Procedural Sedation by Non-Anesthesia Providers

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Procedural Sedation by Non-Anesthesia Providers

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Learner Outcomes

• Identify sedation levels according to the Joint
  Commissions definitions
• Describe anticipated patient responses for each
  level of sedation
• List the required pre-procedural patient
  assessments
• Describe the components of an airway assessment
• Indentify the required assessments and
  monitoring parameters during
• procedural sedation
• Identify appropriate medications for procedural
  sedation
• Identify the role for reversal agents and
  describe monitoring parameters
• List the common complications associated with
  procedural sedation
• Discuss the management of the common
  complications
• Recognize the components of post-procedural
  assessment and care
• Identify the required criteria for patient
  discharge after receiving
• procedural sedation

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• What is Procedural Sedation?

• Procedure A series of steps taken to accomplish
  an end.
• Examples EGD, bronchoscopy, fracture/dislocation
  
• reduction, cardiac catheterization
• Sedation Reduction of anxiety, stress,
  irritability, or
• excitement through the administration of a
  sedative agent
• or drug
• Procedural Sedation Reducing anxiety or stress
  with
• medications in order to perform a procedure.
  These
• medications may include, but are not limited to
  Opiates
• (e.g., morphine, fentanyl) and Benzodiazepines
  (e.g.,
• midazolam, lorazepam)

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• Objectives of Procedural Sedation

• Maintain adequate sedation with minimal risk
• Provide relief from pain and other noxious
  stimuli
• Relieve anxiety and produce at least partial
  amnesia
• Preserve modesty
• Prompt and safe return to activities of daily
  living
• For many procedures, procedural sedation has
  replaced the use of
• general anesthesia because it
• ? Is easier on the patient
• ? Reduces potential complications

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• Definitions Four Levels of Sedation and
• Anesthesia (per TJC)

• Minimal sedation (anxiolysis)
• A drug-induced state during which patients
  respond normally to verbal commands. Although
  cognitive function and coordination may be
  impaired, ventilatory and cardiovascular
  functions are unaffected.
• ? Patient is fully responsive

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Definitions Four Levels of Sedation and
Anesthesia (per TJC)

• Moderate sedation
• A drug-induced depression of consciousness
  during which patients respond purposefully to
  verbal commands, either alone or accompanied by
  light tactile stimulation. No interventions are
  required to maintain a patent airway, and
  spontaneous ventilation is adequate.
  Cardiovascular function is usually maintained.
• ? Stable vital signs, intact airway
• ? Responds to verbal stimulation may utilize
  light touch to support verbal stimulation
• ? Follows simple commands

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Definitions Four Levels of Sedation and
Anesthesia (per TJC)

• Deep sedation
• A drug-induced depression of consciousness during
  which patients cannot be easily aroused but
  respond purposefully following repeated or
  painful stimulation. The ability to
  independently maintain ventilatory function may
  be impaired. Patients may require assistance in
  maintaining a patent airway and spontaneous
  ventilation may be inadequate. Cardiovascular
  function is usually maintained.
• ? Responds to repeated or painful stimulation
  
  
• ? Does not follow commands but may can move
  spontaneously
• Respiratory depression is possible may
  include decreased
• respiratory rate and/or difficulty
  maintaining an open airway
• ? BP and pulse remain stable

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Definitions Four Levels of Sedation and
Anesthesia (per TJC)

• Anesthesia
• Consists of general anesthesia and spinal or
  major regional anesthesia. It does not include
  local anesthesia. General anesthesia is a
  drug-induced loss of consciousness during which
  patients are not arousable, even by painful
  stimulation. The ability to independently
  maintain ventilatory function is often impaired.
  Patients often require assistance in maintaining
  a patent airway, and positive pressure
  ventilation may be required because of depressed
  spontaneous ventilation or drug-induced
  depression of neuromuscular function.
  Cardiovascular function might be impaired.
  
• ? Depression of life sustaining functions (may
  include respiratory depression and/or change in
  BP and pulse)
• ? No response to stimulation, even painful
  stimulation

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• Sedation Continuum Movement from one level of
  sedation to another is
• a dose-related continuum that depends on patient
  response

MINIMAL SEDATION (ANXIOLY SIS) MODERATE SEDATION DEEP SEDATION ANESTHESIA
Responsiveness Normal response to verbal stimulation Purposeful response to verbal or tactile stimulation Purposeful response following repeated or painful stimulation Unarousable even with painful stimulus
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

• Sedation level is dependent on patient response
  NOT external factors or type, dose, route of
  medication.

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• Procedural Sedation is NOT

• Chemical Restraint Medication given for
  behavioral management or to restrict the
  patient's freedom of movement and is not a
  standard treatment for the patient's medical or
  psychiatric condition
• Pain Control Although some of the same
  medications are given for pain control, the
  intent of the intervention is different
• Anxiolysis A medication given to relax the
  patient
• Additional information Side rails are NOT
  restraints when used as safety precautions during
  procedural sedation as long as the DOCUMENTATION
  is there! Can be up on carts for procedure and
  recovery period, then removed!

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• Procedural Sedation by Non-Anesthesia Providers

• Moderate Sedation Procedural Sedation
• Policy is applicable throughout the institution
  (See BJWCH policy)
• Applicable to all health care providers when
  anesthesia personnel
• not present.
• Proceduralist
• Physician, Dentist, or Podiatrist
• Person performing the procedure
• Hospital Privileges must include Procedural
  Sedation
• Assistant
• A credentialed Registered Nurse
• The person who monitors the patient during the
  procedure
• Some situations require more than one
  assistante.g. one
• person to assist the Proceduralist and one to
  solely monitor the
• patient

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• The person monitoring the patient and/or the
  person performing the procedure (Proceduralist)
  must be prepared and competent to treat one level
  lower than the anticipated sedation level.
• The most common indication the patient may be
  beyond moderate sedation into deep sedation is
  respiratory depression, frequently identified
  through a drop in pulse oximetry (Sp02 ).
• If the patient develops significant respiratory
  depression, the Proceduralist and Assistant must
  be prepared to support the patient's airway
  through the use of oral/nasal airways and
  bag-mask ventilation. In addition, the
  Proceduralist must be prepared to insert a
  definitive airway i.e., endotracheal intubation
  or laryngeal mask airway (LMA).

• Properly inserted LMA

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• Assistant Responsibilities
• Patient assessment and interventions
• Appropriate documentation throughout the
  procedure
• ? Reassure patient and monitor patient awareness
  and responses.
• ? Provide comfort measures as needed
• ? Notify Proceduralist of changes/concerns
• ? Documentation of required parameters

• The Assistant is not to leave patient bedside for
  any reason during the procedure (although may
  assist the Proceduralist with short interruptible
  tasks). The assistant must be able to drop those
  tasks if the patient needs attention)

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Pre-Procedural Assessment Steps Include

• Informed Consent (risk, benefits, alternatives
  for both procedure sedation)
• Physical Assessment
• Based on Health History and Review of Systems
• Focused Assessment includes basics
• Heart Lung
• Whatever else is appropriate
• Airway Assessment
• Dentures, loose teeth
• Inability to open mouth
• Cervical arthritis/kyphosis
• Other Structural issues
• Prepare for the possibility of airway
• management issues
• Home/Present Medications
• Planned Level of Sedation
• Identified Risk Level (ASA PS Score)
• Site Marking

Mallampati Scoring
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• Responsible Individual for Discharge

Patient is accompanied by a responsible adult at
discharge

• The person who will provide the patients ride
  home and be available to
• the patient after the procedure must be
  identified before the procedure begins
• For outpatients, this person frequently
  accompanies the patient to the hospital
• If the responsible individual is not present,
  hospital staff need to verify
• the individual by telephone
• If the patient is an inpatient, it might not be
  necessary to identify this
• individual pre-procedure. If the inpatient is
  discharged within 24 hours
• of the procedure, the patient must be discharged
  to a responsible individual
• For outpatients If either the Proceduralist
  (person performing the procedure)
• or the Assistant (person monitoring the patient)
  believes the individual would
• not be appropriate for this role or the patient
  has no one identified, the
• Proceduralist will determine
• ? Can the procedure be cancelled/postponed until
  a responsible individual is available?
• ? Should the procedure be completed and the
  patient kept an additional 4 hours after

• 1r

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Informed Consent

• The person performing the procedure
  (Proceduralist) is to review
• the objectives, risks, benefits of both the
  procedure and the
• plan for sedation
• May be completed at the same time the
  procedure consent is
• obtained
• Informed consent for the sedation does not
  require a patient
• signature, but is completed by checking the
  box on the Pre-
• Procedure/Pre-Sedation Assessment Form. If
  paper forms are
• not available, it is the responsibility of
  the Proceduralist to
• document the patients consent for sedation
  in the pre-procedure note
• If the patient has questions, the
  Proceduralist will be contacted
• to answer patient questions before consent
  is signed (witnessed)

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Assess NPO Status

• Adult patients undergoing sedation for elective
  procedures may not eat solid foods or drink
  non-clear fluids for six hours before
  administration of sedation. Patients may have
  clear liquids up to two hours before the
  procedure
• Options for the patient not within these
  guidelines Cancel or postpone the procedure
• In urgent, emergent, or other situations when
  gastric emptying is impaired, the clinician may
  proceed with the procedure after considering the
  potential for pulmonary aspiration of gastric
  contents, the nature of the intervention, and the
  degree of sedation

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• Risk Assessment American Society of
  Anesthesiologist (ASA)
• PS (Physical Status) Classification
• ASA PS correlates with overall risk
• Needs to be used as a tool along with other
  factors such as type of procedure, medications,
  and
• clinician comfort

Definition Details Examples
ASA PS 1 A normal healthy patient Healthy individual with no systemic disease and undergoing elective surgery. Patient not at extremes of age. (Note Age is often ignored as affecting operative risk however, in practice, patients at either extreme of age are thought to represent increased risk). A fit patient with inguinal hernia. Fibroid uterus in an otherwise healthy woman.

ASA PS 2 A patient with mild systemic disease Individual with one system and well-controlled disease. Disease does not affect daily activities. Other anesthetic risk factors, including mild obesity, alcoholism, and smoking can be incorporated at this level. Non-limiting or only slightly limiting organic heart disease. Mild diabetes Essential hypertension Anemia


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• Risk Assessment ASA PS (Physical Status)
  Classification (continued)

Definition Details Examples
ASA PS 3 A patient with severe systemic disease Individual with multiple system disease or well controlled major system disease. Disease status limits daily activity. However, there is no immediate danger of death from any individual disease. Severely limiting organic heart disease. Severe diabetes with vascular complications. Moderate to severe degrees of pulmonary insufficiency. Angina pectoris or healed myocardial infarction.

ASA PS 4 A patient with severe systemic disease that is a constant threat to life Individual with severe, incapacitating disease. Normally, disease state is poorly controlled or end-stage. Danger of death due to organ failure is always present. Organic heart disease showing marked signs of cardiac insufficiency. Persistent anginal syndrome or active myocarditis. Advanced degrees of pulmonary, hepatic, renal, or endocrine insufficiency.


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• Risk Assessment ASA PS (Physical Status)
  Classification (continued)

Definition Details Examples
ASA PS 5 A moribund patient not expected to survive (24 hours) Patient who is in imminent danger of death. Operation deemed to be a last resort attempt at preserving life. Patient not expected to live through the next 24 hours. In some cases, the patient may be relatively healthy prior to catastrophic event, which led to the current medical condition. Burst abdominal aneurysm with profound shock Major cerebral trauma with rapidly increasing intracranial pressure Massive pulmonary embolus

ASA PS 6 A declared brain-dead patient/organ donor

• "E" is added to the ASA PS number when the
  procedure is done on an emergency basis. This
  indicates that there is an increased risk due to
  the emergence of the patient's condition,
  preparation, or required procedure.

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• Prevent Wrong Site / Wrong Patient/
• Wrong Limb / Wrong Equipment

• Site Verification Marking is done by
• marking "YES on the procedure site
• Responsibility of the Proceduralist
• Site marking is required for cases involving
  right/left distinction, surfaces
  (flexor/extensor) multiple structures (such as
  fingers, toes) or multiple lesions, wounds, or
  levels (such as the spine)
• Completed before the procedure begins
• Marking should include the patients input,
  verification, and understanding

• For more information, see the BJWCH policy
  Universal Protocol for Preventing Wrong Site,
  Wrong Procedure, and Wrong Person Surgery

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Preparation for the Procedure

• Obtain IV access
• Have emergency/resuscitative equipment
  immediately available
• Method of Positive Pressure Ventilation--Ambu
  Bag
• Laryngoscope/ET Tubes
• Emergency Drugs (especially reversal agents)
• Oxygen delivery devices Functioning Suction
• Crash Cart / Respiratory Box
• Patient Monitors
• Noninvasive blood pressure machine
• Cardiac Monitor
• Pulse Oximetry / Capnography (optional)
• Perform the Time Out

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Prevent Wrong Site / Wrong Patient Wrong Limb /
Wrong Equipment
COMPLETE THE TIME OUT!
The Time Out is
completed immediately before the first dose of
sedation/start of the procedure All
members of the procedural team will verbally
acknowledge their agreement to the following
elements as applicable to the procedure
? Patient
identity ? Procedure to be done ? Confirmation
that correct site/side is marked and visible ?
Correct patient position ? Consent form
accurately and correctly completed ? Relevant
image/test results correctly labeled and
displayed ? The need to administer antibiotics
or fluids for irrigation purposes ? Any safety
precautions based on patient history or
medication use
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• Intra-Procedural Monitoring Requirements

• ? REQUIRED - documentation at least every 10
  minutes, or more frequently if indicated
• BP
• Pulse
• Respiratory Rate
• SpO2 (Continuous Pulse Oximetry)
• Sedation Level (RASS)
• End Tidal CO2 Capnography (optional)
• REQUIREDCardiac Monitoring
• Assistants (Procedural Sedation
  Credentialed RNs) will be able to utilize
• rhythm interpretation as a tool to
  identify when more in-depth patient
• assessment is required
• ? Example 1 Heart rate drops assistant
  may stimulate patient, check BP, etc.
• ? Example 2 Heart rate accelerates
  assistant may ask patient about comfort level
  
• Assistants should notify the clinician for
  any noticeable changes in rhythm,
• rate, or other concerns noted on monitor
  for further medical direction.

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• Intra-Procedure Monitoring Requirements

• Level of Sedation
• Assessed with vital signs and documented
• Richmond Agitation Sedation Scale (RASS) used for
  sedation assessment
• Richmond Agitation Sedation Scale (RASS)

Score Term (this column is not included on forms) Description
4 Combative Overtly combative, violent, immediate danger to staff
3 Very agitated Pulls or removes tubes(s) or catheter(s), aggressive
2 Agitated Frequent, non-purposeful movement. Fights ventilator
1 Restless Anxious but movements not aggressive, vigorous
O Alert and Calm Alert and Calm
-1 Drowsy Not fully alert but has sustained awakening (eye opening/eye contact to voice, gt 10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice, lt10 seconds
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice but movement or eye opening to physical stimulation
-5 Unarousable No response to voice or physical stimulation
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Types of Complications

• Complication Causes Generally due to over dosage
  of sedative and analgesic drugs. May also may be
  due to drug-drug interaction. Consider patient
  age, medical history and size
• Types of Complications
• Respiratory depression resulting in hypoxemia
  and /or hypercarbia
• May show as a drop in O2 Saturation or
  Respiratory Rate
• May be related to a changing level of sedation,
  i.e. going from Moderate Sedation
• to Deep Sedation
• Cardiovascular depression Hyper- or
  hypotension, brady- or tachycardia
• Observe trends in blood pressure and pulse
• Proceduralist is to be notified if cardiac
  rhythm changes
• Aspiration
• Silent regurgitation is more likely to happen
  when the patient is over sedated
• Only evidence may be changes in oxygen
  saturation, changes in breath
• sounds, or skin color

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Treatment for Potential Complications

• Respiratory depression
• Stimulate the patient (may be all thats needed)
• Chin Lift
• Oral/Nasal Airway
• Oxygen-increase flow if already on O2
• Positive Pressure Ventilation (bag-valve mask)
• Consider use of emergency equipment (LMA, ET
  tube)
• Consider use of reversal agent
• Call Anesthesia
• Aspiration
• Suction
• Consider intubation
• Chest X-ray
• Bronchoscopy if particulate matter
• For any complication, consider ACLS Guidelines

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Treatment for Potential Complications

• Hemodynamic instability
• Consider fluid bolus/increase IV fluids
• If patient is bradycardic, consider giving
  Atropine (0.5mg IV Push)
• Vasopressors (e.g. dopamine)
• Antihypertensives (e.g. nitroprusside)
• Monitor respiratory status and oxygenation
• Consider use of reversal agent
• ACLS Protocols
• For any complication, consider ACLS Guidelines
• or calling a RRT/Code (x8444)

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• Procedural Sedation
• Pharmacologic Considerations

• 3f)

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• Medication Classes Used for Sedation

• Opiates
• ? Pain control
• ? Give medications only allowed by the IV
  Medication Administration Policy
• Benzodiazepines
• ? Sedation
• ? Watch times of onset. Midazolam IV Push has
  onset of 3-5 minutes.
• Lorazepam IV Push takes 10-20 minutes
• Both opiates and benzodiazepines are frequently
  administer together
• Synergist action on the level of consciousness
  and respiratory depression
• If the patient is in pain, it is helpful to give
  analgesics first. As the pain decreases, the
  patient may more easily respond to sedatives
• Pain may not be present before the procedure but
  most procedures are
• uncomfortable
• Have reversal agents readily available
• ? Remember, reversing benzodiazipines does not
  necessarily reverse respiratory depression
• ? When reversal agents are given, the patient
  must be monitored a minimum of 1 hour after the
  reversal due to possibility of re-sedation

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• Choosing Appropriate Medications
• Agents should be chosen based on the desired
  pharmacological response.
• Depending on the particular agent, one, two, or
  all three of the effects below can be achieved
• Anxiolysis
• Analgesia
• Amnesia
• Adverse effects - The potential side effects of
  any medication in a particular patient must be
  considered. Many sedative agents can produce
  cardiac or respiratory depression
• Pharmacokinetic Considerations - When selecting a
  sedative, the following
• Pharmacokinetic parameters should be considered
  to optimize response in a given situation
• Onset and Duration
• Elimination Route
• Accumulation
• Drug Interactions/Potentiations
• Cross-Tolerance (e,g. patients with prior opiate
  use may require higher doses of opiates. Those
  with prior ethanol exposure may require larger
  doses of benzodiazepines, etc)

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Pharmacokinetics-Route of Elimination
Hepatic Renal
Diazepam Midazolam Lorazepam Fentanyl Meperidine Morphine Propofol Diazepam metabolites Midazolam metabolites Morphine metabolites Meperidine metabolites

• Critical thinking question How would dosages
  change if the patient has liver or kidney
  insufficiency?

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Drug Interactions

• CYP3A4 Inhibitors
• ? Azole antifungals
• ? Diltiazem
• ? Verapamil
• ? Protease inhibitors
• ? Macrolides
• ? Nefazodone
• ? Quinupristin-dalfopristin
• Drug Affected
• ? Midazolam

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• Opioid Cross-Allergenicity

Morphine-like Meperidine-like
Morphine Meperidine
Hydromorphone Fentanyl
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• Opioids Equipotent Doses

Drug Dose (mg)
Fentanyl 0.1
Hydromorphone (Dilaudid) 1.5
Morphine 10
Meperidine (Demerol) 75
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Benzodiazepines

• Cautions
• Consider Dose Adjustments
• Lower doses require in elderly, debilitated or
  chronically ill
• patients
• Patient who receive concomitant opiates should
  have the
• dose reduced by 30-50
• Benzodiazepines are cross-tolerant with
  alcohol, higher
• doses may be required to achieve sedation in
  current heavy
• drinkers.
• Examples of Benzodiazepine Medications
• Midazolam (Versed)
• Valium (Valium)

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Midazolam (Versed)

• Onset 1-5 minutes
• Usual Duration 30-120 minutes (dose-dependent)
  
• Elimination Route Hepatic
• Dose lt60 years 1-2 mg slow IV push. May
  repeat q2 min prn max 0.1 mg/kg (10
  mg)/hour
• gt60 years or debilitated 0.5 mg slow IV push.
  May repeat q3 min prn max 0.05 mg/kg (5 mg)/h
• Dose Adjustment Lower doses by 30-50 in
  elderly, debilitated, severe hepatic impairment,
  chronically ill, or patients receiving
  concomitant opiates.
• Potential Adverse Effects Respiratory
  depression, apnea, respiratory arrest,
  hypotension, tachycardia, inability to maintain
  airway

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Diazepam (Valium)

• Onset 3-10 minutes
• Usual Duration 6-8 hours
• Elimination Route Hepatic
• Dose 2-5 mg slow IV push. May repeat dosage
  q10 min prn max 0.1-0.2 mg/kg (10mg)
• Concerns Irritating to veins, Significant
  accumulation can occur, hypotension and
  bradycardia may occur with rapid injection
• Potential Adverse Effects Respiratory
  depression, apnea, respiratory arrest,
  hypotension, tachycardia, inability to maintain
  airway

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Opiate Analgesics

• Examples of Opiate Analgesics Include
• Fentanyl (Sublimaze)
• Morphine

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Fentanyl (Sublimaze)

• Onset 1-2 minutes
• Usual Duration 3060 minutes
• Elimination Route Hepatic (inactive
  metabolites)
• Dose 25-50 mcg/dose slow IV push. May repeat
  q3-5 min prn max 500 mcg/4 hours. Rapid I.V.
  infusion may result in skeletal muscle and chest
  wall rigidity, impaired ventilation, or
  respiratory distress/arrest nondepolarizing
  skeletal muscle relaxant may be required.
• Half Life 2-4 hours
• Notes Rapid onset sedative and analgesic
  effect, synergy with benzodiazepines, minimal
  histamine release (less hypotension than
  morphine)
• Concerns Tolerance develops, Accumulates over
  time
• Potential Adverse Effects Respiratory
  depression, apnea, respiratory arrest,
  hypotension, tachycardia, inability to maintain
  airway, bradycardia.

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Morphine

• Onset 5-10 minutes with a peak at 20 minutes
• Usual Duration 2-4 hours (prolonged in elderly
  with
• hepatic dysfunction)
• Elimination Route Hepatic
• Dose 1-2 mg slow IV push. May repeat dosage
  q3-5 min prn max 20 mg
• Concerns Hypotension due to histamine release,
  may accumulate, tolerance develops, decreases GI
  motility
• Potential Adverse Effects Respiratory
  depression, apnea, respiratory arrest,
  hypotension, tachycardia, nausea/vomiting,
  inability to maintain airway

42
Other Agents

• Examples of Other Agents Use for Sedation
  Include
• Ketamine (Ketalar)
• Propofol (Diprivan)

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Ketamine (Ketalar)

• Onset within 1 minute
• Duration 10-15 minutes
• Dosage 0.2-0.75 mg/kg slow IV push over 1-2
  minutes
• Half Life 45 minutes
• Elimination Hepatic and excreted in the urine
  and feces
• Notes Should be administered with a
  benzodiazepine to decrease emergence reactions
  including vivid dreams, hallucinations, and/or
  delirium. Assistant should have no other
  dutiesonly monitoring the patient. Patients
  should be monitored a minimum of one hour after
  completion of the procedure
• Potential Adverse Effects Tachycardia, systemic
  and pulmonary hypertension, hallucinations, vivid
  dreams, delirium

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Propofol (Diprivan)

• Onset less than 1 minute
• Duration 3-10 minutes
• Dosage 1 mg/kg slow IV push. May repeat with
  0.5 mg/kg q3-5 minutes prn
• Half Life 40 minutes
• Elimination Hepatic
• Notes Rapid onset sedative with NO analgesic
  effect. Tolerance develops, urine turns green
• Potential Adverse Effects Respiratory
  depression, apnea, respiratory arrest,
  hypotension, inability to maintain airway

BJWCH RNs may not administer an IV bolus of
Propofol for Procedural Sedation. If this agent
is used, the Proceduralist must administer the
bolus.
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Etomidate (Amidate)

• Onset less than 1 minute
• Duration 3-5 minutes
• Dosage 0.1-0.2 mg/kg slow IV push over 30-60
  sec. May repeat with
• 0.05 mg/kg q3-5 minutes prn
• Elimination Hepatic
• Potential Adverse Effects Commonly causes
  myoclonus, pain upon injection, adrenal
  suppression (typically no clinical significance
  unless repeated doses are used within a limited
  time span) may cause nausea, vomiting, and lower
  seizure threshold does not alter hemodynamics
  causes a slight to moderate decrease in
  intracranial pressure that only lasts for several
  minutes does not cause histamine release useful
  for patients with trauma and hypotension

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• Reversal Agents

Naloxone (Narcan) Flumazenil (Romazicon)
Reverses Opiates Benzodiazepine
Dosing 0.4-2 mg q 2-3 min, up to 10 mg 0.2 mg q 1 min, up to 1 mg
Onset 1-2 min 1-2 min
Duration 30-60 min 30-90 min
Adverse Effects Can precipitate withdrawal, pulmonary edema Seizures Reversing BZD-induced hypoventilation has not been established
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• Post-Procedural Requirements

• Procedural Orders
• Orders given orally throughout the procedure
  must be
• written in the patient medical record or
  entered via
• computerize provider order entry (CPOE)
• If the assistant is utilizing handwritten
  documentation
• forms, the Proceduralists signature, date,
  and time must be
• included on the bottom of the monitoring
  form.
• A post-procedural note must be documented in
  the patients
• medical record
• Monitoring Requirements
• Blood Pressure, Pulse, Respiratory Rate, and
  SpO2 are to be
• documented every 10 minutes (more frequently,
  if indicated)
• An Aldrete Score must be completed upon
  completion of the
• procedural and with each vital sign
  documentation during the
• recovery period

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ALDRETE POST PROCEDURE RECOVERY SCORE
A Baseline Pre-Procedural Aldrete Score must be
obtained before sedation is initiated, because
the Post-Procedural Aldrete Scores are compared
to the baseline score A Post- Procedural Aldrete
Score is obtained at the end of the procedure and
then repeated every 10 minutes until the patient
meets discharge criteria. To meet discharge
criteria, a minimum of two (2) consecutive
Aldrete Scores AFTER the end of the procedure
must be at the baseline score or the baseline
score minus one with stable vital signs
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Discharge Criteria
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• Discharge Criteria (cont.)

• In the event that reversal agents (naloxone,
  flumazenil)
• were used, allow a minimum timeframe of 1 hour
  after the
• last dose to ensure that the patient does not
  become re-
• sedated after reversal effects have abated
• Patients who will be discharged to home and
  received IV
• medications for relief of pain, nausea,
  and/or vomiting, etc.
• must be observed for no less than two (2)
  Aldrete/vital sign
• assessments following the administration of
  such medication
• Critical thinking If the patient has
  liver/kidney
• insufficiency, metabolism and/or excretion
  of the drugs
• might be impaired. This might prolong the
  effect of the
• drug(s) resulting in a need for longer
  recovery-area time

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• Discharge Instructions

• Discharge Instructions Need to Include
• Purpose and expected effects of sedation
• Patient's post-discharge care
• Emergency phone number
• Post-discharge Medications
• Dietary/activity restrictions
• No driving for 24 hours
• Avoid alcohol for 24 hours
• Other instructions appropriate for the procedure

52

• References
• Anesthesiology Critical Care Drug Handbook.
  (2011). (10th Ed.). Hudson, OH Lexi-Comp,
  Inc.
• ASA (2002). Practice Guidelines for Sedation and
  Analgesia by Non-Anesthesiologists.
  Anesthesiology 2002 961004-1017.
• Department of Health and Senior Services (DHSS)
  Centers for Medicare and Medicaid Services (CMS)
  Conditions of Participation Anesthesia Services.
• The American College of Emergency Physicians
  (ACEP) (Nov 8, 2011) Medscape Reference
  http//emedicine.medscape.com/article/109695-overv
  iew.
• The Joint Commission (2011) Comprehensive
  Accreditation Manual for Hospitals.

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