Conscious Sedation

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Conscious Sedation

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Case Presentation

• ?xx, 74 year-old age man. C.CPET whole body
  scanThe area of increased FDG uptake at the
  hepatic flexure of the colon can be due tumor
  involvement or normal bowel activity
• Further evaluation with CT scan is recommended
• CREAT. 4.3 mg/dl
• S-SCOPE BX 91/06/27 unpleasant

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Unpleasant endoscopy

• Unsedated endoscopy (43 refusal rate for upper
  GI endoscopy with no sedation, 65-83 refusal
  rate for unsedated colonoscopy )
• Whereas other patients will need prolonged, more
  stimulating therapeutic endoscopic procedures
  that require total patient compliance.
• Zaman A. A randomized trial of peroral versus
  transnasal unsedated endoscopy using an ultrathin
  videoendoscope. Gastrointest Endosc 1999
  49279-284
• Early DSPatient attitudes toward undergoing
  colonoscopy without sedation. Am J Gastroenterol
  1999 941862-1865

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Patient factors affecting tolerance of unsedated
endoscopy

• 509 patients undergoing unsedated diagnostic
  gastroscopy aided by topical pharyngeal
  anaesthesia
• Gag reflex, young age, a high level of anxiety,
  poor tolerance of previous examinations and
  female sex
• Rex DK Patients willing to try endoscopy
  without sedation associated clinical factors and
  results of a randomized controlled trial.
  Gastrointest Endosc 1999 49554-559.

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GI endoscopy complication

• Bleeding, perforation, and infection
• 0.1 for upper endoscopy
• 0.2 for colonoscopy
• Cardiopulmonary complications 21,011 procedures
  5.4 per 1000 procedures
• Aspiration
• Oversedation
• Hypoventilation
• Vasovagal episodes
• Airway obstruction
• Rankin GB. Indications, contraindications and
  complications of colonoscopy. In
  Gastroenterologic Endoscopy 1989

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Endoscopic design and intubation route

• Ultrathin (5-6 mm) endoscopes
• Less traumatic and easier to tolerate for
  patients having UGIE without sedation
• Nasal route provides a direct route to the
  esophagus avoiding sensitive oropharyngeal
  structures with less stimulation of the gag
  reflex

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• Routine administration of sedation , The
  incidence of unplanned absence from work the day
  after outpatient colonoscopy has been shown to be
  4

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What is Conscious Sedation?

• Altered state of consciousness
• Minimizes pain and discomfort through the use of
  pain relievers and sedatives
• Able to speak and respond to verbal cues
  throughout the procedure
• Communicating any discomfort they experience to
  the provider.
• Amnesia may erase any memory of the procedure.

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Depth of Sedation Definition of General
Anesthesia and Levels of Sedation/Analgesia
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Non-Anest Practice Guidelines for Sedation and
Analgesia byNon-Anesthesiologists
hesiologists Anesthesiology 2002 96100417
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Who Can Administer Conscious Sedation?

• Qualified providers
• Certified Registered Nurse Anesthetists (CRNAs)
• Anesthesiologists
• Physicians
• Dentists
• Oral surgeons are qualified providers of
  conscious sedation

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When is Conscious Sedation Administered?

• In hospitals, outpatient facilities, e.g.,
  ambulatory surgery centers, doctors offices
• Breast biopsy
• Vasectomy
• Minor foot surgery
• Minor bone fracture repair
• Plastic/reconstructive surgery
• Dental prosthetic/reconstructive surgery
• Endoscopy (example diagnostic studies and
  treatment of stomach, colon and bladder )

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Definition of Terms

• Sedation and Analgesia describes 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.
• Monitoring is the measurement of physiologic
  parameters, including the use of mechanical
  devices as well as clinical observations. The RN
  may delegate this function.
• Assessment is the continuous, systematic
  collection, validation, and communication of
  patient data for the purpose of planning,
  implementing, and evaluating nursing care.
  Assessment is directed toward the attainment of
  specific patient outcomes. The RN should not
  delegate this function.
• Assistive personnel are staff without a nursing
  license (e.g., GI assistants, medical
  technicians, respiratory therapists) who have
  direct patient care responsibility and are
  supervised by an RN.

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Preprocedure evaluationPatient Evaluation

• strongly agreehistory, physical examination
  increases the likelihood of satisfactory sedation
  and decreases the likelihood of adverse outcomes
  for both moderate and deep sedation
• (1) abnormalities of the major organ systems
• (2) previous adverse experience with
  sedation/analgesia as well as regional and
  general anesthesia
• (3)drug allergies, current medications, and
  potential drug Interactions
• (4) time and nature of last oral intake and
• (5) history of tobacco, alcohol, or substance use
  or abuse

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Preprocedure Preparation

• Strongly agree that appropriate preprocedure
  counseling of patients regarding risks, benefits,
  and alternatives to sedation and analgesia
  increases patient satisfaction
• Guidelines for Preoperative Fasting
• (1) the target level of sedation
• (2) whether the procedure should be delayed
• (3) whether the trachea should be protected by
  intubation

Preprocedure Fasting Guidelines
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Problems with sedation (sedation and
procedure-related complications )

• Desaturation
• Arrhythmias
• Myocardial ischemic episodes
• O2 saturation less than 95
• premorbid cardio-respiratory disease
• Continuous electronic monitoring (oxygen
  saturation, electrocardiogram (ECG), non-invasive
  blood pressure (NIBP)
• Froelich F, Thorens J, Schwizer W -- Gastrointest
  Endosc 1997 451-9
• Alcain G, Guillen P. Predictive factors of oxygen
  desaturation during upper gastrointestinal
  endoscopy in nonsedated patients. Gastrointest
  Endosc 1998 48143-147

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Airway Assessment Procedures for Sedation
andAnalgesia
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Monitoring

• strongly agree monitoring level of
  consciousness reduces risks for both moderate and
  deep sedation
• be avoided if adverse drug responses are detected
  and treated in a timely manner i.e., before the
  development of cardiovascular decompensation or
  cerebral hypoxia
• Pulmonary Ventilation
• Oxygenation
• Hemodynamics

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Recording of Monitored Parameters

• (1) before the beginning of the procedure
• (2) after administration of sedative
• analgesic agents
• (3) at regular intervals ( 5-min) during the
• procedure
• (4) during initial recovery
• (5) just before discharge

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Pulmonary Ventilation

• Capnography, measurement of carbon dioxide
  retention, may be useful in prolonged cases

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Oxygenation

• strongly agree early detection of through the
  use of oximetry
• hypoxemia more likely to be detected by oximetry
  than by clinical assessment alone
• pitch beepalarms
• Supplemental Oxygen

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Hemodynamics

• Blunt the appropriate autonomic compensation for
  hypovolemia and procedure-related stresses or
  inadequate (hypertension, tachycardia)
• Response to verbal commands control his airway
  and take deep breaths
• young children, mentally impaired or
  uncooperative patients, oral surgery, upper
  endoscopy
• Continously EKG
• Blood pressure

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Arrhythmias -- sedation in the endoscopy

• five- to sixfold higher in patients with
  pre-existing cardiac disease
• endoscope size
• the presence of hypoxemia
• premorbid cardiorespiratory disease

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Emergency Equipment for Sedation andAnalgesia
(1)
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Emergency Equipment for Sedation andAnalgesia(2)
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Availability of Emergency Equipment

• Suction, appropriately sized airway equipment,
  means of positive- pressure ventilation
• Intravenous equipment, pharmacologic antagonists,
  and basic resuscitative medications
• Defibrillator immediately available for patients
  with cardiovascular disease

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Training of Personnel

• Strongly agree education and training
• (1) potentiation of sedative-induced respiratory
• depression by concomitantly administered
  opioids
• (2)inadequate time intervals between doses of
  sedative or analgesic agents, resulting in a
  cumulative overdose
• (3) inadequate familiarity with the role of
  pharmacologic antagonists for sedative and
  analgesic agents
• ACLS,BLS

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Combinations of SedativeAnalgesic Agents

• Equivocal regarding moderate sedation
• Deep sedation, satisfactory Intravenous
  combinations of sedativeanalgesic agent
• Fixed combinations of sedative and analgesic
  agents may not allow
• Appropriately titrated strongly agree that
  incremental drug administration improves patient
  comfort and decreases risks

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Drugs used in conscious sedation for endoscopy
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Benzodiazepines

• the majority of endoscopic procedures
• relaxation , cooperation and anterograde amnesia
  
• titrated
• respiratory depression
• synergistically increased with the use of
  intravenous opiates, the midazolam dose should be
  reduced by 30
• 0.5-2 mg given slowly intravenously
• repeating doses every 2 to 3 minutes
• total dose is 2.5 to 5 mg

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Midazolam-Induced Sedation for Upper
Gastrointestinal Endoscopy Assessment of
Endoscopist and Patient Satisfaction

• 352 patients upper gastrointestinal endoscopy
  were sedated with midazolam given
• Ages of the patients ranged between 16 and 79
  years (average 41.6 12.7 years).
• Anterograde memory was found in 310 (88.0)
• 342 patients (98.0) cooperated well
• Side effects were rarely seen (3.6), and
  included nausea, vertigo, and vomiting
• Acceptability of further endoscopy in 338
  (96.0)
• No significant cardiopulmonary problems
• Gastroenterology Nursing Volume 26(4)
  July/August 2003 pp 164-167

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• Most patients and endoscopists prefer some form
  of premedication be given (Bell, 1990)
• Intravenous diazepam or midazolam have been used
  by the majority of endoscopists (Wille et al.,
  2000)
• Midazolam quickly gained popularity after it was
  introduced in the mid-1980s (Zakko, Seifert,
  Gross, 1999)
• Many endoscopists prefer midazolam for conscious
  sedation because it has short duration of action
  and efficient amnesic effect (Whitwam,
  Al-Khudhairi, McCloy, 1983Wille et al., 2000)
• Midazolam was accused of more than 40
  sedation-related deaths, which made its safety in
  the setting of conscious sedation questionable
  (Zakko et al., 1999). These adverse events may
  have been related to the fact that when midazolam
  was first used

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Opiates --Fentanyl

• Pain threshold, alters pain reception, and
  inhibits ascending pain pathways
• Sedation is 25 to 50 µg, repeated every 1 to 2
  minutes
• Total dose is 50 to 200 µg
• Half-life is 2 to 4 hours

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Opiates --Meperidine

• pain threshold, alters pain reception, and
  inhibits ascending pain pathways
• sedation is routine procedures is 50 to 100 mg

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Reversal Agents

• Naloxone and flumazenil available whenever
  opioids or benzodiazepines administered

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Special Considerations

• Age gt60 years
• Inability to cooperate
• Significant developmental delay
• Severe comorbidity (e.g., cardiac, pulmonary,
  hepatic, renal, or central nervous system
  disease)
• Morbid obesity
• History of sleep apnea

• History of drug or alcohol abuse
• Pregnancy
• Emergency procedure with lack of patient
  preparation
• Airway anomalies

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Recovery Criteria after Sedationand Analgesia

• 1. Medical supervision of recovery and discharge
  after moderate or deep sedation is the
  responsibility of the operating practitioner or a
  licensed physician.
• 2. The recovery area should be equipped with, or
  have direct access to, appropriate monitoring and
  resuscitation equipment
• 3. Patients receiving moderate or deep sedation
  should be monitored until appropriate discharge
  criteria are satisfied .The duration and
  frequency of monitoring should be individualized
  depending on the level of sedation achieved .the
  overall condition of the patient, and the nature
  of the intervention for which sedation/analgesia
  was administered. Oxygenation should be monitored
  until patients are no longer at risk for
  respiratory depression

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Recovery Criteria after Sedationand Analgesia

• 4.Recovery area once vital signs are stable and
  the patient has reached an appropriate level of
  consciousness. Level of consciousness, vital
  signs, and oxygenation (when indicated) should be
  recorded at regular intervals.
• 5. A nurse or other individual trained to monitor
  patients and recognize complications should be in
  attendance until discharge criteria are
  fulfilled.
• 6. An individual capable of managing
  complications (e.g. establishing a patent airway
  and providing positive pressure ventilation)
  should be immediately available until discharge
  criteria are fulfilled

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Guidelines for discharge

• 1. Patients should be alert and oriented infants
  and patients whose mental status was initially
  abnormal should have returned to their baseline
  status. Practitioners and parents must be aware
  that pediatric patients are at risk for airway
  obstruction should the head fall forward while
  the child is secured in a car seat.
• 2. Vital signs should be stable and within
  acceptable limits.
• 3. Use of scoring systems may assist in
  documentation of fitness for discharge.
• 4. Sufficient time (up to 2 h) should have
  elapsed after the last administration of reversal
  agents (naloxone, flumazenil) to ensure that
  patients do not become resedated after reversal
  effects have worn off.
• 5. Outpatients should be discharged in the
  presence of a responsible adult who will
  accompany them home and be able to report any
  postprocedure complications.
• 6. Outpatients and their escorts should be
  provided with written instructions regarding
  postprocedure diet, medications, activities, and
  a phone number to be called in case of emergency.

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Discharge criteria after sedation
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Evidence-Based Medicine

• A focused history and physical is required prior
  to the administration of moderate sedation. (C)
• Routine monitoring of the patients pulse rate,
  blood pressure, oxygen saturation are useful in
  identifying early problems. (B)
• Monitoring of EKG recordings may be helpful in
  selected cases. (C)
• Capnography, measurement of carbon dioxide
  retention, may be useful in prolonged cases. (A)
  
• The use of benzodiazepines and/or opiates will
  result in a satisfactory outcome in nearly all
  patients. (B)
• Endoscopists prefer the combination of these
  drugs, but it adds little benefit from the
  patient's viewpoint. (A)
• (A), Prospective controlled trials.
• (B), Observational studies.
• (C), Expert opinion

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