Download Sedation and Analgesia for Procedures

You have recently submitted a privilege form to the Fairview System Credentialing Office and
requested Moderate and Deep Sedation (sedation/analgesia). Privileges are required in order to
perform moderate and deep sedation at any of the Fairview facilities. To complete your request for
Moderate and Deep Sedation privileges, the following is necessary:
1. Review the enclosed Physician Self-Learning packet. The criteria for privileges require that
you read all the information, complete the case studies and take the quiz at the end of the
packet. You must achieve an 80% on the quiz, which you do not need to return.
2.
By signing the attestation of the privilege form, you are attesting that you have reviewed the
Self-Learning packet and scored at least 80% on the quiz.
If you have any questions, please contact the Fairview System Credentialing Office at 612-672-7700.
Fairview Health System
Sedation/Analgesia
Physician Self-Learning Packet
Fall, 2002
JoAnn Grimm, CRNA and Marnie Huss, RN
Learning Specialists
Edited By: Dr Ian Hasinoff
Clinical Director of Anesthesia
Perioperative Services
Fairview University Medical Center
Updated policy and m edication grids July / 2006, 2012
2
Sedation/Analgesia
Introduction
The Joint Commission on Accreditation of Healthcare Organizations (JC) has defined
specific standards for the administration of moderate and deep sedation, analgesia and
anesthesia. This policy was created to comply with these 2001 Standards, which are based
on the American Society of Anesthesiologists (ASA) "Guidelines for Sedation and Analgesia
by Non-Anesthesiologists." The standards also state that "individuals administering
moderate or deep sedation and anesthesia are qualified and have the appropriate
credentials to manage patients at whatever level of sedation or anesthesia is achieved,
either intentionally or unintentionally." Privileging physicians to perform moderate/deep
sedation meets the intent of "appropriate credentials."
The purpose of this Self-Learning Packet is to provide the physician with information
necessary to safely and appropriately care for patients receiving moderate to deep
sedation/analgesia. This packet is in no way inclusive of all assessments and interventions
that might be necessary for an individual patient. Practitioners involved with the care of
patients receiving sedation are responsible for understanding and following this policy.
3
Sedation/Analgesia Self-Learning Packet
Objectives
After completion of this self-learning packet, the physician will be able to:
•
•
•
•
•
•
•
Define the levels of sedation/analgesia
Discuss the indications, contraindications, actions, administration, dosage, potential side
effects related to sedatives, analgesics, and antagonists
Describe the patient assessments before, during, and after sedation/analgesia.
State the advantages and limitations of pulse oximetry
Describe the interventions for deepening sedation
Identify the appropriate equipment for patient care areas where sedation/analgesia are
administered
Discuss the Fairview System policy “Sedation and Analgesia for Procedures”
This packet contains the system policy, appendices, and attachments referred to in the
policy. Additional information to further define levels of sedation, appropriate assessments,
interventions, and documentation is also included. Questions and case studies are provided
to assess assimilation of information.
4
Sedation/Analgesia Self-Learning
Packet
Contents
The sedation continuum…………………………………………………………………….…..6
Pharmacological recommendations……………………………………………………….…8
Non-pharmacological interventions……………………………………………………….…9
Patient assessment and monitoring………………………………………………………...10
Interventions for deepening levels of sedation/analgesia……………………….….14
“Sedation and Analgesia for Procedures” Policy………………………………………..17
Physical Status Classification of the ASA…………………………………………………..21
Mallampati Classification………………………………………………………………………...22
Modified Aldrete Score…………………………………………………………………………...23
Guidelines for Safe Discharge after Ambulatory Surgery…………………………….24
Sedation Analgesia Recommended Elements of Documentation………………….25
Commonly Used Medications…………………………………………………………………..27
Documentation Form……………………………………………………………………………. 35
Self Study Quiz....………………………………………………………………………………….37
Case Studies
Sedation/Analgesia Questions
5
The Sedation Continuum
Sedation/analgesia is the practice of producing a calming or sedating effect and/or
analgesia through the use of medications. There is no clear delineation among the
levels of sedation. JC Standards emphasize that the patient's sedation level
is not determined by the drug dose but by the patient's responses to the medication(s). A
drug dose producing minimal sedation for one patient may be deep sedation, or, although
rare, general anesthesia in another. This requires astute assessment of the patient at all
times while the patient is receiving sedative/analgesic medications or recovering from them.
The following graphic illustrates the sedation continuum:
>>>>>>>>>>>>>>>>>>>>>>>>>>>
<<<<<<<<<<<<<<<<<<<<<<<<<<<
Minimal
(Anxiolysis)
Moderate
(Conscious Sedation)
Deep
Anesthesia
6
SEDATION CONTINUUM GRID
The Sedation Continuum Grid defines typical signs and symptoms for each level.
Minimal
Sedation
(Anxiolysis)
Cognitive function
may be impaired
Moderate
Sedation/Analgesia
(Conscious Sedation)
Depression of
consciousness, easily
arousable
Normal response
to verbal
commands
Responds purposefully
to verbal commands,
may require light
tactile stimulation
Protective
Reflexes
(Laryngealcough,
pharyngealgag)
Airway
Maintained
Maintained
Able to maintain
patent airway
Able to maintain
patent airway
Spontaneous
Ventilation
Adequate
Cardiovascular
Function
Maintained
Responsiveness
Deep Sedation/
Analgesia
Anesthesia
Depression of
consciousness,
cannot be easily
aroused
Loss of
consciousness
Responds
purposefully
following repeated
or painful
stimulation
Partial/Complete
loss of protective
reflexes
Not arousable
even with
painful
stimulation
Loss of
protective
reflexes
Adequate
May require
assistance to
maintain patent
airway
May be impaired
Often requires
assistance to
maintain
patent airway
Often
impaired
Maintained
Maintained
May be
impaired
If the intent is deep sedation, protective reflexes, the ability to
maintain an airway, and ventilation may be impaired.
7
Pharmacological Recommendations
Sedatives, benzodiazepines, and opioids used for sedation/analgesia may cause
somnolence, confusion, diminished protective reflexes (e.g. cough, swallow and gag),
airway obstruction, and depressed respiratory and cardiovascular functions. Opioids may
also cause nausea and vomiting. Since the level of sedation may easily change from light to
deep, continuous monitoring of respiratory and cardiac function is essential.
Knowledge of the medications used in sedation/analgesia and reversal agents is the
responsibility of the practitioner ordering the administration of each agent as well as the
practitioner who performs the actual administration and assessment of patients receiving
these agents.
Recommendations for medication administration include:
•
•
•
•
•
•
•
•
•
Administer medications slowly.
Administer medications in incremental doses.
Assess/reassess the patient after each dose.
Consider that individual patient response to a particular dose of medication may
vary significantly.
The cardiovascular and respiratory depressive effects of opioids and sedatives are
potentiated when used in combination.
Drug dosages may need to be decreased based on the patient’s medical condition:
e.g. age; cardiac, pulmonary, hepatic and renal function.
Drug dosages may need to be increased based on the patient’s current tolerance to
opioids and sedatives.
The amount of stimulation the patient receives may influence the level of
sedation/analgesia observed: e.g. during the actual procedure the patient may be
awake and alert. During the recovery period when the stimulation is gone the patient
may slip into a deeper level on the sedation continuum.
Additional resources available to obtain further information on commonly used
sedation/analgesia medications include pharmacists, Medline, and medication
reference books.
8
Non-Pharmacological Interventions
The ways clinicians interact with patients also helps to reduce their anxiety prior to and
during a procedure. Non-pharmacological methods to help reduce the patient's anxiety
include:
Adequate pre-procedure preparation. Knowledge of what is going to happen during the
procedure (sounds, sensations etc.) reduces patient's fear of the unknown. Explanations
about the actions of the medications to be used and what the patient may experience
after the drugs are administered reduce anxiety. Identification and use of past comfort
measures provides additional support. For example, some patients may prefer to talk,
some may prefer to be quiet, or some may want help with visualization.
• Emotional support. Empathize with the patient: talk with the patient not just at them.
Allow and encourage the patient to talk.
• Professionalism. A calm, unhurried professional atmosphere comforts patients.
Unprofessional, social talk amongst care providers is not beneficial to patients and could
increase their stress.
• Supportive environment. Control extraneous noise and traffic. Choose music of the
patient’s preference, not the staff's.
•
9
Patient Assessment and Monitoring
Refer to the policy for required assessment and monitoring parameters pre,
intra, and post-procedure. A thorough baseline (pre-procedure) assessment provides
a reference point, which allow care providers to recognize changes in the patient’s
condition. Early detection of undesirable patient responses allows for rapid intervention
and treatment.
Undesirable effects of sedation/analgesia include:
•
•
•
•
•
•
•
•
Loss of consciousness
Hypotension
Agitation
Combativeness
Hypoventilation/decreased oxygen saturation
Respiratory depression
Airway obstruction
Apnea
Age
1-6 months
6-12 months
1-2 yr
2-4 yr
4-6 yr
6-8 yr
10-12 yr
> 14 yr
Age-Specific Normal Vital Signs
Weight (Kg) Respiratory Rate
Heart Rate
4-6
24-30
120
6-10
24-30
130
10-12
20-24
130
12-14
20-24
120
16-18
20-24
100
20-26
12-20
100
30-45
12-20
75
>50
10-14
70
BP (sys) mm Hg
80 +/- 10
89 +/- 29
96
+/- 30
99
+/- 25
99
+/- 20
105 +/- 13
112 +/- 19
120 +/- 20
Changes in pulmonary and cardiovascular findings may indicate deepening levels of
sedation/analgesia, which require increasing monitoring and assessment.
10
Pulmonary Assessment
Early recognition of signs and symptoms of inadequate ventilation prevents the patient from
becoming hypoxemic or hypercarbic. Signs of a change in the patient’s general status
indicate a need for reassessment of the patient's respiratory status.
Assessments that may indicate a difficult airway are:
•
•
•
•
•
•
•
Inability to open the mouth
Poor cervical spine mobility
Receding chin
Large tongue
Prominent incisors
Short muscular neck
Morbid obesity
Proceed with caution if the patient has any of these findings: it may be difficult to maintain
or reestablish an airway.
Signs and symptoms of airway obstruction or inadequate ventilation
•
•
•
•
•
•
•
•
•
•
•
•
•
Snoring
Stridor
Nasal flaring
Tracheal or thoracic retractions
Decreased or absent breath sounds
Decreased oxygen saturation
Loss of chest expansion
Rocking of chest and abdomen
Change in mental status: restless, combative, decreased level of consciousness
Change in skin color: pale or dusky
Change in rate and depth of respirations
Change in heart rate and/or blood pressure: may either increase or decrease
Apnea
11
Principles of Pulse Oximetry include:
•
•
•
•
•
•
Noninvasive method of measuring the oxygen saturation of arterial blood
based on absorption of light at a specific wavelength by red blood cells
Measures ratio of oxygenated blood to the total amount of oxygen and expresses it
as a percentage
Heralds a hypoxic event before clinical signs
Requires pulsating vascular bed
SpO2 >90% = paO2 >60 mm Hg (with normal oxyhemoglobin curve)
SpO2 <90% indicative of hypoxemia
Advantages
Simplicity
Noninvasive
Continuous display
Sensitivity to changes in blood oxygen
levels
Ability to be applied to all ages
Relatively low expense
Limitations-Pulse oximeter may not
provide accurate reading when there is:
Motion at sensor site
Interference from ambient or extrinsic light
sources
Low perfusion states (hypotension, cold
extremeties)
Significant dysrhythmias
Carbon Monoxide or Methemoglobin in blood
Severe anemia (Hgb <5 gm/dl)
Electrical Interference
Suggestions for obtaining an accurate pulse oximeter reading:
•
•
•
•
•
Pick a warm well-perfused finger
Be sure the probe fits securely, but not too tight
Be sure the finger is clean
Be sure the patient’s heart rate matches the oximeter heart rate. If the oximeter
is not picking up accurately, try another finger, the ear, or the patient's nose.
Plethysmographic waveform monitoring may be helpful to validate a good signal. i.e.
pulse wave monitoring
Suggestions for troubleshooting the pulse oximeter:
•
•
•
•
When an alarm sounds-CHECK THE PATIENT
If the patient is in trouble-forget the oximeter and TREAT THE PATIENT
If the patient is ok-check the oximeter
Patient’s heart rate and oximeter rate should be the same rate/rhythm. If the
oximeter’s heart rate differs from the patient’s actual heart rate, the pulse oximeter may
not be picking up the correct arterial pulse. The oxygen saturation reading may not be
accurate.
12
Cardiovascular Assessment
Recognition of patients at a higher risk for developing cardiovascular complications as a
result of their sedation is an important assessment for care providers to make. Patients
with known cardiovascular disease, hypertension, dehydration, and elderly patients are at
higher risk for developing hypotension. Monitor blood pressure frequently in these patients.
Correlate changes in the patient’s heart rate on the pulse oximeter with the patient’s radial
or apical pulse. If the heart rate and/or rhythm change, EKG monitoring should be initiated.
Signs and symptoms of inadequate tissue perfusion include:
•
•
•
•
•
•
•
Decreased blood pressure
Increased/decreased heart rate and/or arrhythmias
Cool and/or mottled, pale or dusky extremities
Changes in mental status: confusion, light headedness, agitation, combativeness,
decreased LOC
Inability to obtain a pulse oximetry reading
Decreased capillary refill
Decreased urine output (if monitoring)
The frequency of assessments, monitoring, and documentation should be increased if a
patient exhibits an undesirable change in their physical assessment or level of
sedation/analgesia.
13
Interventions for Deepening Levels of Sedation/Analgesia
Patients may occasionally slip into a deeper level of sedation than had been originally
intended. If this occurs it is crucial for the care providers to intervene immediately. Follow
the ABCDs of basic emergency intervention: Airway, Breathing, Circulation,
Defibrillation/Drugs. Do not hesitate to call a code if more help is needed.
•
Airway: Maintain head in neutral midline position with the neck extended.
Perform the head-tilt, chin lift or jaw thrust procedures as needed to relieve airway
obstruction.
The Head-tilt, chin lift maneuver is performed by lifting the chin with the fingertips
underneath the bone at the center of the chin. Add the head tilt if necessary. Tilt the
head by placing a hand on the patient’s forehead and tilting the head back so the chin
comes up.
The Jaw thrust is performed by placing fingers under the angles of the mandible and
lifting the jaw forward.
(These procedures should be practiced as part of BLS training.)
Nasal and oral airways may also be utilized to maintain an open airway. A nasal
airway supports upper airway patency in a patient with minimal to moderate
obstruction and is well tolerated by awake or sedated patients with an intact gag
reflex. The proper nasal airway size may be estimated by the distance from the nares to
the angle of the mandible. Nasal airways can cause epistaxis and are usually avoided
with patients who are receiving anticoagulation therapy. An oral airway maintains
upper airway patency in patients who have airway obstruction from the tongue and soft
palate but may not be well tolerated if the patient’s gag reflex is intact.
Complications from the use of oral airways include vomiting, laryngospasm, and
dental trauma. The wrong size of oral airway may worsen the obstruction. The
correct size of the oral airway may be estimated by holding the airway against the
patient’s face; the tip of the airway should end just cephalad to the angle of the
mandible. If the airway is too short, it may compress the tongue; if it is too long,
it may lie against the epiglottis.
14
•
Breathing
Support the patient's respiratory efforts with bag/valve/mask if the patient’s respiratory
rate and depth are inadequate to maintain ventilation. With a respiratory rate less than
8 the patient may need to be manually stimulated or reversed with naloxone according
to hospital policy.
•
Circulation
Fluids, patient positioning (legs up or trendelenburg), drugs, and/or CPR may be
indicated for inadequate cardiac output (circulation) and tissue perfusion.
•
Drugs
Medications may be indicated either for reversal of sedation/analgesia or for supportive
measures, i.e. to support circulation. Reversal agents, naloxone (Narcan®) and
flumazenil (Romazicon), and other emergency medications found on the crash cart,
should be immediately available. Diminished reflexes, depressed respiratory function,
and impaired cardiovascular function may occur with drugs used for moderate and deep
sedation. Refer to appropriate medication references.
Differential Diagnosis: Once the patient is stabilized the underlying cause of the
symptoms and/or event must be sought: e.g. If a diabetic patient is confused - is the cause
due to the medications given or to a low blood glucose?
Emergency Equipment: Size appropriate emergency equipment listed in the policy, and
according to individual patient need, must be immediately available when moderate or deep
sedation are preformed
15
Fairview Health Services
“Sedation and Analgesia for Procedures”
Policy
This policy is available on line through the Fairview Intranet
Policies and Procedures homepage.
Policy update 3/06
16
System Policy
Code: S:PC-2012
Entity: Fairview Health Services
Manual: Policy and Procedure
Category:
Subject:
Provision of Care, Treatment and Services
Sedation and Analgesia for Procedures
Purpose: To ensure safe, consistent patient care when procedure-related sedation and
analgesia is indicated.
Definitions: 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.
Moderate sedation/analgesia (“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 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.
Anesthesia:
Consists of general anesthesia and 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
may be impaired.
Mallampati classification: (See Attachment 2)
Required airway assessment competency listed in the best practice for moderate
sedation by the University HealthSystem Consortium. An airway assessment is
to be included in the pre-sedation assessment.
Modified Aldrete Score: (See Attachment 3)
A suggested method for measuring and documenting recovery from sedation.
Exclusions: This policy does not apply to the following patients:
1. Patients receiving low dose sedative and/or analgesic medications for the
treatment of pain, anxiety, or sleep disruption common to hospitalized
patients.
2. Patients on chronic doses of sedation or antihistamines for existing conditions.
3. Patients receiving minimal sedation for diagnostic and therapeutic procedures
where respiratory and cardiovascular functions are not affected. They are able
17
4.
5.
Policy:
to respond normally to verbal commands even though cognitive function and
coordination may be affected. (e.g. minimally invasive procedures such as
echocardiograms or voiding cystourethrograms). As such, they will not be
allowed to drive, but are excluded from the other requirements of the policy.
Patients receiving mechanical ventilation through an artificial airway or
patients receiving sedation either intermittently or continuously in an intensive
care setting as part of routine care.
Patients receiving chronic analgesia or anxiolysis for neoplastic or other
conditions that require periodic escalation of therapy for pain relief or anxiety.
1. Patients who have received any sedation, narcotic analgesics, or antihistamines
for procedures are not allowed to drive home.
2. Outpatients are to have responsible adult or family member to accompany them
at discharge and drive them home. A service providing medically trained
drivers or attendants would be acceptable. A cab service would not be
acceptable.
3. Prescribing providers must be privileged for the appropriate level of
sedation/analgesia. Board-certified physicians in emergency medicine, critical
care medicine, neonatology, and oral maxillofacial surgery are considered, by
their certification, to be competent and therefore, not required to consult
anesthesia care provider as indicated below.
4. Any time deep sedation and analgesia or anesthesia is anticipated appropriately
privileged practitioners must be in attendance. The practioner must be able to
intubate and rescue those patients who show need for intubation and/or rescue.
5. A consultation with an anesthesia care provider is recommended for a patient
who:
a. Has known respiratory compromise or hemodynamic instability
i. Presents with significant comorbid conditions or sleep apnea.
ii. Has an ASA physical status of 4
d. Is assessed to have a Mallampati classification of III (see Attachment 2)
6. A consultation with an anesthesia care provider is required for:
a. Patients with an ASA physical status of 5
b. Infants who are born prematurely (<37 weeks gestation) who at the time
of the procedure are <60 weeks postconception and who are not
residing in the neonatal intensive care unit or pediatric intensive care
unit (Note: postconceptual age is the gestational age at birth plus the
age since birth [e.g., a baby born at 32 weeks who is 12 weeks old is 44
weeks postconception.])
c. Patients with a history of airway problems during sedation/analgesia or
general anesthesia
d. Patients with a history of adverse reaction to sedation/analgesia or
general anesthesia
e. Children with neuromuscular disease affecting respiratory or brain stem
function
f. Patients who are assessed to have a Mallampati classification of Class
IV (see Attachment 2)
7. Sedation and analgesia can be performed in any location where competent
personnel and the required equipment are available.
8. Sufficient numbers of personnel (in addition to the licensed independent
practitioner performing the procedure) with demonstrated competency must be
present to:
a. Appropriately evaluate the patient prior to beginning moderate or deep
sedation (RN/MD)
b. Provide the moderate or deep sedation (RN/MD)
c. Monitor and assess the patient (RN)
d. Assist with performing the procedure
e. Recover and discharge the patient either from the post-sedation area or
from the patient care area according to pre-established discharge
criteria. (RN)
9. RN staff administering sedation will have:
a. No other concurrent responsibilities during the procedure.
18
b. Current BLS certification
c. Basic ability to recognize a cardiac dysrhythmia for
monitoring purposes
d. Working knowledge of sedatives/analgesics and
antagonists
e. Completed education for sedation and analgesia
f. Completed additional education and competency
verification to assist physician with deep sedation
g. Ongoing education in care of pediatric patients as
appropriate
10.
Age and size-appropriate equipment for care and resuscitation
is available for monitoring vital signs, including heart and
respiratory rates, blood pressure, and oxygenation. Equipment
includes:
11.
a. Blood pressure cuff
b. Audible pulse oximetry equipment
c. Readily available crash cart (minimally includes ventilation
management equipment, O2, suction equipment and emergency
medications)
d. Cardiac monitor when indicated
Recommended medications are:
a. Fentanyl (short-acting opioid)
b. Midazolam (short acting benzodiazepine)
c. Other agents that are approved by the System Formulary Committee in
consultation with anesthesia and in consideration of the areas in which
they are used (see also medication grid).
12. The patient’s response to care provided throughout the sedationsupported procedure is documented in the patient’s record.
Procedure: 1. Outpatients are instructed to have responsible adult or family member to
accompany them at discharge and drive them home. Should a patient arrive for
a procedure without a responsible adult, the patient should be given the option of
not receiving any medication or rescheduling the procedure (may need to consult
with the performing LIP as to appropriateness of not receiving medication and
the performance of the procedure).
2. Patients are instructed regarding NPO status. (See entity-specific guidelines.)
3. Care for all patients with planned moderate or deep sedation /analgesia
includes:
a. Pre-sedation assessment to include:
•
History and physical with focused airway exam (to include
auscultation of the heart and lungs and airway evaluation)
•
Assignment of ASA status
•
Assessment of sleep apnea
b. Formulation of a sedation plan
c. Informed consent
d. Reassessment immediately prior to sedation
e. Assessment on admission to and discharge from post sedation area.
4. Monitoring During Procedure
a. Continuously (prolonged without any interruptions at any
time) monitored heart rate and oxygenation by audible
pulse oximetry
b. Respiratory frequency and adequacy of pulmonary
ventilation are continually (repeated regularly and
frequently in steady, rapid succession) monitored.
c. Vital sign and patient assessment every 5-15 minutes as
19
condition warrants (minimally heart rate, respiratory rate,
O2 saturation, blood pressure and if indicated, heart
rhythm). Vital signs should be monitored after each
medication administration and with any significant event.
d. Assessment of pain & sedation level with vital signs
e. EKG is monitored in patients with significant
cardiovascular disease or when dysrhythmias are
anticipated or detected.
5. Post-procedure
a. For deep sedation, continuously monitored heart rate and
oxygenation by audible pulse oximetry. Respiratory rate,
blood pressure, and if indicated, heart rhythm monitored
minimally every 15 minutes. . (See also Attachment 3,
the Modified Aldrete score, for guidance in assessment of
recovery status.)
b. For moderate sedation, monitoring minimally every 30
minutes.
c. Minimum recovery time-one hour post medication or
meets established discharge criteria for patient care area.
d. Minimum of 2 hours post procedure observation and
monitoring if patient has received a reversal agent.
6. Discharge
a. Follow pre-established discharge criteria. (See also
Attachment 4, the “Guidelines for Safe Discharge After
Ambulatory Surgery”, for guidance in assessment of
recovery status.)
b. A responsible adult must accompany outpatients. Patients
who have received any sedation, narcotic analgesics, or
antihistamines for procedures cannot drive themselves
home. It is recommended that the responsible adult remain
with the patient for 6 hours. If the patient is unable to have
a responsible adult stay with them after the procedure,
additional recovery time may be considered before
discharge.
c. Patients are discharged by a qualified Licensed Independent Practioner
or according to criteria approved by the medical staff.
7. Documentation
a. Documentation forms may vary.
b. Documentation to include:
• The recommended elements (see attached.)
• Use of a sedation scale to quantify level of sedation
during and after the procedure.
• Use of a pain scale to quantify level of pain during and
after the procedure.
• Name and/or signature of person responsible for
patient at the time of discharge.
8. Adverse outcomes of patients undergoing sedation/analgesia are collected,
analyzed, and addressed according to entity procedures.
20
External Ref: “Moderate Sedation Best Practice Recommendations”, University Health System
Consortium, 2005
Internal Ref: Entity-Specific Attachments:
• FLHS: FLHS Addendum, Medication Grid, Audit Tool, Consent Form,
Ambulatory Discharge, Decision-Making Checklist, Minimum Sedation
Guidelines, NPO Guidelines, Sedation Record
• FSH: Medication Grid
• UMMC Medication Grid
Source: System-wide Sedation and Analgesia Committee
Approved by: Policy Committee
Date Effective: 9/02
Date Revised: 3/06
Date Reviewed: 3/06
Attachment 1
ASA Physical Classification System
P1
P2
P3
P4
P5
P6
A normal healthy patient
A patient with mild systemic disease
A patient with severe systemic disease
A patient with severe systemic disease that is a constant threat to life
A moribund patient who is not expected to survive without the operation
A declared brain-dead patient whose organs are being removed for donor
purposes.
(http://www.asahq.org/clinical/physicalstatus.htm; March 9, 2006)
21
Attachment 2
Mallampati Classification
The Mallampati classification is based on the finding that visualization of the glottis is impaired
when the base of the tongue is disproportionately large. Assessment is made with the patient sitting
upright, with head in neutral position, the mouth open as wide as possible, and the tongue protruded
maximally. The modified classification includes four categories:
Class I
Faucial pillars, soft palate, and uvula are visible.
Class II
Faucial pillars and soft palate may be seen, but uvula is masked by the base of the
tongue.
Class III
Only soft palate is visible. Intubation is predicted to be difficult.
Class IV
Soft palate not visible. Intubation predicted to be difficult.
22
Attachment 3
The Modified Aldrete Score
Activity
Able to move four extremities voluntarily or on
command
Able to move two extremities voluntarily or on
command
Unable to move extremities voluntarily or on
command
Respiratory
Able to breathe deeply and cough freely
Dyspnea or limited breathing
Apneic
Circulation
BP + 20% of preanesthetic level
BP + 20-49% of preanesthetic level
BP + 50% of preanesthetic level
Consciousness
Fully awake
Arousable on calling
Not responsive
O2 Saturation
Able to maintain O2 saturation >92% on room air
Needs O2 to maintain O2 saturation >90%
O2 saturation <90% even with O2 supplement
Total
Score
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Patients with scores of 8-10 may be transferred to the next phase of recovery.
Aldrete, J. Antonio: Modifications to the Postanesthesia Score for Use in Ambulatory Surgery. Journal of PeriAnesthesia
Nursing, Vol 13, No 3 (June), 1998: pp 148-155
23
Attachment 4
Guidelines for Safe Discharge After Ambulatory Surgery
Score
Activity
Able to move four extremities voluntarily or on command
Able to move two extremities voluntarily or on command
Unable to move extremities voluntarily or on command
Respiratory
Able to breathe deeply and cough freely
Dyspnea or limited breathing
Apneic
Circulation
BP + 20% of preanesthetic level
BP + 20-49% of preanesthetic level
BP + 50% of preanesthetic level
Consciousness
Fully awake
Arousable on calling
Not responsive
O2 Saturation
Able to maintain O2 saturation >92% on room air
Needs O2 to maintain O2 saturation >90%
O2 saturation <90% even with O2 supplement
Dressing
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Dry and clean
Wet but marked and not increasing
Growing area of wetness
2
1
0
Pain free
Mild pain handled by oral medication
Severe pain requiring parenteral medication
2
1
0
Able to stand and walk straight*
Vertigo when erect
Dizziness when supine
2
1
0
Able to drink fluids
Nauseated
Nauseated and vomiting
2
1
0
Has voided
Unable to void but comfortable
Unable to void and uncomfortable
2
1
0
Pain
Ambulation
Fasting-Feeding
Urine output
Total
*May be substituted by Romberg’s test, or by picking up 12 clips in one hand.
A score of 18 or higher is required for home discharge.
Aldrete, J. Antonio: Modifications to the Postanesthesia Score for Use in Ambulatory Surgery. Journal of PeriAnesthesia
Nursing, Vol 13, No 3 (June), 1998: pp 148-155
24
Attachment 5
Sedation Analgesia Recommended Elements of Documentation
RN Pre-Sedation Assessment
• Vital signs: Temp/Pulse/Resp, BP, O2 saturation
• Height/weight
• NPO status
• Pain level
• Level of consciousness
• Health history including:
• Medications/allergies
• Screens for nutrition, function, communicable/infectious disease,
domestic abuse
• Females: Pregnant/nursing
• Labs (as indicated)
• Diagnostic tests (as indicated)
• Venous access device
• ID band
• Allergy band (as indicated)
• Physician assessment (history/physical)
• Affirmation of Informed Consent
• Outpatients: Responsible adult
• Patient teaching
•
•
•
•
•
•
MD Pre-Sedation Assessment
History/physical including:
• Review of past medical history
• Review of anesthesia/sedation history
• Assessment for sleep apnea
• Medications/allergies
• Physical exam: Heart/lungs/airway
Vital signs review
Labs (as indicated) review
Diagnostic tests (as indicated) review
Informed consent for sedation
ASA assignment
25
• Sedation plan
• Reassessment immediately prior to procedure
•
•
•
•
•
•
•
Intra-Procedure
Vital signs: Temp/Pulse/Resp, BP, O2 saturation
Sedation level
Pain level
Supplemental O2 (as indicated)
Medications
VAD/IV fluids
Adverse outcomes
•
•
•
•
•
•
•
Post-Procedure
Vital signs: Temp/Pulse/Resp, BP, O2 saturation
Sedation level
Pain level
Admission and discharge criteria scores
Discharge teaching/instructions (as indicated)
Outpatients: Responsible adult
Adverse outcomes
Miscellaneous
• Names/titles of staff
• Pertinent procedure-specific information
26
PRE-SEDATION AGENTS
Drug
Atropine
Route
IV, IM, PO,
PR, SQ
Dose/Titration
<5kg:
IV, IM, PO, PR, SQ 0.1 mg
Note this is based on 0.02 mg/kg/dose with a
minimum of 0.1mg/dose in this population.
ANTISECRETORY AGENTS
Onset
Duration
PO, IM: 15
4 hours
minutes – 1 hour
Side Effects/Precautions
Use with caution in patients with tachycardia, thyrotoxicosis, obstructive diseases of the
GI tract, obstructive uropathy, spastic paralysis, myasthenia gravis, and cystic fibrosis.
Monitor heart rate since atropine may cause tachycardia.
IV: 10 minutes
Pregnancy Category C
No definite association with malformations, possible drug class association. Has been
used to decrease secretions before c-sections. May cause decreased respiratory rate in
fetus. The AAP considers atropine compatible with breastfeeding, although the extent to
which it passes in to breast milk is unknown.
5-50 kg:
IV, IM, PO, PR, SQ 0.01-0.02 mg/kg/dose
Minimum dose 0.1mg
Maximum dose 0.5mg
Adult Dose or patient > 50kg:
0.4 mg SQ, IM, or IV
Maximum dose 1mg
Glycopyrrolate
IV, IM
<5kg:
IV, IM: 0.05 mg
Note this is based on 0.01 mg/kg/dose with a
minimum of 0.05mg/dose in this population.
IV: 1-10 minutes
Up to 7 hours
IM: 15-30 minutes
Monitor heart hate: may cause tachycardia.
Use with caution in patients with tachycardia, thyrotoxicosis, obstructive diseases of the
GI tract, obstructive uropathy, spastic paralysis, cystic fibrosis, hepatitis, and myasthenia
gravis.
Pregnancy Category B
Crosses placenta, but less than atropine.
Possible drug class association with minor malformations. Has been used to decrease
secretions before c-sections. Anticholinergic of choice for anesthesia for
electroconvulsive therapy in pregnant patients.
No breastfeeding data available.
5-50 kg:
IV, IM: 0.005-0.01 mg/kg/dose
Minimum Dose: 0.05 mg
Maximum Dose: 0.25mg
Adult Dose or patient > 50kg:
0.1-0.3mg IM/IV
Maximum dose 0.5mg
LOCAL AGENT
Drug
1% Lidocaine
Route
Infiltration
Dose/Titration
3-5 mg/kg/dose via infiltration (not
parenterally)
Onset
45-90 seconds
Duration
1-2 hours
Maximum dose in combination with
epinephrine: 7 mg/kg
Side Effects/Precautions
Doses may vary based on procedure, degree of anesthesia needed, tissue vascularity and
duration of effect required.
Consider degree of dosage in patients with impaired liver function.
Pregnancy Category C
Rapidly crosses placenta. No evidence of association with large categories of major or
minor malformations. Has been used for epidural anesthesia during labor. Possible
complications for infant include: decreased muscle strength/tone, CNS depression,
seizures, apnea. Treatment of choice for ventricular arrhythmias during pregnancy.
TOPICAL AGENT
Drug
4% Lidocaine
(LMX-4 or EMLA)
Route
Topical
Dose/Titration
Children weighing <10 kg:
Apply topically to an area not larger than 100
cm (typically half of a 5gm tube)
Children weighing 10-20 kg:
Apply topically to an area not larger than 200
cm (typically a 5gm tube)
Onset
30 minutes
Duration
1-2 hours after
removal of cream
Side Effects/Precautions
Apply to intact skin. Covering with an occlusive dressing is optional
Lidocaine is Pregnancy Category C
Note: The above dosages are only intended to be used only as guidelines. Depending upon patient, slightly higher or lower doses may be necessary.
Last Update: February, 2006, Fairview Pharmacy Services
Agents for Adult Sedation
Drug
Midazolam
Drug
Fentanyl
Benzodiazepine – For Sedation, Amnesia, and Relief of Anxiety Only. Not for Pain Control
Dose/Titration
Onset
Duration
Side Effects/Precautions
IV:
Duration after single
Adults < 65 yrs old
Adverse Drug Reactions:
1-2 mg IV over 1 minute; wait 2 minutes
1-5 min
dose = 20-40 minutes
1. CNS effects/withdrawal
to evaluate response; if needed, give 1
(IV)
2. Respiratory depression, apnea
mg IV slowly every 4 minutes until
3. Anterograde amnesia
Elimination =
desired response (usually not more than 5
4. Hiccups, nausea, vomiting
metabolized by the
mg needed)
5. Rarely hypotension
liver, excreted in urine
and feces
Not removed by hemodialysis or peritoneal dialysis
Adults >/= 65 yrs old
0.5-1.5 mg IV over 1 minute; wait 2
Active metabolite =
minutes to evaluate response; titrate in
Pregnancy category D
Yes
0.5 mg increments every 4 minutes to
Freely crosses placenta, although more slowly than lorazepam and diazepam. Possible complications for newborn:
desired response (up to a maximum of
hypotonia, lethargy, sucking difficulties, IUGR, withdrawal symptoms.
Half-life = 1-12 hrs
3.5 mg)
Excreted in breast milk. Mean Milk: Plasma ration 0.15
(longer with chronic
dosing)
Unknown effect on breastfeeding infant-prolonged exposure not recommended
Narcotic – For Pain Control Only. Not Appropriate for Sedation, Amnesia, or Relief of Anxiety
Dose/Titration
Onset
Duration
Side Effects/Precautions
IV:
30-60 minutes
Adverse Drug Reactions:
Adults < 65 yrs old
25-50 mcg IV over 2-3 minutes (may
3 minutes
1. Respiratory depression, apnea
repeat every 5-10 minutes to a maximum
Elimination= hepatic
2. Bradycardia, hypotension
dose of 200 mcg in 60 minutes)
3. Nausea and vomiting
Half-life=2-7 hours
4. Sedation
5. Decreased gut mobility
Adults >/= 65 yrs old
25-50 mcg IV over 2-3 minutes (may
6. Urinary retention
repeat every 5-10 minutes to a maximum
dose of 100 mcg)
Hypotension with rapid administration
The respiratory depressant effect of fentanyl may last longer that the analgesic effect
May have synergistic effect when used with Versed®; consider lower doses when used in this combination
Consider the total dose of all narcotics used
Pregnancy Category B (Category D if used in high doses for prolonged periods at term). Freely crosses placenta. No
reports of congenital defects. Possible effects on newborn include withdrawal and respiratory depression
Excreted in breast milk. AAP considers morphine compatible with breastfeeding
Narcotic Reversal Agent
Drug
Naloxone
Dose/Titration
Take contents of one 0.4 mg/ml ampule
(use filter needle) and dilute with 9ml of
normal saline to a total volume of 10ml.
This will provide a concentration of
0.04mg/ml. Give 1ml (0.04mg) IV q1-2
minutes until desired degree of reversal is
obtained. May need to repeat dose every
20-30 minutes, or more frequently.
Observe for re-sedation, return of
respiratory depression.
For narcotic overdose where rapid and
full reversal is necessary, the entire
contents of the 0.4 mg/ml ampule may be
given IV (undiluted) – repeat as necessary
to obtain necessary response.
Onset
IV:
2-3 minutes
Duration
Duration after single
dose = 1-2 hours
Elimination =
conjugated in the liver,
eliminated in the urine
Side Effects/Precautions
May precipitate withdrawal symptoms (e.g. hypertension, sweating, agitation, nausea, and irritability) in patients
dependent on opiates. Use with caution in these patients, and in those with chronic cardiac and pulmonary diseases.
Naloxone effects may wear off before the effects of the narcotic do, and sedation and respiratory depression may
reoccur.
Active metabolite =
No
Adverse Drug Reactions:
Excessive reversal, withdrawal symptoms, agitation
Drug Interactions:
May reverse hypotensive and bradycardic effects in clonidine overdose
Half-life= 30-80 min
The duration of action of the opioids may exceed that of Naloxone, so REPEATED DOSES may be necessary
Pregnancy Category B
Freely crosses placenta. Has been safely given to infants immediately after delivery. No information on safety of use
during pregnancy.
No breastfeeding data available.
AGENTS FOR ADULT SEDATION
Benzodiazephe Reversal Agent
Drug
Dose/Titration
0.2mg IV over 15 seconds
If the desired level of consciousness is not
obtained after waiting an additional 45
seconds, may repeat with 0.2mg at 60second intervals, up to a maximum total
dose of 1mg.
Flumazenil
Onset
IV:
10-120
seconds
Peak
Response=
6-10
minutes
Duration
Duration after single
dose = 60-90 minutes
Elimination =
eliminated by hepatic
metabolism
Side Effects/Precautions
Do not use in patients with a tricyclic antidepressant overdose. Seizures may occur in patients who are physically
dependent on benzodiazepines or are receiving them for control of seizures. Flumazenil effects may wear off before
the effects of the benzodiazepine do, and sedation may reoccur. May not reliably reverse respiratory depression.
Adverse Drug Reactions:
Seizures (see above), arrhythmias (rare), nausea and vomiting.
Active metabolite =
May accumulate in hepatic impairment.
In the case of re-sedation, repeated doses
No
may be administered at 20-minute
Pregnancy Category C
intervals as needed. For repeat treatment,
Half-life= 45-80 min
No breastfeeding data available.
no more than 1 mg (given as 0.2mg/min)
should be administered at any one time,
and no more that 3 mg should be given in
any one hour.
Note: The above dosages are only intended to be used only as guidelines. Depending upon patient, slightly higher or lower doses may be necessary.
References:
1.
2.
3.
4.
5.
An updated report by the American Society of Anesthesiologists Task Force on sedation and analgesia by non-anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists.
Anesthesiology 2002:96:1004-1017.
Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointestinal endoscopy 2003:58:317-22
PengP, Sandler AN. A review of the use of fentanyl analgesia in the management of acute pain in adults. Anesthesiology 1999:90:576-99
Bahn EL, Holt KR. Procedural sedation and analgesia: a review and new concepts. Emerg Med Clin N Am 2005;23:503-17
Horn E, Nesbit SA. Pharmacology and pharmacokinetics of sedatives and analgesics. Gastrointest Endoscopy Clin N Am 2004;14:247-68
Last Updated: February 2006, Fairview Pharmacy Services
Drug
Fetanyl
(Various brands)
Route
IV
Drug
Naloxone
(Narcan)
Route
IV
Medications for Pediatric Sedation
Narcotics- For pain control only. Not appropriate for sedation, amnesia, or relief of anxiety.
Dose/Titration
Onset
Duration
Side Effects/Precautions
Neonates: 1-2 mcg/kg/dose, may repeat at 3-5
1 – 3 minutes
IV: <60 minutes
Respiratory depression, apnea, hypotension, bradycardia, dizziness, nausea.
minute intervals until effect, then every 30-60
Rapid infusion may result in chest wall rigidity, give over 3-5 minutes
minutes
Decrease dosages in hepatic and renal insufficiency and elderly, debilitated patients.
T1/2 = 2-4 hours
Infant (18-36 months): 1-2 mcg/kg/dose, may
Pregnancy Category B (D if prolonged use or high doses)
repeat at 3-5 minute intervals until effect, then
Freely crosses placenta. No reports linking fentanyl to congenital defects.
every 30-60 minutes
Possible complications for newborn: withdrawal, respiratory symptoms
Children <12 years old:
1-2mcg/kg/dose, may repeat in 30-60 minutes
Excreted in breast milk. AAP considers morphine compatible with breastfeeding.
>12 yrs: 0.5-1 mcg/kg/dose, up to 50mcg/dose
May repeat in 30-60 minutes
Dose/Titration
To provide a gradual / titratable reversal:
Take contents of one 0.4mg/ml ampule; using a
filter needle, dilute with 9ml of normal saline to a
final volume of 10ml
Narcotic Reversal Agent
Onset
Duration
1-2 minutes
1-3 hours
T ½ = 1.5 hours
Side Effects/Precautions
Pulmonary edema, nausea, sweating, tachycardia, irritability
May precipitate withdrawal. Contraindicated in patients with chronic narcotic usage.
Avoid use in neonates born to mothers with narcotic or cocaine addiction
<20kg; <5 yrs
Give 0.25ml (0.01mg) IV; repeat every 1-2
minutes as needed to achieve desired reversal
20kg; >5yrs
Give 1ml (0.04mg) IV; repeat every 1-2 minutes
as needed to achieve desired reversal
Use with caution in cardiac disease or chronic pulmonary disease
Caution: Reversal of narcotic effect may wear off before the effects of the narcotic; redosing may be necessary
For full reversal: Give 0.2mg/kg IV (max dose
of 2mg); may be repeated q2min, as required
Benzodiazepines- For sedation, amnesia, and relief of anxiety only. Not for pain control.
Drug
Route
IV/IM
Midazolam
(Versed)
Dose/Titration
Neonates:
0.05-0.2 mg/kg/dose Q 1-4 hrs
Onset
PO: 20-30
minutes
Duration
PO: 2-6 hours
IV: 20-30 minutes
Side Effects/Precautions
Respiratory depression, hypotension, bradycardia, hiccups, apnea.
Decrease dosages in hepatic and renal insufficiency.
IV: 1-5 minutes
PO and
Rectal
IV
IV
<12 years:
0.25-0.5 mg/kg PO 30-45 min before procedure
May repeat 0.25mg/kg/dose PO x 1.
Max PO dose = 1mg/kg up to a total of 20mg
T1/2 = 1-4 hours
May cause paradoxical excitement.
Monitor RR, HR, BP, O2 saturation
Pregnancy Category D: freely crosses placenta. Possible complications for newborn:
hypotonia, lethargy, sucking difficulties, IUGR, withdrawal
0.05-0.1mg/kg IV 3 minutes before procedure
Titrate to a maximum of 0.4-0.6mg/kg IV
Excreted in breast milk. Milk:plasma ratio = 0.15
Unknown effect on breastfeeding infant
>12 years: 0.5mg IV every 3-4 minutes to a total
dose of 2.5-5mg. A total dose >5mg is generally
not needed.
Benzodiazepine Reversal Agent
Drug
Flumazenil
(Romazicon)
Route
IV
Dose/Titration
Children:
0.01 mg/kg (MAXIMUM 0.2mg/dose) IV over 15
seconds; may repeat 0.01mg/kg (0.2mg
MAXIMUM) every minute to MAXIMUM
TOTAL CUMULATIVE DOSE of 0.05mg/kg or
1mg, whichever is less
Onset
IV: 1 – 3
minutes
Duration
45-90 minutes
Side Effects/Precautions
Hypoventilation, may precipitate seizure.
T1/2 = 30-90 minutes
Pregnancy Category C
No breastfeeding data available.
30
Drug
Chloral Hydrate
Drug
Pentobarbital
Drug
Thiopental
Rectal
Route
PO or
Rectal
Route
PO,
IM,
PR,
IV
Route
Rectal
Dose/Titration
Neonates: 30-50 mg/kg PO or rectal, 30-60
minutes prior to procedure; only single dose
Infant (18-36 months): 50-75 mg/kg PO or
rectal, 30-60 minutes prior to procedure. May
repeat 25mg/kg/dose x 1 dose. Max dose for
infants is 100mg/kg up to 1 gram per day
Children (1-12 years old):
25-75 mg/kg x 1 dose.
May repeat 25mg/kg x 1 dose.
(max 2 grams / day)
Dose/Titration
>6 months-4 years:
PO, IM, PR: 2-4 mg/kg to max of 100 mg.
IV: 1-2 mg/kg, then 1-2 mg/kg q5-10 min
>4 years – adolescents:
PO, PR: 1.5-3 mg/kg to max of 100 mg.
IM: 2-6 mg/kg to max of 100 mg.
IV: 1-2 mg/kg, then 1-2 mg/kg q5-10 min.
Maximum total dose: 6 mg/kg
Adolescents:
PO, IV: 100 mg prior to procedure.
Maximum total dose: 500 mg
Dose/Titration
PR: 10-20 mg/kg
Onset
10-20 minutes
Other Agents
Duration
4-8 hours
Onset
IV: 1 minute
PO, IM, PR: 30-60
minutes
Side Effects/Precautions
Use with caution in porphyria.
Possible side effects: respiratory depression, increase in bilirubin, paradoxical excitement.
T1/2 = 4-12 hours
Pregnancy Category C. No reports linking chloral hydrate to fetal abnormalities. Sedative
effects in fetus not studied.
Excreted in breast milk. AAP considers chloral hydrate compatible with breastfeeding.
Risk of drowsiness or sedation for breastfeeding infant.
Duration
1-4 hours
Side Effects/Precautions
Rapid IV injection may cause respiratory depression, apnea, laryngospasm,
bronchospasm, and hypotension. Administer dose over 10-30 minutes
Do not inject at a rate > 50 mg/min.
Monitor respiratory, cardiovascular and CNS status
Pregnancy Category D. No data suggesting association with major malformations.
Hemorrhagic disease and barbiturate withdrawal in the newborn are theoretic possibilities.
Significant toxicity on neural development and sexual function has been noted with
Phenobarbital. Excreted in breast milk. Effect on the infant is unknown.
Onset
10-15 minutes
Duration
60-120 minutes
Side Effects/Precautions
Contraindicated in porphyria and status asthmatics. May cause paradoxical excitement.
Since drugs cannot be titrated by the rectal route, monitor closely for over sedation --monitor RR, HR, and BP.
Pregnancy Category B. Safety during pregnancy has not been determined. No
breastfeeding data available.
The AAP and WHO considers thiopental usually compatible with breastfeeding.
Drug
Methohexital
Rectal
Route
Rectal
Dose/Titration
PR: 10-20 mg/kg
Onset
10-15 minutes
Duration
60 minutes
Side Effects/Precautions
Contraindicated in porphyria and temporal lobe epilepsy. May cause paradoxical
excitement. Since drugs cannot be titrated by the rectal route, monitor closely for over
sedation ---monitor RR, HR, and BP
Pregnancy Category B. Safety during pregnancy not determined. No breastfeeding data
available. The AAP considers Methohexital compatible with breastfeeding. The
Thomson Lactation Rating states that infant risk cannot be ruled out..
Last Update: February 2006, Fairview Pharmacy Services
References:
1. Cravero JP and Blike GT, Review of pediatric sedation. Anesth Analg 2004;99:1355.
2. Flood RG and Krauss B. Procedural sedation and analgesia for children in the emergency department. Emerg Med Clin North Am 2003; 21:121
3. Kaplan RF and Young CI. Sedation and analgesia in pediatric patients for procedures outside the operating room. Anesthesiol Clin North Am 2002;20:181.
4. Krauss B and Green S. Sedation and Analgesia for procedures in children. N Engl J Med 2000;342:938
5. Rodriguez E and Jordan R. Contemporary trends in pediatric sedation and analgesia. Emerg Med Clin North Am 2002;20:199
6. Tolia V, Peters JM, Gilger MA. Sedation for pediatric endoscopic procedures. J Pediatr Gastroenterol Nutr 2000;30:47.
31
ANESTHETIC AGENTS FOR SEDATION
NOTE: MEDICATIONS WHICH MAY BE USED ONLY IN THE INTENSIVE CARE UNITS OR IN THE ED AND ORAL SURGERY CLINIC - BY PRIVILEDGED AND CREDENTIALED
ANESTHESIOLOGISTS, INTENSIVISTS, ED PHYSICIANS, ORAL SURGEONS OR THE ANESTHESIA SERVICE. COMBINATIONS OF DRUGS MAY ALSO POTENTIATE THE RISK OF APNEA AND
AIRWAY OBSTRUCTION; THEIR USE SHOULD ALSO BE RESTRICTED TO THE ABOVE LOACTIONS.)
ULTRA SHORT ACTING / ANESTHETIC
Drug
Route
Dose/Titration
Onset
Duration
Side Effects/Precautions
IV
20 seconds
4-10 minutes
Comments: Use cautiously in patients, <10 yrs of age, may induce seizures and
Etomidate
Pediatric Sedation:
IV: 0.1-0.2 mg/kg
epileptiform activity, therefore etomidate should be used with caution in epileptic
(Amidate)
Peak effect: 1 min
patients. Transient myoclonic movements unrelated to seizure activity is frequently seen.
Pediatric Induction for RSI:
IV: 0.2-0.4 mg/kg
Safer to use with poor cardiac function.
Pregnancy Category C. Animal and human studies have shown no teratogenicity with
the use of Etomidate. None detected in breast milk 4 hours after use.
Adult Sedation:
IV: 0.05-0.1 mg/kg
Adult Induction for RSI:
IV: 0.2-0.4 mg/kg
*Use lower doses for sedation, higher doses will
result in general anesthesia.
Drug
Ketamine
(Ketalar)
Route
PO,
PR, IV
Dose/Titration
Pediatric Sedation:
PO and Rectal: 4-8 mg/kg 30 minutes prior to
procedure.
IV: 0.05-1 mg/kg over 2-3 min
Supplemental doses: ½ of initial dose
IM: 2-4 mg/kg; may use with Atropine 0.01-0.02
mg/kg, midazolam 0.05-0.1 mg/kg
Pediatric Induction for RSI:
IM: 5-10 mg/kg
IV: 1-2 mg/kg
SEDATIVE, GENERAL ANESTHETIC
Onset
Duration
Side Effects/Precautions
PO: 30-45 minutes PO: 10-30 minutes
IV: Do not exceed 0.5 mg/kg/min. (conc. <2mg/ml)
Monitor cardiovascular effects, HR, BP, RR and O2 saturation.
IM & PR: 5-15
IM 10-30 minutes
May cause apnea, laryngospasm, respiratory depression, tachycardia, hypertension and
minutes
increased salivation. Contraindicated in the presence of head injury because it may
cause increased ICP and intraocular pressure. Dysphoric reactions not uncommon, upon
IV: 1 minute
IV 5-15 minutes
emergence. Treat with benzodiazepines.
Pregnancy Category B. No report of malformations in humans. Possible complications
(dose-related) included: maternal hypertension, increased muscle tone, newborn
apnea/respiratory depression, depressed neonatal neurobehavioral. Undetectable
amounts in breast milk 11 hours after use.
Adult Sedation:
IV: 0.25 – 1 mg/kg
(not recommended PO/PR for adults)
Adult Induction for RSI:
IV: 1-2 mg/kg
Contraindicated <3 months.
*Low dose Ketamine may be used for pain
management outside of this protocol.
Drug
Propofol
(Diprivan)
(*NOTE: See
Propofol Policy for
additional
information)
Route
IV
Dose/Titration
Pediatric:
IV: Load: 0.5- 1 mg/kg; titrate as needed
Infusion: 25-100 mcg/kg/minute
Induction for RSI: 1-2 mg/kg IV
*Use lower doses for sedation, higher doses (100300 mcg/kg/min) result in general anesthesia
Adults:
IV: Load: Moderate Sedation 0.25-0.5 mg/kg
Induction for RSI: 1-2 mg/kg IV
Titrate as needed
Infusion: 25-100 mcg/kg/min
Onset
30 seconds
Peak Effect:
2 minutes
Duration
3-10 minutes
Side Effects/Precautions
Continuous monitoring and airway management required. Apnea and airway obstruction
occur at high doses. May cause dose related hypotension. Not recommended for
patients with increased ICP or impaired cerebral circulation unless the patient is
intubated with assisted ventilation. Not recommended for patients with poor cardiac
function. Monitor RR, BP, HR, O2 saturation, and ABG’s.
Pregnancy Category B. Safety during pregnancy has not been determined. No
breastfeeding data available. Contraindicated in soy or egg allergies.
ANESTHETIC AGENTS FOR SEDATION
ANESTHETIC ADJUNCTS, SHORT ACTING BARBITURATES
Drug
Thiopental
(Pentothal)
Route
IV
Dose/Titration
Pediatric Sedation:
IV: 0.5-1 mg/kg
Total recommended dose infused slowly over 35 minutes.
Pediatric Induction for RSI:
IV: 2-8 mg/kg
Onset
30 seconds
Duration
5-10 minutes
Side Effects/Precautions
Contraindicated in porphyria and status asthmatics.
Monitor RR, HR, & BP
Apnea and airway obstruction may occur.
Hypovolemic patients are at risk for hypotension.
Pregnancy Category C. Rapid placental transfer. Prolonged exposure could result in
accumulation in the fetus with possible teratogenic effects. No breastfeeding data
available.
Adult Sedation:
IV:0.5- 1 mg/kg slowly over 3-5 min
Adult Induction for RSI:
IV: 2-8 mg/kg IV, divided in 2-4 doses
Drug
Methohexita
(Brevital)
Route
IV
Dose/Titration
Adult Sedation:
IV :0.25-0.5 mg/kg
Adult Induction for RSI:
IV: 0.5-1 mg/kg
Onset
30 seconds
Duration
5-10 minutes
Side Effects/Precautions
Contraindicated in porphyria
Side Effects: Rare severe allergic reactions, allergic skin reactions, histamine release,
hypotension, twitching, shivering, tremors, hiccups (11%), cough, respiratory depression
Pediatric Sedation: Rectal route advised, due
to pain of IM injections. IV not recommended
Rectal dose:10-20 mg/kg
Pediatric Induction for RSI:
Rectal Dose: 25mg/kg
Note: The above dosages are only intended to be used only as guidelines. Depending upon patient, slightly higher or lower doses may be necessary.
**NOTE: Do not use the “DTP” cocktail (Demerol, Phenergan, and Thorazine). Its use has been associated with seizures, dystonia, respiratory depression and even
death.
Last Update March, 2006, Fairview Pharmacy Services
33
Sedation Grid –Age Adjusted Dosing of Medications References
1.
2.
3.
Horn E, Nesbit SA. Pharmacology and pharmacokinetics of sedatives and analgesics. Gastrointest Endoscopy Clin N Am 2004;14:247-268.
Tsui BCH, Wagner A, Finucane B. Regional anesthesia and the elderly. Drugs Aging 2004;21:895-910.
Fick DM, Cooper JW, Wade WE, Waller JL, Maclean R, Beers MH. Updating the beer’s criteria for potentially inappropriate medication use in older adults. Arch Intern
Med 2003;163:2716-2724.
34
SEDATION/ANALGESIA FOR DIAGNOSTIC & THERAPEUTIC PROCEDURES
DOCUMENTATION FORMS
PHYSICIAN RESPONSIBILITIES
Prescribing providers must be privileged for the appropriate level of sedation/analgesia.
•
•
•
•
Pre-Sedation Assessment:
Complete “Pre-Procedure Physical Assessment” section of the form
Obtain patient informed consent
Document “Classification of Physical Status ASA Score”
Assess patient immediately prior to sedation/procedure and sign,
date and time form (required documentation)
Intra-Procedure
• Perform the procedure, direct the administration of the sedation/analgesia.
Post Procedure/Discharge
• Complete post-procedure note and orders.
Sign Post-Procedure section of the form, date and time form
To meet regulatory requirements all sections of the documentation forms must be filled out.
On the outpatient procedures form (four-page form), the credentialed/privileged clinician must
complete the bottom of page 2. On the inpatient procedures form (two-page form) this section is
located on the bottom of page 1.
All clinicians must adhere to Safety Protocol for Invasive and/or High Risk Procedures (Site
Marking and Verification) Policy Code: S:PC-2013 and document appropriately.
Conclusion
The objectives of sedation and analgesia are:
• Mood alteration.
• Comfortable and cooperative.
• Decreased pain.
• Elevation of the patient's pain threshold with minimal changes in vital signs.
• Partial amnesia.
• Prompt and safe return to activities of daily living.
Knowledge of the principles of sedation is crucial to delivering safe care to the patients who
will benefit from these medications and techniques. It is imperative that care provider’s
administering or monitoring sedation/analgesia understand and adhere to the policy
governing the use of this practice within the Fairview System.
36
Test Your Knowledge!
37
Case Studies
The following scenarios were created to enhance critical thinking in situations that
may be encountered. Think about how you would react in each situation and then
review the discussion points on the following page.
1.
The end of the procedure is near and you have been monitoring your patient
closely. The patient has received 2 mg of Versed pre-procedure and 100 mcg
of Fentanyl intra-procedure. The patient’s vital signs have been stable. He has been
drowsy and requires tactile stimulation in order to respond appropriately to
verbal commands. His pulse oximeter readings have been between 94 and 98% on
room air. What concerns do you have for the patient?
2.
A 150 kg, somewhat anxious, gentleman is being admitted for a procedure.
His orders read “3 mg Versed pre-procedure IV”. The patient has a history of sleep
apnea. How do you prepare for this patient’s care?
3.
An elderly 45 kg woman, with increased liver enzymes, is scheduled for a
procedure this a.m.. You decide to use Versed® and Fentanyl. What precautions do
you take with this patient?
4.
A diabetic patient is admitted for a renal biopsy. During the procedure the patient
seems a little confused. The pulse oximeter reading is 90%, her heart rate is slightly
increased, and her blood pressure is slightly decreased from pre-procedure. The preprocedure pulse oximeter reading was 99%. How should you advise the monitoring
clinician?
5.
During a procedure, you are advised that the patient’s respiratory rate has decreased
to 8. The pulse oximeter is reading 96%.
38
Discussion Points for Case Studies
1. This patient is at risk to slip into a deeper level of sedation/analgesia in the postprocedure period when the stimulation of the procedure is over.
2. Talk with the patient about the procedure and explain what might be felt and heard.
Dose the medication to effect. Because of the sleep apnea and obesity this patient is
more prone to airway obstruction and apnea-decreased ventilation. A nasal airway
may be appropriate for this patient should complications develop. Due to this
patient's size a larger dose of medication may be required to achieve the desired
level of sedation/analgesia.
3. Due to this patient's age, weight, and liver function a smaller doses of medications
may be required. Give medications slowly and dose to effect. Versed and Fentanyl
potentiate each other’s effects.
4. Check this patient’s:
A: Airway-assure patency and intervene as needed.
B: Breathing-rate and rhythm- initiate O2.
C: Circulation-correlate patients heart rate with the pulse oximetry monitor for
accuracy of saturation reading.
D: Drugs-assure that resuscitation medications are available.
D: Differential Diagnosis-confirm source of confusion (low glucose or
hypoxemia/hypercarbia.)
Monitoring: increase frequency of assessments and documentation until patient
returns to baseline.
5. This patient may need tactile stimulation to maintain or increase ventilations. You
may need to assist the patient with bag-valve mask ventilation . Additional doses of
sedative medications should not be given. Consider reversal if unable to maintain
ventilation. Constant monitoring of respiratory function into the post-procedure
period is crucial.
39
Sedation/Analgesia Questions
1. The RN designated to monitor/assess a patient during a procedure utilizing
sedation/analgesia may assist the physician performing the procedure as needed.
T
F
2. Transport of sedated patients must be done by providers who are able to monitor,
assess and intervene if needed.
T
F
3. Patients who have met discharge criteria must have a responsible companion to
escort and drive them home.
T
F
4. Documentation during a procedure must occur
a) Every 5 to 15 minutes as conditions warrant
b) After administration of every medication
c) With any significant event
d) All of the above
5. Size appropriate equipment and supplies must be immediately available.
T
F
6. Which of the following medications reverses the effects of Benzodiazepines.
a) Narcan (Naloxone)
b) Romazicon (Flumazenil)
7. Which of the following medications reverses the effects of Narcotics.
a) Narcan (Naloxone)
b) Romazicon (Flumazenil)
8. Dosage adjustments may be needed for
a) Elderly
b) Impaired renal function
c) Hepatic insufficiency
d) All patients depending on their response to the medication
9. The effects of reversal agents may wear off before the effect of the sedative or
analgesic.
T
F
40
10. A patient received 3 mg of Versed IV 10 minutes ago. In what level of sedation will this
patient be?
a) Minimal
b) Moderate
c) Deep
d) Unable to determine
11. A patient who is moderately sedated may need assistance to maintain a patent airway.
T
F
12. A patient who is deeply sedated will follow a simple command to open his eyes.
T
F
13. Of the following, which are signs of inadequate airway/ventilation?
a) Snoring
b) Change in LOC
c) Loss of chest expansion
d) Nasal Flaring
e) All of the above
14. All of the following describe moderate sedation except:
a) Allows protective reflexes to be maintained
b) A medically controlled state of depressed consciousness or unconsciousness from
which the patient is not easily aroused and is unable to respond purposefully to
physical stimulation or verbal command
c) Retains the patient’s ability to maintain a patent airway independently and
continuously
d) Permits appropriate response by the patient to physical stimulation or verbal
command (e.g: open your eyes”)
e) The drugs, doses and techniques are not intended to produce a loss of
consciousness
15. A 55-year-old woman has a history of adult onset diabetes mellitus. She also has a
history of hypertension. Both diseases are controlled by diet alone. She is scheduled
for a colonoscopy. This patient is an ASA Physical Classification of:
a) ASA I
b) ASA II
c) ASA III
d) ASA IV
e) ASA V
16. Prior to performing a procedure with sedation/analgesia the physician must perform or
provide the following:
a) A brief medical history and physical exam
b) A signed consent form
c) An ASA Patient Classification Status
d) Verify the patient’s NPO status
e) All of the above
41
17. An excellent indicator of adequate moderate sedation is:
a) Unconsciousness
b) Bradycardia
c) Slurred Speech
d) Unresponsiveness
e) A normal blood pressure and heart rate
18. Monitoring parameters include:
a) Heart rate, blood pressure, respirations
b) Heart rate, blood pressure, and oxygen saturation
c) Heart rate & rhythm, blood pressure, respirations, oxygen saturation and level of
consciousness
d) Heart rate & rhythm, blood pressure, oxygen saturation and respirations
e) Heart rate, blood pressure, respirations, and oxygen saturation
19. The RN monitoring the patient receiving sedation/analgesia:
a) May be the Charge Nurse
b) May also circulate in the room and get equipment from the hallway
c) May not be engaged in any other activity during this period
d) May not apply oxygen if needed
e) Should do the preoperative history and physical prior to the procedure
20. Naloxone (Narcan) can be used to reverse all of the following except:
a) Midazolam
b) Merperidine
c) Fentanyl
d) Morphine
e) Sublimaze
21. Your patient had respiratory depression. You have given 150 mcg of Fentanyl. The
patient will not respond to verbal stimulation. You should give Flumazenil to reverse the
effects of the narcotic:
a) True
b) False
22. What information is not needed in the history for a patient undergoing a procedure
using sedation/analgesia:
a) Allergies
b) Past experiences with anesthetic drugs
c) Pregnancy or menstrual history
d) Last meal
e) All of the above are necessary in the history
42
23. Prior to discharge the nurse must have all of the following except:
a) Written instructions from the physician for the patient
b) Name and telephone number of a responsible adult to accompany the patient
c) Number of the ride arranged with public transportation and address they are to
take the patient to
d) Complete documentation of the entire procedure including the recovery period
e) Assured the patient’s ability to void and retain oral fluids
24. All of
a)
b)
c)
d)
e)
the following are considered clear liquids except:
Plain coffee or tea
Breast milk
Grape juice
Apple juice
Water
25. It is prudent to wait 6 hours prior to performing sedation/analgesia on a patient who
has had Cream of Tomato soup within the last hour:
a) True
b) False
43
Answers to Sedation/Analgesia Questions
1. F
2. T
3. T
4. D
5. T
6. B
7. A
8. D
9. T
10. D
11. F
12. F
13. E
14. B
15. B
16. E
17. C
18. C
19. C
20. A
21. B
22. E
23. C
24. B
25. A
44