Published on February 3, 2014
Procedural Sedation By Sandy McLellan, RN, CGRN Norman Endoscopy Center
primun non nocere First, Do No Harm
• • • • • • OBJECTIVES Understand levels of procedural 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
These patients and their safety are in our hands • • • • We must screen We must monitor We must have procedures in place to correct We must be prudent in our sedation and zealous in our monitoring
Levels of Sedation • Minimal Sedation (anxiolysis) – First or lower level of sedation – A drug-induced state during which patients respond normally to verbal commands – Although cognitive function and coordination function may be impaired, ventilatory and cardiovascular functions are unaffected
Moderate Sedation / Analgesia • Also called Conscious 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.
Deep Sedation / Analgesia • A drug-induced depression of consciousness during which patients cannot be easily aroused by repeated or painful stimulation. Reflex withdrawal from a painful stimulus is not considered to be purposeful response • The ability to independently maintain ventilatory function may be impaired • Patients may require assistance in order to maintain a patent airway • Spontaneous ventilation may be inadequate • Cardiovascular function is usually maintained
General Anesthesia • Deepest level of sedation • A drug-induced depressed level of consciousness where patients are NOT arousable, even with painful stimuli • Airway often requires intervention and spontaneous ventilation is often inadequate. • Cardiovascular function may be impaired.
Continuum of Depth of Sedation Minimal 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 *Reflex withdrawal from a painful stimuli is NOT considered a purposeful response 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.
Who Can Administer Sedation? • Oklahoma Board of Nursing regulates which nurses can administer sedation in the state of Oklahoma – An LPN cannot administer sedation medications but can monitor a patient who has been sedated – An trained RN can administer minimal and moderate sedation under the direction of a licensed physician. Must maintain current BLS and ACLS certification. They should not administer deep sedation and the OBN clearly states that they cannot administer anesthesia – Anesthesia can only been administered by licensed CRNA
What are the responsibilities of sedation nurse? • Assessment: VS, LOC, 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
Intra-Procedure Sedation Nurse Responsibilities • Do “time out” just prior to procedure. Utilize Safe Surgery Checklist to ensure necessary checks have occurred • Have no other responsibilities other than monitoring the patient • Administer meds by following procedure policy recommendations, in small, incremental doses, titrate to effect • Administer Oxygen as needed/ordered • VS, LOC at least every 5 minutes • Document response to meds, complications, interventions, etc.
Post-procedure Sedation Nurse Responsibilities • Ensure all procedural documentation is completed • Take patient to recovery room, when stable • Document patient assessment upon arrival to recovery room • Give report to nurse assuming patient’s care
What Equipment Do I Need? • • • • • • • • Oxygen Suction Ambu-bag Airways Crash cart with AED Sedation medications Reversal agents Monitoring devices – – – – Pulse oximeter B/P cuff Cardiac monitor CO2 monitor (with anesthesia)
Medications used for Sedation • • • • Versed (midazolam) Fentanyl (sublimaze) Demerol (meperidine) Diprivan (propofol)
Versed (midazolam) • • • • • • • • Water soluable Amnesic effect Reduces anxiety No analgesic properties Painless on injection Respiratory depression Initial dose 1 – 2 mg Onset of action (1 – 2 minutes) • Peaks 3-4 minutes • Short acting (duration of 15-80 minutes) • Resedation is unlikely • Reversal agent is Romazicon (flumazenil)
Fentanyl (sublimaze) • • • • Initial dose 50–100mcg Onset of action 1–2 minutes Peaks 3–5 minutes Duration of effect 30-60 minutes • Analgesic; no amnesic properties • Respiratory depressant; may cause episodes of apnea • The respiratory depression may last longer than the analgesic effects. • Overdose or rapid administration can lead to respiratory depression, apnea, rigidity and bradycardia; if these remain untreated, respiratory arrest, circulatory depression or cardiac arrest • Reversal agent: Narcan (naloxone)
Demerol (meperidine) • Analgesic property for moderate to severe pain • Initial dose: 25-50 mg • Additional doses: 25mg every 2-5 minutes titrated to effect • Onset: 3-6 minutes • Peak: 6-7 minutes • Duration: 60-180 min. • Reversal agent: Narcan (naloxone) • Depresses cough reflex • Can cause respiratory depression and CNS depression • Contraindicated for people who take MAO inhibitors • Often causes nausea and vomiting in patients • Overdose or rapid administration can lead to respiratory depression, apnea, rigidity and bradycardia; if these remain untreated, respiratory arrest, circulatory depression or cardiac arrest
Diprivan (propofol) • Loss of consciousness usually occurs within Peaks in 90 seconds • Given in procedure atmosphere (short duration), the effects usually wear off in 10 to 15 minutes • No analgesic properties • No amnesia properties • Respiratory depressant, frequently causes apneic episodes that last over 60 seconds. • Unless totally unconscious they do not lose their hearing. • The most significant adverse effect of propofol is hemodynamic destabilization. Propofol can substantially reduce cardiac output • Expect a drop in BP of 20% after initial dose from baseline • SpO2 will drop initially and then recover • Can only be administered by licensed anesthesia person • There is no reversal agent
SYNERGISTIC EFFECTS of medications
Synergistic effects • Combining a sedative such as a benzodiazepine, an opioid or a anesthetic, can potentiate the effects of the medications and can increase the likelihood of adverse outcomes, including ventilatory depression and resultant hypoxemia • The administration of one of the above drugs can reduce the amount of the second in a different class that is needed to achieve the desired level of sedation. • Keep in mind that medications taken at home can also potentiate the effects of medications given during the procedure (i.e. narcotics, CNS depressants)
Sedation can be risky with certain patient populations
Patient Factors Affecting Response to Sedation • The following factors are among those placing the patient at greater risk for complications: 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 / Tobacco, alcohol, or substance abuse; previous paradoxical reactions to adverse experience with sedation; standard sedative neuropsychiatric disorders; allergies; drug reactions
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Sources • Use of Sedative Medications in the Intensive Care Unit, Stanley A. Nasraway Jr., MD., FCCM, Department of Surgery, Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts • SGNA, www.sedation.org • Oklahoma Board of Nursing • AGA Institute Review of Endoscopic Sedation
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