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Procedural Sedation Care of the Child and Adult A Self- Learning Module

This module has been approved for 2.0 Contact Hours

Florida Board of Nursing Provider Numbers

Revised 1/18 Colleen Claffey MSN RN-BC CEN CPEN, Risa Combs BSN RN

Revised (2010/2011) Debbie Holladay RN BAE, Allison Losia RN CPON, Sylvia Mathis RN, Barbara Williams RN BSN

Originally Written by:Jennifer Kadis, RN, MSN, CPAN (6/00, 6/02) Pediatric Module: Regina Mathison, RN, CPN, MBA (2002)

Colleen Solomon, RN, CNOR (1997)

Revised: 8/05, 12/07, 12/09, 1/11, 1/18

Course Name: Procedural Sedation Course # 20-22360 Credit Hours: 2.0

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MHS FBON 50-1317

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Procedural Sedation Self-Study Module

Purpose: This module is designed to enhance awareness of the nurse’s role, scope of practice and care when administering and/or monitoring patients receiving procedural sedation. This module also includes a discussion of the nursing responsibilities in the event of an adverse reaction or a life-threatening complication.

Objectives: Upon completion of this self-study module, the learner will be able to:

1. Define the continuum of sedation. 2. Differentiate between levels of sedation. 3. List at least 3 differences in clinical appearance between procedural

sedation and deep sedation. 4. Describe complications and high risk factors of sedation. 5. Discuss the indications for and the goals of sedation in children. 6. Define pre-procedure, intra-procedure, and post-procedure assessment

parameters. 7. Define the ASA classification system. 8. Discuss methods of drug administration and specific agents. 9. List 3 potential complications of procedural sedation and describe the

nursing interventions. 10. Discuss the Aldrete Score pre and post procedure. 11. List at least 5 criteria for discharge from procedural sedation level of care.

Competency in Monitoring of Procedural Sedation: In order to obtain and maintain competency in the care of the sedated patient, the RN will:

1. Attend the initial 2 hour Procedural Sedation Workshop. 2. Complete the procedural sedation e-learning on The TREE bi-annually. 3. Complete procedural sedation initial competence checklist for

employee file. 4. Review procedural sedation self-study packet as per specific

department standards. 5. Complete procedural sedation competency skill set annually as per

specific department standards. 6. Must hold current PALS or ACLS certification

Introduction

This self-learning module is designed to provide the information necessary to administer procedural sedation safely and effectively.

Procedural Sedation, also known as Moderate or Conscious Sedation, refers to sedation and/or analgesia given under the supervision of a physician to allay patient anxiety and to control pain during diagnostic or therapeutic procedures.

The information contained in this packet follows the established guidelines of Joint Commission (Standard PC.13.20, 13.30, and 13.40), American Association of Nurse Anesthetists, American Society of Anesthesiology, American Society of Peri-Anesthesia Nurses, Association of Peri-Operative Nurses and the Florida State Board of Nursing.

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Definitions

The Joint Commission on Accreditation of Healthcare Organizations is an accrediting body whose purpose is to improve the quality of care provided to the public. The Joint Commission standard for sedation applies “when patients receive, in any setting, for any purpose, by any route, moderate or deep sedation as well as general anesthesia, spinal, or other major regional anesthesia.

Minimal Sedation (Anxiolysis) is 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.

Moderate Sedation (Procedural/Conscious Sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by minimal tactile stimulation. No interventions are required to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep Sedation/Analgesia is 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.

* Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.

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 may be impaired.

The Continuum of Sedation

Sedation occurs on a continuum from minimal sedation to general anesthesia and patients progress along that line based on the medication given, the route, the dose and the patient’s own current clinical status.

/ / / /

Procedural sedation may be administered and monitored by an RN competent in the care of sedated patients. Deep sedation and general anesthesia are to be initiated only by an anesthesia provider. The non-anesthesia provider caring for the patient must be able to recognize the clinical differences between the levels of sedation, and be able to rescue the patient, should the patient progress to a deeper level than was intended. For example, the healthcare provider capable of monitoring or administering Procedural Sedation must be able to recognize when that patient has slipped into Deep Sedation, and be able to provide any necessary emergency care. This care may include airway support, fluids, more frequent assessments, or an immediate consult with an anesthesia provider or other practitioner with advanced airway skills, if necessary.

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Minimal Procedural Deep Anesthesia Sedation (Moderate or Sedation Anxiolysis) Conscious

Sedation)

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LEVELS OF SEDATION

Level Other Terms Patient Responsiveness Airway Spontaneous Ventilation

Cardiovascular Function

Minimal Sedation Anxiolysis Responds normally to verbal commands

Unaffected Unaffected Unaffected

Procedural (Moderate) Sedation

Conscious Sedation, Twilight sleep

Responds purposefully to verbal commands, either alone or with light tactile stimulation

Patent, no intervention needed

Adequate Usually maintained

Deep Sedation Not easily aroused, but responds purposefully after repeated or painful stimulation

May be impaired; intervention may be needed

May be impaired intervention may be needed

Usually maintained, possibly change in heart rhythm or blood pressure

General Anesthesia

Not arousable, even upon painful stimulation

Often impaired; intervention often needed.

Often depressed; positive pressure ventilation usually required

May be impaired

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Goals of Procedural Sedation

 Reduce pain and anxiety.  Change level of consciousness.  Maintain level of consciousness appropriate to the level of sedation

needed.  Maintain baseline vital signs.  Ensure safe and prompt return to pre-procedure functional status.

Unresponsiveness and unconsciousness ARE NOT

the objectives of procedural sedation.

What is NOT Procedural Sedation:  Sedation given for labor of childbirth  Pre-operative medication  Postoperative pain relief, including use of

PCA  PO medications given prior to procedure  Sedation given for mechanically

ventilated patients

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Pediatric Procedural Sedation – Key Elements

Diagnostic, therapeutic and surgical procedures are commonly performed on neonates, infants, and children in various settings throughout MHS. At any given time it is possible to find a pediatric patient who is undergoing a computerized tomography scan (CT scan) in the Radiology Department or an infant who requires an electroencephalogram (EEG) in Pediatric Ambulatory Services, while yet another child is having laceration repair in the Pediatric Emergency Department.

Fear, anxiety, temperament, age and developmental stage of the child contribute to his or her ability to cooperate during necessary procedures such as these. To ensure cooperation, it is important to take the time to prepare an anxious child prior to a procedure:

• •

Approach the child in a non-threatening manner. Consider the child’s age and developmental level

when interacting. • •

Use vocabulary that the child can understand. Attempt to build trust – be honest about what will and

will not hurt.

During the procedure, non-pharmacological measures may be employed to enable the child to stay calm and cope with the situation:

•Encourage parental participation as much as possible. • Allow the child to bring a small toy or stuffed animal to the procedure for security. • Use distraction techniques (i.e., light conversation, bubbles, toys, books, music, etc.). • Use guided imagery (i.e., “Close your eyes and think of your favorite place.”). •Request Child Life staff or humor therapist (if available) to work with the child before and during the procedure. • Keep pain to a minimum.

After the procedure, the child should be rewarded for his or her efforts to cooperate (i.e., praise, stickers, age-appropriate toy, etc.).

Sedation is routinely used to increase a child’s cooperation during a procedure while decreasing his or her pain and memory of the experience. A child who has had a previous unpleasant experience at a hospital may be difficult to manage long before any noxious stimuli occur. This child may require sedation when another child the same age may not. Sedation should allow a child to tolerate an unpleasant procedure while meeting the following goals:

• • • • • •

The child’s safety and welfare are maintained. Pain or discomfort is minimal. Anxiety is relieved. Cooperation is maximized. Effects on vital signs are minimal. Amnesia is maximized, if possible.

Knowing the normal vital sign parameters in children is extremely important as children may easily progress to a deeper state of sedation than what was originally intended. In many instances, a child is likely to require deep sedation, where an adult would require little or no sedation (i.e., placement of a peripherally inserted central catheter (PICC)). Sedation of children may be associated with serious risks such as hypoventilation, apnea, airway obstruction, and respiratory or cardiac arrest.

Pediatric Heart Rates

The normal pediatric heart rate is influenced by the child’s age and activity level and such pathologic conditions as fever, dehydration or loss of blood. There is a wide variation in the normal heart rate and a gradual decline with age. The child’s clinical condition and level of consciousness must always be considered when the heart rate is evaluated. Refer to TABLE I: Normal Ranges of Heart Rates for Children. Bradycardia in children often results from respiratory insufficiency; once airway patency and adequate oxygenation and ventilation are established, the heart rate usually returns to normal without further intervention. If early recognition and proper intervention do not occur, cardiac arrest can eventually ensue from prolonged hypoxemia and acidosis. Thus in the pediatric age group attention must first be directed toward establishment of a patent airway, effective ventilation, adequate oxygenation, and circulatory stabilization. An apical pulse should be taken in children less than two years old.

TABLE I

Normal Ranges of Heart Rates for Children Heart Rate (beats/min)

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AGE RESTING (Awake)

100 - 180 100 - 220 80 - 150 70 -110 55 - 90

RESTING (Sleeping)

80 - 160 80 - 180 70 - 120 60 – 100 50 – 90

EXERCISE (Fever)

Up to 220 Up to 220 Up to 200 Up to 180 Up to 180

Newborn 1 week - 3 months 3 months - 2 years 2 years – 10 years 10 years to adult

Pediatric Blood Pressures

For an accurate reading, the blood pressure cuff should cover 2/3 of the upper or lower extremity (i.e., 2/3 of upper arm, calf, etc.). Refer to TABLE II: Normal Ranges of Blood Pressure for Children.

Wong’s Nursing Care of Infants and Children. 7th edition. P. 186

The “quick” formulas below may be used to estimate pediatric blood pressures according to age:

1-7 years: Age in years + 90 = systolic 8-18 years: (2 X Age in years) + 83 = systolic 1-5 years: 56 diastolic 6-18 years Age in years + 52 diastolic

Wong’s Nursing Care of Infants and Children. 7th edition. P. 186

TABLE II

Normal Ranges of Blood Pressures for Children AGE Systolic Blood Pressure

(mm Hg) Diastolic Blood Pressure (mm Hg)

Neonate Infant (6 months) Toddler (2 years) School Age (7 years) Adolescent (15 years)

60-90 87-195 95-105 97-112 112-128

20-60 53-66 53-66 57-71 66-80

In children, perfusion status changes will usually occur before a change in blood pressure is noted. It is important to assess distal and proximal pulses, capillary refill, skin temperature and color in addition to heart rate and blood pressure when evaluating a child’s cardiovascular status.

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Pediatric Respiratory Rates

Normal spontaneous breathing is accomplished with minimal work and is quiet. Respirations are abdominal in infants and young children and then become diaphragmatic. The normal respiratory rate is inversely related to age; it is rapid in the neonate and then decreases in older infants and children. Respiratory rates increase in the presence of excitement, anxiety, exercise, pain or fever. Refer to Table III: Normal Respiratory Rates for Children.

TABLE III

Normal Respiratory Rates for Children

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AGE Rate AGE (breaths/min)

10 years 12 years 14 years 16 years 18 years

Rate (breaths/min)

Newborn 1 - 11 months 2 years 4 years 6 years 8 years

35 30 25 23 21 20

19 19 18 17 16 - 18

Pediatric Pulse Oximetry

Pulse oximetry provides an early warning of oxygen desaturation before cyanosis or changes in vital signs can be observed. Normal pulse oximetry readings in children are 95 – 99% and in neonates 85 – 90% on room air. An oxygen delivery system should be available at the patient’s bedside before sedation is administered.

Pediatric Capnography

Capnography measures pulmonary ventilation (end-tidal CO2 of each exhalation - EtCO2) and is able to instantaneously detect small changes in cardio-respiratory function before pulse oximetry readings change. This continuous measurement provides an immediate indication of any change in ventilatory status (i.e.; apnea, hypoventilation, or airway obstruction) and will be used and documented for most procedurally sedated pediatric patients. Continuous EtCO2 monitoring is also required for use in the Pediatric patient during Deep Procedural Sedation (i.e. physician-administered Ketamine/Propofol). EtCO2 monitoring may be suspended at any time at the physician’s discretion if the EtCO2 monitoring may awaken a stable pediatric patient and interfere with the procedure being performed.

Process of Procedural Sedation for Adults and Children

The process of administering and/or monitoring a patient for procedural sedation involves several KEY elements:

1. Determining if the ordered sedation falls under the guidelines for procedural sedation.

2. Determining if the patient is an appropriate candidate for nurse-monitored sedation.

3. Preparing the patient and the setting.

4. Patient care during the procedure.

5. Recovery of the patient after the procedure.

6. Discharge from the sedation level of care.

The risk of complications is diminished if all these elements are addressed safely and successfully

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Is this Procedural Sedation?

A frequent question that arises is how do I know if what is ordered for my patient is procedural sedation? Keep in mind that minimal sedation (anxiolysis) is mild sedation that is ordered for relief from anxiety or pain in a conscious patient. The patient is easily awakened by normal or softly spoken verbal commands and is oriented when awake. The patient is able to respond normally to verbal commands. There is no change in vital signs and there is no significant risk of losing protective reflexes. The patient is able to maintain pre-procedure mobility. (ASA Sedation Model Policy)

Procedural (moderate/conscious) sedation is a depressed level of consciousness in which the patient is able to maintain a patent airway without intervention and can be aroused by verbal or light tactile stimulation. They can respond to verbal commands by appropriate action or brief words.

It is important to understand that it is the patient’s response to a medication and not a particular medication or route that actually determines if the procedural sedation guidelines are to be followed. This rule applies to children as well as adults.

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Regardless of the procedure being performed or the medication being administered, sedation represents a continuum, in which the patient may easily progress from a state of procedural sedation to one of deep sedation or general anesthesia.

Decision Tree

When sedation has been ordered for a patient, the nurse must first determine whether this constitutes procedural sedation. You can do this by asking two key questions as shown on the decision tree below:

1. Am I giving the medication to decrease pain and/or anxiety during a Procedure?

Yes No

2. Do I expect the medication to alter the patient’s level of Consciousness or vital signs?

Not Procedural Sedation

Yes No

Procedural Sedation

Minimal Sedation

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Is this Procedural Sedation?

*The presence of an anesthesia provider automatically indicates an anesthesia case, regardless of the medication administered. The medications listed above are examples only, and do not represent the only choices for procedural sedation.

Situation Is medication being given to

ease pain and/or anxiety for a procedure?

Do I expect the medication to affect LOC or vital signs?

Procedural Sedation?

Versed 1 mg and Morphine 4 mg IV for reduction of dislocated shoulder

Yes Yes Yes

Xanax 0.25 mg po 1 hour before MRI Yes No No Minimal Sedation Morphine 4 mg IV for complaints of post-op pain No Possibly No, pain relief Chloral hydrate per rectum or orally for CT scan Yes Yes Yes Anesthesia provider comes to the bedside for cardioversion*

Yes Yes No It is Anesthesia, not sedation

Versed 2 mg, Sublimaze 100 mcg for cardioversion Yes Yes Yes Morphine PCA No Possibly No, pain relief

Is this an appropriate case for nurse-monitored sedation?

It’s important to take a full medical and nursing history prior to beginning sedation because the sedation itself is not without risk. There are several factors that determine the patient’s risk for sedation, two of which must be determined by the physician who is prescribing the sedation. The first factor is the determination of the ASA score:

The ASA score is a classification system devised by the American Society of Anesthesiologists (ASA) to rank the patient’s physical status and corresponding risk of sedation on a scale from 1 to 6. The scale is:

ASA 1 - Normal, healthy patient with no systemic disease

ASA 2 - Mild to moderate systemic disease, controlled on medication, i.e. controlled hypertension, diabetes.

ASA 3 - Severe systemic disease with functional limitation that is not incapacitating, i.e. asthma, heavy smokers, obesity or multiple severe systemic illnesses (hypertension, COPD, diabetes or coronary artery disease), all well-controlled on medications, any patient with a history of MI or CVA.

ASA 4 - Severe systemic disease that is incapacitating and life- threatening, i.e. poorly controlled hypertension, diabetes, CAD, or multiple medications.

ASA 5 - A moribund patient not expected to survive 24 hours regardless of intervention.

ASA 6 – A patient declared brain-dead whose organs are to be removed for donation.: This patient is being maintained on ventilator support.

Patients who are in category ASA 1 or ASA 2 are appropriate for monitoring by a RN who is competent in procedural sedation. Anesthesia providers are available for consultation for patients in categories 3, 4, and 5. An anesthesia consult is highly recommended for any patient with an ASA score of 4 or 5. Patients with an ASA of 6 are not candidates for nurse-monitored procedural sedation.

The second physician decision involves assessment of airway adequacy. This is extremely important because medications commonly used for sedation are respiratory depressants. As the majority of complications involve airway or breathing difficulties, it’s important to know if there are potential problems with opening the airway or ability to ventilate the patient.

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The physician will classify the airway as:

Adequate – no significant risk factors identified

At Risk – for example, a receding chin, history of TMJ, history of cervical, neck problems, craniofacial abnormality. Inability to fully open mouth or flex the neck, i.e., anything that may make managing that patient’s airway difficult.

High Risk – for example, history of head or neck surgery, head or neck deformity, morbid obesity, history of difficult airway problems. This also includes a history of sleep apnea.

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• Seizure Disorders – Use of Romazicon for benzodiazepine reversal may increase seizure threshold.

• Insulin-Dependent Diabetes – signs and symptoms of hypoglycemia may be confused with a drug reaction

• History of long-term pain medication use or substance abuse – medications commonly used for moderate sedation may have little or no effect.

• History of strokes or MoyaMoya disease in children

• GI Reflux or full stomach – increases the risk of vomiting and aspiration into the lungs

• Thyroid Dysfunction

• •

Hyperthyroidism – patients may be difficult to sedate Hypothyroidism – effects of sedative medications may be prolonged.

• Patient or family history of malignant hyperthermia. • Congenital abnormalities such as:

•Down’s Syndrome- may pose an airway management problem due to short neck and large tongue. •Pierre Robin – small lower jaw, soft cleft palate, tongue has tendency to fall back and down – may occlude airway. • Goldenhar syndrome – multiple facial abnormalities

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Potential Risk Factors in Adults and Children There are additional factors that may increase the risk for adverse reactions and complications from sedation and may require consultation with an anesthesia provider. These include:

• Cardiovascular History – may increase the risk of hypoxia, arrhythmias, blood pressure problems.

• Pregnancy – medications may adversely affect fetus; higher risk of aspiration for mother

• Significant Kidney or Liver Disease – may require reduction in medication doses and/or longer recovery time.

• Previous problems with sedation, analgesia or anesthesia. • “Opiate naïve” –effective dosing and medication effects will vary • Snoring or Sleep Apnea – may indicate difficulty with intubation. • Patients receiving MAO inhibitors – select opioid analgesics. • Patients receiving tricyclic antidepressants or CNS depressants – may have an

additive effect with sedative medications.

Pre-Procedure Preparation

Once it’s determined that the patient is an appropriate candidate for nurse-monitored sedation, both the patient and the setting must be prepared. The assessment of the patient must include the ASA score, airway evaluation, and presence of risk factors. It must also include:

1. Baseline physical status, such as skin color, level of consciousness 2. Baseline vital signs 3. Baseline Aldrete score 4. Allergies 5. Current medications, including herbal supplements and OTC products. 6. NPO status:

*In the event of an emergency, the need for sedation may outweigh the risk of aspiration a full stomach, and a consultation with an anesthesia provider is recommended.

from

7. Medical and surgical history 8. Patent IV access, if applicable i.e.; pediatric patient that receives PO Chloral

Hydrate may not have IV 9. Baseline pain level 10. Informed consent/patient education 11. Current History and Physical (within 24 hours of procedure) 12. ASA and airway assessment 13. Review most recent lab results

The area must also be properly prepared for sedation. This includes: 1. Oxygen and a delivery method, i.e. nasal cannula, mask 2. Suction 3. Cardiac monitor for all adults 4. Cardiac monitor for all children who’ve received IV sedation; for other routes,

monitoring heart rate and saturation by pulse oximetry is sufficient 5. Pulse oximeter 6. End Tidal CO2 monitor

NPO Guidelines Minimum Fasting PeriodAdults

Solid food/Non-clear liquids Clear Liquids Pediatric Patients Milk/solid foods Formula Breast milk Clear Liquids

6-8 hours 2 hours

6-8 hours 6 hours 4 hours 2 hours

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6. Blood pressure cuff 7. IV solutions 8. Reversal agents, located in crash carts 9. Ambu bag and emergency supplies, i.e. crash cart nearby and readily available 10. All equipment must be age-appropriate, i.e., pediatric or adult

An important scoring system is used to asses the patient’s recovery from the sedative effects and to determine their eligibility for discharge from that level of care (whether from the procedure area or home). The scoring system used to determine this is the Aldrete score, ranges from 1-10. While this is a system used to assess the degree of post-procedure recovery, it’s important to make a baseline assessment for comparison purposes. Discharge criteria generally assume an Aldrete score of at least 8 or greater. That’s usually not possible if the patient scored less than 8 before the sedation was administered, such as a quadriplegic, a confused patient, or a patient who is oxygen dependent.

The Aldrete score provides a simple, reliable way to evaluate status. When evaluating the pre-procedure Aldrete score, evaluate the patient based on his/her usual status, i.e. usual blood pressure, respiratory status, etc.

ALDRETE SCORE:

Activity 2……Able to move all 4 extremities 1……Able to move two extremities voluntarily on command 0……Unable to move extremities

Respiration 2……Able to deep breathe and cough without difficulty 1……Dyspnic, shallow, or limited breathing 0……No spontaneous respirations

Circulation 2……B/P and/or heart rate +/- 20% of pre-procedure levels 1……B/P and/or heart rate +/- 20-50% of pre-procedure levels 0……B/P and/or heart rate is < 50% of pre-procedure levels

Consciousness 2……Fully awake 1……Arousable to verbal stimulus or light touch 0……Unresponsive

Oxygenation 2……Able to maintain O2 saturation greater than 92% or baseline on room air

1……Needs O2 to maintain saturation greater than 92% 0……O2 saturation less than 92% even with oxygen

supplement

Intra-Procedure Responsibilities

* Before proceeding – the RN and the physician must reassess the patient immediately prior to the administration of the first dose of medication. This is the “TIME OUT” or “Pause for the Cause”. Crew Resource Management outlines the need to verify the patient’s identity and procedure.

Procedural sedation may be performed in any location where the standard of care can be met. This means that oxygen, suction and monitoring equipment are required, and age-appropriate emergency equipment must be readily available. The RN must be clinically competent to administer medications and monitor the patient who is receiving sedation.

This means that this RN may not assist the physician with the procedure; if assistance is needed, an additional person is required. This also means that this RN may not leave the room to obtain supplies, check on other patients or be occupied in any way that prevents continuous monitoring of the patient during and immediately after the procedure.

The MOST IMPORTANT point is:

THE RN WHO IS RESPONSIBLE FOR MONITORING THE PATIENT DURING THE COURSE OF SEDATION MUST HAVE NO OTHER RESPONSIBILITIES THAT WOULD

COMPROMISE CONTINUOUS MONITORING.

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During the procedure and course of sedation, the RN is responsible for:

 Assessment of airway and breathing

 Oxygen delivery

 Assessment of IV site

 Assessment of response to medication and procedural interventions

 Providing emotional support, reassurance to the patient

 Vital signs – at least every 5 minutes during the procedure, and more often if indicated. Measurement of blood pressure and EtCO2 may cause arousal in small children who would otherwise remain sedated; in that case, for nurse administered sedation,blood pressure readings and EtCO2 monitoring may be suspended for a stable pediatric patient at the discretion of the RN and/or the physician overseeing monitoring of the patient. Cardiac rhythm is required for all adults and for all children who receive IV sedation. For other routes of medication administered to children, monitoring of heart rate and oxygen saturation via pulse oximetry is sufficient

 Continuous pulse oximetry measurement

 Continuous End-Tidal CO2 monitoring and documentation.

 Continuous cardiac rhythm monitoring

 Observe for and report any changes to the physician, such as,  Changes in vital signs, oxygen saturation  Airway or respiratory difficulty  Arrhythmias  Restlessness  Cyanosis  Flushing or pallor  Diaphoresis  Complaints of nausea, dizziness, palpitations, pain

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The RN must document all data appropriately.

Capnography

Another way to monitor your patient’s respiratory status is with Capnography.

Capnography measures pulmonary ventilation (end-tidal CO2 of each exhalation - EtCO2) and is able to instantaneously detect small changes in cardio-respiratory function before pulse oximetry readings change. This continuous measurement provides an immediate indication of any change in ventilatory status (i.e.; apnea, hypoventilation, or airway obstruction).

Capnography is recorded by displaying a numerical EtCO2 and a wave form on the monitor. These are separate monitoring parameters and should be recorded on the Sedation/Procedure Record Form in the appropriate areas. Understanding of the waveform and its indications is an important part of the educational preparation and the competency of the procedural sedation monitoring RN. For patients who are non- intubated, most of our anesthesia/physician staff is in agreement that the waveform is the most accurate indication of the patient’s EtCO2 status than the numerical value which may change frequently. However, knowledge of both the normal range for both parameters is necessary for the RN monitoring the patient.

Waveform recognition and understanding of the waveform in EtCO2 is the most accurate monitoring tool for measuring and recording hypoventilation in the sedated, non-vented patient. A positive

waveform indicates adequate ventilation and should be documented on the procedure sedation record form.

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Pulse Oximetry measures the oxygen saturation of hemoglobin in peripheral blood. Pulse oximetry measures oxygenation, not ventilation. Pulse oximetry value changes are not immediate and therefore its use is limited.

There are several important key points to understand regarding the medications commonly used in procedural sedation:

1. The GOAL of procedural sedation is to use the least amount of medication to produce the needed effect. Some things that may help are allowing sufficient time for the medication to take effect before beginning the procedure. It’s also helpful to explain the procedure and sedation to the patient, using simple terms, and provide frequent reassurance, both verbally and by touch. Establishing a calm, trusting, reassuring relationship between the patient and the RN may help to decrease the amount of medication needed to produce the desired level of sedation in the patient.

2. Nearly all sedative agents cause some degree of respiratory or cardiovascular depression. These medications need to be given cautiously in children, the elderly or patients with liver or kidney disease.

3. Medications have to be titrated to individual patient condition and response. Refer to hospital policy and drug information sources for specific medication guidelines.

4. Procedural sedation is almost always given via IV in the adult patient, but may be given by other routes of administration in pediatrics. Medications given intravenously tend to work more quickly and may be associated with a higher number of complications.

5. Procedural sedation may involve giving two types of medications, one for anxiety and one to prevent pain. Remember that this combination often has a synergistic effect, which means that both drugs given together have a greater effect than each would if given separately; total doses may have to be reduced.

6. Reversal agents are given for adverse reactions such as respiratory depression or loss of consciousness, not as a routine measure. A patient who has received reversal agents must be monitored an additional two hours past the end of the procedure, as the sedatives/narcotics duration of action last longer than the reversal agents.

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Medications Used in Procedural Sedation

The pharmacological agents used to induce sedation may be sedatives, barbiturates, hypnotics and/or anesthetics given via different routes. Although PO Meds are not used for procedural sedation in adults, care should be taken when administering them as anxiolytics for minimal sedation depending on the patient’s medication history, general condition, or age. Reassessment of the patient’s level of consciousness and vital signs frequently is critical in determining if that patient has crossed the line into a state of procedural sedation. Medications used in Pediatric patients for procedural sedation may take the route of intra-nasal, IV, rectal and PO.

The advantage of IV procedural sedation is a rapid onset, which can be titrated to the patent’s response. This, in turn, decreases recovery time as well as the incidence of nausea and vomiting, gag reflex impairment and motor disturbances. It should be noted that the intramuscular route is typically avoided in children whenever possible, unless there is time for a topical anesthetic to be administered prior to the injection.

Unpredictable absorption, metabolism and excretion of medications make the patient (especially children or the elderly) particularly vulnerable to complications of over- sedation. Familiarity with reversal drugs or antagonists, available for both narcotics and benzodiazepines, is essential. Drug dosages should be titrated to the patient and his or her response in consideration of age, weight and clinical condition.

For complete description of drug indications, use, actions, etc., please refer to the Micromedex in the hospital information systems. The following sedation dose schedule serves as a guideline only. Each patient must be individualized as to his or her past medical history, present condition and goals of sedation.

 Sedatives and Anxiolytics • Benzodiazepines produce sedation, amnesia, diminished anxiety, and skeletal muscle relaxation and anti-convulsant effects. They have no analgesic properties. Adverse effects include respiratory depression, laryngospasm, cardiac arrhythmia, bradycardia, hypotension, and CNS excitement. Reversal may be obtained with Flumazenil (Romazicon®).

 Lorazepam (Ativan®) Adult Dose: 1-2 mg IV or 0.5 – 2 mg. PO – Minimal

Sedation 0.05 – 0.1 mg/kgPediatric Dose:

IV slowly over 2 – 5 minutes. Titrate dose to desired effect. Dilute with equal volume of dilutant. Hypersensitivity to the drug, depressive disorder/psychosis 1-5 minutes IV in Pediatrics 5-15 minutes IV in Adults

Contraindications:

Onset:

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Peak: 15 – 20 minutes in Pediatric patients About 2 hours in adults Amnesic effect: 6 – 8 hrs. Duration of side effects in adults can last up to 48 hours.

Duration:

 Diazepam (Valium®)* Adult Dose: 2-5 mg. IV over 1 minute may repeat every 5-

10 minutes – DO NOT EXCEED 20mg in 60 minutes. 0.1 – 0.2 mg/kg IV injected slowly: less than 1 – 2 mg/min IV push. Titrate dose to desired effect. Hypersensitivity to the drug, comatose, respiratory depression, and severe uncontrolled pain. Hypotension, bradycardia, and cardiac arrest can result from rapid IV infusion. 1-5 minutes IV 8 minutes 30 minutes to one hour, May be up to 24 hours in adults.

Pediatric Dose:

Contraindications:

Onset: Peak: Duration:

* IV not recommended in children.

 Midazolam (Versed®)* Adult Dose: 0.5 – 2.5 mg IV every 2-5 min to a

TOTAL Dose (Adults): 0.1 – 0.2 mcgs per kg 0.05 – 0.2 mg/kg IV Titrate dose to desired effect. Total maximum IV dose = 0.6mg/kg 0.5 – 0.7mg/kg PO Hypersensitivity to the drug, existing CNS depression, shock, and uncontrolled pain 1 – 5 minutes 30 minutes to one hour in pediatric patients. Adults: May last 2-6 hours. Pediatric patients generally require higher doses than adults and younger pediatric patients may require higher doses than older pediatric patients on a mg/kg due to differences in metabolism and volume distribution

*Pediatric Dose:

Contraindications:

Onset: Duration:

*Requires direct physician supervision during administration to pediatric patients

 Narcotics •Opioids produce analgesia and sedation. Adverse effects include respiratory depression, hypotension, airway obstruction, bradycardia, cardiac arrest, and seizures. Reversal may be obtained with Naloxone (Narcan®).

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 Morphine Sulfate Adult Dose: Pediatric Dose:

2-5 mg IV, slowly 0.05 – 0.1 mg/kg IV Titrate to desired effect every 5 minutes. Usually used as premedication for anesthetic procedures. Administer VERY slowly. MAXIMUM 10mg. per dose. Hypersensitivity to the drug, increased ICP, severe respiratory depression, liver or renal insufficiency Rapid (1-3 minutes) 20 minutes 1 – 2 hours

Contraindications:

Onset: Peak: Duration:

 Dilaudid (Hydromorphone) - ADULTS Adult Dose: Onset: Duration: Contraindications:

0.5-2 mg IV, slowly over 2-3 minutes 5-15 minutes 4-5 hours May increase risk of respiratory depression when used in combination with phenothiazines, in patients with hepatic or renal insufficiency, elderly patients, or those taking CNS depressants.

- significant respiratory depression -nausea and vomiting -hypotension Note: 2 mg Dilaudid = 10 mg. of morphine

Side Effects:

 Fentanyl (Sublimaze®)* Adult Dose: 25-50 mcg. Over 1-2 minutes may repeat in 1-

2 minutes with a TOTAL dose of 1-3 mcg/kg 0.5 – 2 mcg/kg as a slow IV bolus. May repeat every 3 min. to desired effect. Titrate dose to desired effect to a TOTAL dose of 50 Mcg/dose Hypersensitivity to the drug, increased ICP, severe respiratory depression, renal or liver insufficiency 1 – 3 minutes 3 – 5 minutes 30 minutes to 1 hour May cause skeletal muscle and chest wall rigidity and difficulty in breathing. Greater Incidence of chest wall rigidity in infants and small children. Bradycardia and increased ICP.

*Pediatric Dose:

Contraindications:

Onset: Peak: Duration: Side Effects:

*Requires direct physician supervision during administration to pediatric patients

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 Barbiturates •Barbiturates produce sedation and amnesia, and depress pain responses. Adverse effects include respiratory depression, laryngospasm, cardiac arrhythmia, bradycardia, hypotension, and CNS excitement. In Pediatric patients pentobarbital, secobarbital, And methohexital have been used for short-term procedures such As CT scans and radiation therapy. Patients on barbiturates must Be carefully monitored for respiratory depression and emergency respiratory support equipment should be available prior to administration.

 Dose:

Pentobarbital (Nembutal®) (used in pediatric patients) 2 mg/kg IV slow administration is essential; rapid IV injection may cause respiratory depression and hypotension; Wait 10 minutes, then 1 mg/kg every 5 minutes for desired effect. Maximum total dose over 30 minutes is 4 mg/kg. Do not give faster than 50 mg/min. IM: Inject deep into large muscle

Contraindications: Hypersensitivity to barbiturates, liver insufficiency IV: Within 1 minute IM: 10-15 minutes 10 – 30 minutes IV: 15 minutes IM: 4 – 10 hours

Onset:

Peak: Duration:

 Hypnotics •Hypnotics are short-acting with no analgesic or amnesic properties. Adverse effects include respiratory depression, headache, confusion, dizziness, ataxia, nausea/vomiting, diarrhea, and paradoxical excitement. Many physicians consider Chloral Hydrate to be the drug of choice for sedation of children before diagnostic, dental or medical procedures. Its general use as a hypnotic has declined.

 Chloral Hydrate (Noctec®) Pediatrics Dosing: Diagnostic procedure – Procedural sedation

40 – 100 mg/kg orally (max single dose is 2 Grams) or PR Maximum dose 2 grams in two divided doses. EEG Procedure – Procedural sedation: 25 mg/kg orally or rectally (max 1 gram per single dose) Nuclear Medicine Procedure –0-70 mg/kg Orally (max accumulated dose of 100mg/kg) Procedural sedation: 25-100 mg/kg Orally or Rectally ; may repeat 25-50 mg/kg 30 minutes

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later except in neonates (single dose only); maximum total dose is 2 Grams or 100mg/kg (whichever is less). Hypersensitivity, hepatic or renal impairment, gastritis or ulcers, and severe cardiac disease 30 minutes Unknown 4 – 8 hours None

Contraindications:

Onset: Peak: Duration: Reversal agent:

 Alpha Adrenergic Agonists/Sedative (Pediatric Use ONLY at this time for Procedural Sedation)

• Precedex (Dexmedetomidine) – *** Used at this time only for Pediatric procedures in pediatric Procedural areas, IR, CVI, ICU, Peds ambulatory, Oncology areas – NOT used in the Pediatric ED***

Precedex (Dexmedetomidine) Sedation for Non-Invasive Imaging Studies

1. The use of Dexmedetomidine sedation as the primary sedative for non-invasive studies is emerging. The RN administering Dexmedetomidine will follow their unit specific protocol in order to safely administer, recognize, and treat side effects of Dexmedetomidine.

2. Final concentration of 4 micrograms per mL in Normal Saline is used for Nurse Administered Sedation

3. Dexmedetomidine will not be used for any patient receiving Digoxin.

4. Notify Physician if noted. Dexmedetomidine is contraindicated in patients with heart block or Moyamoya disease or recent strokes

Dose: 2-3 mcg/kg bolus over 10 minutes followed by 1-2 mcg/kg/hr infusion

Contraindications: Patients on Digoxin, patients with heart blocks, and patients with Moyamoya disease

Onset with bolus dose: Duration:

IV: 3-5 minutes IV: can be up to 4 hr, but once continuous infusions discontinued, effects last approximately 30 minutes – 1 hour None. Treatment for adverse effects is to discontinue infusion.

Reversal agent:

• Has emerged recently as an option for procedural sedation • Usually administered in the critical care setting

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•Normal side effects: bradycardia, hypotension, transient hypertension • Chemically related to clonidine •Produces sedative, anxiolytic, and analgesic effects with fewer adverse effects (specifically respiratory depression) than conventional Opioids and/or benzodiazepines • Administered as a drip infusion after bolus dose. •Should be noted that safety and effectiveness in children less than 18 years of age has not been established (Prod Info PRECEDEX(R) intravenous injection, 2008).

 Anesthetic Agents – Administered ONLY by a physician and these patients are monitored ONLY by a physician in Pediatric Patients

•Anesthetic agents act upon the brain to produce general anesthesia, which is partial or complete loss of sensation with loss of consciousness. Since anesthesia may result in partial or complete loss of protective reflexes, only certified physicians may administer and continuously monitor patients receiving these medications throughout the procedure. In the Adult ED, an RN may monitor the patient but MAY NOT administer the medication.

• ****Ketamine (Ketalar®)* Adult Dose: Pediatric Dose:

0.5 – 2 mg/kg IV Titrate to desired effect. 0.5 – 1 MG/KG IV over 2-3 minutes; 3 – 4 mg/kg IM**

Do not exceed 2 mg/kg – may produce anesthesia Contraindications: Increased ICP, hypertension, CHF, patients

with psychotic disorders, hypersensitivity to the drug Hypertension, tachycardia, muscle hyperactivity, increased airway resistance, depressed cough reflex, vivid dreams, nausea/vomiting, (and respiratory depression or apnea with large or rapid infusions) IV 40 seconds in adults, IV in pediatrics onset is 1-2 minutes and IM 3 – 4 minutes IV 5 – 10 minutes, IM 12 – 25 minutes Pediatric: 5-10 minutes Adults: 1 – 2 hours

Adverse effects:

Onset:

Peak: Duration:

• ***Propofol Restricted to use by Pediatric Intensivist, PICU or Anesthesia Physicians for IV push procedural sedation

Dose: 1 – 2 mg/kg IV bolus

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• Shake well before using. Do not administer via filter of less than 5 micro pore size. • Contraindications should include hypersensitivity to other components of the formulation; e.g., this formulation egg yolk phospholipids and egg lecithin. • Adverse effects: Seizures, apnea, hypotension, nausea/vomiting, pain at injection site, and cardiac arrest • •

Onset: 10-50 seconds Duration: Single dose: 3-10 minutes

• ***Etomidate: Administered by Physicians to Adult ED Procedural Sedation patients only Dose: 0.1 to 0.2 mg/kg over 30 to 60 seconds followed by

0.5 mg/kg every 3 – 5 minutes as needed for sedation.

Contraindications: Hypersensitivity to Etomidate products

Precautions: A) due to hazards of prolonged suppression of endogenous

cortisol and aldosterone production, this formulation is not intended for administration by prolonged infusion

B) marked hypotension C) severe asthma D) severe cardiovascular disease

Adverse Reactions  Endocrine & metabolic: Adrenal suppression  Gastrointestinal: Nausea, vomiting on emergence from anesthesia  Local: Pain at injection site (30% to 80%)  Neuromuscular & skeletal: Myoclonus (33%), transient skeletal

movements, uncontrolled eye movements

*** Please Note: RNs in the Memorial Healthcare System may NOT administer Ketamine, Etomidate or Propofol as a bolus IV sedation medication. All bolus Ketamine, Etomidate or Propofol must be administered by credentialed MDs. The Florida Board of Nursing is very clear in our state statutes (RN) cannot administer Ketamine, Propofol and Etomidate as an IV bolus.

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 Reversal Agents Flumazenil (Romazicon®) reverses the sedative effects and psychomotor impairment but not respiratory depression associated with benzodiazepine administration. Naloxone (Narcan®) reverses the CNS and respiratory depression caused by narcotics. Antagonists should be available when either of these types of medications is used.

Reversal agents are administered to reverse the effects of a specific type of sedation medication.

 Dose:

Naloxone (Narcan®) Pediatric: 0.01 – 0.1 mg/kg IV Adult: 0.04 mg IV every 2-3 minutes until pt. Responds not to exceed 2 mg.

Indications: Reverses respiratory and CNS depression after narcotic use 1-2 minutes Pediatric: 20-60 minutes Adults: 45 minutes Hypersensitivity to drug Hyper- or hypotension, tachycardia, nausea/vomiting; confusion, agitation: reversal of analgesia

Onset: Duration:

Contraindications: Adverse effects:

* Narcan is to be diluted to make a concentration of 0.04 mg/ml in adults

 Flumazenil (Romazicon®) Adult Dose: Pediatric Dose:

0.2 mg over 30 seconds, IV 0.01 mg/kg IV (max dose 0.2 mg). May repeat after 45 seconds, then every 60 seconds. Administer dose at a rate not to exceed 0.2 mg/min in children. Benzodiazepine antagonist Hypersensitivity to the drug, seizure disorders, or patient on routine benzodiazepines Seizures in patients receiving benzodiazepines for the treatment of seizure disorders, arrhythmia, dizziness, headache, and agitation Adults: 1mg Pediatrics: 0.05 mg/kg or 1 mg.

Indications: Contraindications:

Adverse effects:

Total dose:

Recovery of the Patient after Sedation:

Once the procedure is finished the RN must monitor the patient until:

The Aldrete score is 8 or within 20% of baseline vital signs. This means that the patient must be awake, able to move and maintain saturation greater than 92% on room air. If the baseline Aldrete score was less than 8, the patient must be returned to their pre-sedation level.

Vital signs need to be taken at least every 15 minutes until stable or within 20% of baseline. Ranges for vital signs are:

The patient’s baseline vital signs and clinical status must always be considered. Heart rate, respiratory rate

and blood pressure may be elevated with fever, stress or fear.

The RN recovering the patient must also observe and document any unusual events or post-procedure complications, how those events were managed, and the patient’s condition, including pain level.

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Age Resp. Heart Rate (Awake)

Heart Rate (Asleep)

Systolic Diastolic B/P

Infant/Neonate 30-60 100-180 75-150 60-90 35-60 Toddlers 24-40 80-110 60-90 87-105 53-66 Preschoolers 22-34 70-110 60-90 95-105 53-66 School-Age 18-30 65-110 60-90 96-110 55-69 Adolescents 12-16 60-90 50-90 97-112 57-71 Adults 12-18 60-100 50-80 112-128 66-80

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Complications

The most common complications of procedural sedation are respiratory depression and cardiovascular problems. Respiratory depression is most often caused by medications. This patient may have a decreased respiratory rate, shallow respirations and a decrease in oxygen saturation. As the patient becomes more relaxed, the tongue may obstruct the airway. Opening the airway using a head-tilt, chin lift method or by placing an infant’s head in the “sniffing” position may be all that’s needed to relieve an airway obstruction.

Applying oxygen before the sedation decreases the likelihood that the patient will become hypoxic during the sedation. If not applied before, apply supplemental oxygen at the first sign of respiratory difficulty.

Pulse Oximetry provides a simple, reliable method of monitoring a patient’s oxygenation status during sedation. However, the readings may not be reliable if the patient is anemic, edematous, or has a condition that may affect circulation in the extremities, such as peripheral vascular disease or severe hypotension.

Normal oxygen saturation is 92-100%, but, remember that a slight fall in Saturation (SaO2) is associated with a sharp decline in oxygen concentration (PaO2).

NOTE: Cyanosis is usually not observed until SaO2 falls below 65%, which can be associated with a paO2 as low as 40 mm Hg!!! In neonates, due to the presence of fetal hemoglobin with the shift of oxygen dissociation to the left, paO2s are lower with equivalent saturations

than the values above.

Saturation % paO2 (mm Hg) 90% = 60 mm 88% = 55 mm 80% = 50 mm 75% = 40 mm

Managing Respiratory Difficulty

Identify breathing difficulty or hypoxia, by low SaO2, snoring, stridor, restlessness, tachycardia

Instruct patient to take a deep breath. If no response, touch or shake patient and repeat instructions to deep

breathe

Is spontaneous breathing present and/or adequate?.

Yes No

Check patency of airway Check breath sounds

Establish an airway a. head tilt, chin lift b. artificial airway c. consider reversal

agents.

Problem resolved Reassess status – Is pt. breathing?

Yes No No

Yes

Assess pt. Oxygen Monitor VS.

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Oxygen Oxygen Ventilate with Monitor v.s. Monitor v.s. ambu.

Further assessment Consider intubation. Consider reversals

The second most common complication concerns cardiovascular changes. may include:

These

If the patient is extremely unstable, institute Basic Life Support measures, and attend to the CAB: Circulation, Airway and Breathing

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Signs and Symptoms Nursing Intervention A. Hypotension

B. Hypertension

C. Bradycardia

D. Arrhythmias

1. Administer IV fluids as ordered 2. Consider reversal agents 3. Patient’s legs may be elevated slightly.

1. Ensure proper ventilation, retention of pCO2 may cause elevated blood pressure.

2. Consider need for additional sedation. 3. Administer anti-hypertensive medication as

ordered. 4. Consider stopping procedure.

1.Ensure oxygenation 2. Arouse patient 3.Administer medications, i.e. Atropine, Robinul as ordered by physician 4.If thought to be vagal, consider stopping procedure (common with colonoscopy).

1.Consider hypoxia as the primary cause. 2. Administer or increase oxygen flow. 3.Administer anti-arrhythmic, such as Lidocaine, as ordered.

Discharge from Sedation Level of Care:

In this instance, “discharge” means that the patient no longer requires such a high level of nursing care and frequency of monitoring and are discharged from sedation care and not necessarily, physical discharge from an area, although that may also happen. A patient who has been “discharged” from procedural sedation no longer requires EKG or pulse oximetry monitoring for effects of the medication and has returned to baseline in terms of vital signs and level of consciousness

Patients may be discharged from sedation protocol once this criteria has been met:

 Aldrete score of 8 or greater, or return to baseline  Patient is awake, alert, oriented or as baseline;  Airway is patent, gag reflex is present and no breathing difficulties are noted;  vital signs are stable, within acceptable limits, ideally within 20% of pre-procedure

level;  Skin is warm and dry, color good  Pain is controlled  Controlled nausea, no vomiting  Ability to ambulate, or as baseline  Able to tolerate fluids  Stable in terms of the procedure, such as dry dressing, no bleeding, etc.  Remember that patients who have received reversal agents must be monitored for

at least two hours after the dose of reversal  Outpatients are to be given written instructions regarding post-procedure diet,

activities, etc.  Outpatients must be discharged in the company of a responsible adult.  No patient who has received sedation is allowed to drive home.

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References Adams,D. and Dervay, K. (2012). Pharmacology of Procedural Sedation. American

Association of Critical Care Nurses Advanced Critical Care, 23(4), 349-3 54.

American Association of Nurse Anesthetists. Non-anesthesia Provider Procedural Sedation and Analgesia: Considerations for Policy Development. Retrieved from https://www.aana.com/docs/default-source/practice-a ana-com-web-documents-(all)/non-anesthesia-provider-procedural- sedation-and-analgesia.pdf?sfvrsn=670049b1_2

American Society of Anesthesiologists. ASA Model Policy. Website: www.asahq.org.

American Society of Anesthesiologists (2017). Advisory on Granting Privileges for Deep Sedation to Non-Anesthesiologist Physicians: Quality management and departmental administration.

American Society of Anesthesiologists. Distinguishing monitored anesthesia care (“MAC”) from moderate sedation /analgesia (conscious sedation). Approved statement by ASA House of Delegates October 27, 2004. Amended October 21, 2009.

Association of Operating Room Nurses (2007). Recommended practices for managing the patient receiving moderate sedation/analgesia. 2007 Standards, Recommended Practices, and Guidelines. 467-472.

Hockenberry, M. and Wilson, D. (2015). Wong’s Nursing Care of Infants and Children, 10th edition.

Eberson, C., Hsu, R. and Borenstein, T. (2015). Procedural Sedation in the Emergency Department. Journal of the American Academy of Orthopaedic Surgeons, 23(4), 233-242.

Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals (CAMH). The Official Handbook. (2006). Oakbrook Terrace, Ill; JCAHO. Pc41-pc43.

Kost, M. (2004). Moderate Sedation/Analgesia: Core Competencies for Practice. 2nd ed. St. Louis: WB Saunders.

Kost, M. (2004). Questions and Answers in Sedation/Analgesia. Specialty Health Education Inc., Blue Bell, PA.