
  threat to life (heart failure)
• 5. Moribund, not expected to live 24 hours

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Pre-Procedure Counseling

• Counseling about the type of sedation and
  associated risks, benefits and alternatives and
  documentation of acceptance by the
  patient/representative

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ASA Pre-procedure Fasting Guidelines

• Ingested Material
• Clear Liquids
• Breast Milk
• Infant Formula
• Nonhuman Milk
• Light meal

• Minimum Fasting Period
• 2 hours
• 4 hours
• 6 hours
• 6 hours
• 6 hours

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Recording of monitored parameters

• Reassess just before beginning procedure, after
  administering sedative/analgesic agents, regular
  intervals during procedure, initial recovery,
  just before discharge
• Continuously monitor
• Pulse and cardiac rhythm
• Blood pressure 5 minute intervals
• Oxygen saturation
• Level of Consciousness
• Ventilatory function
• Color
• No recommended guidelines for frequency of
  monitoring

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Availability of individual monitoring patient

• Moderate sedation
• May assist with minor, interruptible tasks once
  the patients level of sedation/analgesia and
  vital signs are stable as long as adequate
  monitoring for level of sedation is maintained
• Deep sedation
• May have no other duties than patient monitoring

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Staff Training

• Understand the pharmacology of the agents being
  administered as well as the role of pharmacologic
  antagonists for opioids and benzodiazepines
• Recognize associated complications of receiving
  sedation/analgesia
• One individual capable of establishing an airway,
  PPV, and method for summoning assistance
• One individual with advanced life support skills
  immediately available 5 min for moderate
  sedation, in room for deep sedation

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Availability of Emergency Equipment

• Should be present whenever sedation/analgesia is
  administered
• Pharmacologic antagonists, appropriate sized
  airway equipment and method for providing PPV
  with supplemental oxygen, suction, resuscitation
  medications
• Defibrillator present for deep sedation or
  moderate sedation in patients with cardiovascualr
  disease

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Supplemental Oxygen

• Reduces the frequency of hypoxemia
• Consider for moderate sedation and administer for
  deep sedation

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Medications

• The choice of agent and technique for sedation
  should be dependent of the preference and
  experience of the individual provider
• Again, must be able to rescue patient from a
  deeper level of sedation that what was planned
• The primary causes of morbidity associated with
  sedation/analgesia are drug-induced respiratory
  depression and airway obstruction

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Medications

• Combined sedative and opioid is effective for
  moderate and deep sedation
• Increase doses incrementally to achieve the
  desired analgesia/sedation

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Medications

• Benzodiazepines
• Induce relaxation and cooperation and often
  provide an amnestic response
• Titrate to effect and patients tolerance
• Significant respiratory depression can occur,
  especially when combined with opiates

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Medications

• Midazolam(Versed)
• Causes anterograde amnesia
• Can get paradoxical response
• Starting dose 0.5-2mg IV slowly and titrate to
  desired effect every 2-3 minutes
• Typical dose is 2.5-5mg
• Reduce dose if given with other CNS depressants

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Medications

• Diazepam(Valium)
• Longer half-life than midazolam, less amnestic
  properties
• Initial bolus of 2.5-5mg titrating every 3-4 min

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Medications

• Benzodiazepine overdosage
• Symptoms
• Respiratory depression, hypotension, coma,
  stupor, confusion, apnea
• Treatment
• Encourage deep breathing?supplemental O2 ?PPV if
  spontaneous ventilation inadequate
• Reversal agent Flumazenil(Romazicon)

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Medications

• Flumazenil(Romazicon)
• Reverses CNS depression by blocking binding of
  the benzodiazepine to its receptor
• Limited efficacy in reversing respiratory
  depression
• May precipitate acute withdrawal, including
  seizures, in those on long-term benzodiazepines
• Dose 0.2mg IV q 1 min prn 5 doses/series
  repeat series q 20 min Max 3mg/hour

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Medications

• Opiates
• Increase pain threshold, alter pain reception,
  inhibit ascending pain pathways
• Use with caution in those taking other CNS
  depressants
• Can lower seizure threshold in those with h/o
  seizures

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Medications

• Fentanyl(Sublimaze)
• Can cause significant hypotension
• Dose 25-50mcg q 1-2 min until desired effect
• Typical dose is 50-200mcg
• 2-4 hour half-life
• In high doses can cause chest wall rigidity and
  respiratory difficulty

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Medications

• Meperidine(Demerol)
• Caution in those with renal impairment
  metabolites accumulate and may lead to seizures
• Dose 50-100mg, titrate to desired effect

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Medications

• Opiate overdosage
• Symptoms
• Similar to benzodiazepine overdosage extreme
  sedation and respiratory depression
• Treatment
• Fluids and even vasopressors may be required to
  manage cardiovascular complications
• Reversal agent - Naloxone(Narcan)

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Medications

• Naloxone(Narcan)
• Watch closely for re-sedation after reversal
  wears off
• First line to reverse respiratory depression if
  benzo-opiate combo given
• Causes release of catecholamines caution
• Acute withdrawal in those on chronic opiates
• Dose 0.1-0.4mg IV/SC q 2-3min

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Medications

• Droperidol(Inapsine)
• Butyrophenone neuroleptic tranquilizer
• Use in combo with opiates and benzodiazepines for
  complex endoscopic procedures
• Produces an anti-emetic and anti-anxiety effect
• Mild sedative and alpha-adrenergic inhibitory
  action
• Dose 1.25-2.5mg IV Max 5mg

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Medications

• Droperidol(Inapsine)
• Can cause hypotension, tachycardia, prolonged
  drowsiness and extrapyramidal side effects
• Associated with QT prolongation and development
  of torsades de pointes
• Should be considered when
• Anticipated intolerance of standard sedatives
• Anticipated long procedure time

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Medications

• Promethazine(Phenergan)
• Use as an adjunct to benzodiazepines/opiates
  during endoscopy or use as an anti-emetic
• Strong alpha-adrenergic blocking effects
• Rapid administration may cause transient
  hypotension
• Dose 12.5-25mg IV

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Medications

• Propofol(Diprivan)
• Ultra-short-acting hypnotic agent that provides
  amnesia but minimal analgesia
• Increases likelihood of deep sedation as well as
  risk of rapid decrease in level of consciousness
  and cardiorespiratory functioning
• May produce general anesthesia
• Potentiates effects of opiates and sedatives
• Half-life 1-4 min

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Medications

• Propofol(Diprivan)
• Joint statement by ACG, AGA, and ASGE
• No convincing benefit compared with opiate/benzo
  combinations when used for standard upper and
  lower endoscopy
• Better for prolonged and therapeutic procedures
• Non-anesthesiologists can administer
• Recovery time is faster and patients can
  potentially perform independent transfer after
  procedure

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Medications

• Propofol(Diprivan)
• Dose Initial bolus of 20-40mg followed by
  10-20mg boluses to maintain sedation
• Regulations governing administration by nursing
  personnel vary by state
• Must be able to rescue patient from general
  anesthesia

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Post-procedure

• Monitoring
• Watch for adverse effects from instrumentation or
  sedation
• Duration depends on perceived risk to patient
• Discharge when vitals are stable and level of
  consciousness is appropriate
• Prolonged period of amnesia and/or impaired
  judgment and reflexes may exist
• Competent companion must accompany patient and
  ideally be with them throughout the day
• Give written instructions detailing signs and
  symptoms of potential adverse outcomes and
  complications and 24 hour contact if needed