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Procedural Sedation
Lutheran Medical Center
v.2011-12
1
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Procedural Sedation
1. Definitions along the Sedation Continuum
Minimal Sedation
“Anxiolysis”
Procedural Sedation
“Conscious Sedation”
Deep Sedation
General Anesthesia
Normal response
to verbal
stimulation
Purposeful response
To
to verbal
verbal or
or tactile
tactile
stimulation
Purposeful response
Following
following repeated
repeated
or painful stimulation
Unarousable
even with painful
stimulus
Airway
Unaffected
No intervention
required
Maybe
Intervention may
be
required
Intervention often
required
Spontaneous
Ventilation
Unaffected
Adequate
May be inadequate
Frequently inadequate
Cardiovascular
Function
Unaffected
Usually maintained
Usually maintained
May be impaired
Responsiveness
Specific differences:
Procedural and Deep
•
Response?
•
Airway intervention required?
•
Ventilation?
•
Cardiovascular function?
for both
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Procedural Sedation
2. Verification of Provider Credentials (prior to EVERY procedure
even if the physician performed the procedure yesterday)
Call Medical Staff Services or the Hospital Supervisor if you cannot obtain this
information
1.
2.
3.
4.
5.
6.
7.
Login to the Portal (my.exempla.org)
Open the Delivering Care tab
Choose the Privileges link
Choose appropriate hospital from the dropdown list
Enter search criteria
Click Submit
Click the provider’s name to see:
 Privileges granted
 Suspension status
 Other information
For more details concerning requirements for specific privileges:
1. Click the Medical Staff tab
2. Choose Privileges Sheets link in the top right corner of the page
3. Open the appropriate list to see further definitions of the privileges granted
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Procedural Sedation
3a. Prerequisites tasks for the licensed independent practitioner (LIP)
•
History
•
Baseline Physical Examination
•
Upper Airway Assessment
•
ASA Score
•
Plan of Care – rationale for procedure and sedation plan
•
Informed Consent
•
COR status
•
Re-assessment – immediately before the administration of sedation
•
Discharge criteria
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Procedural Sedation
3b. NPO Status Recommendations - Elective and Emergent Procedures
Solids &
Non-Clear Liquids*
Clear Liquids**
More than 8 years
8 hours
4 hours
3 - 8 years
6 hours
3 hours
6 months to 3 years
6 hours
2 hours
Less than 6 months
4 hours
2 hours
Age
* Non-clear liquid = breast milk, formula
** Clear liquids = water, clear juices, black coffee and tea (no milk)
NPO status for emergent and urgent procedures is determined by:
•
patient’s status
•
procedural risk and type
•
degree of sedation anticipated
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Procedural Sedation
4a. RN Responsibilities:
•
Acts under the direction of a credentialed Medical Staff Member
•
Reviews/completes pre-procedure & post-procedure assessment
•
Administers medications for sedation/analgesia
•
Monitors patient
•
Completes required documentation
•
Ensures patient/family education
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Procedural Sedation
4a. Respiratory Therapist Responsibilities:
•
Acts under the direction of a credentialed Medical Staff Member
•
Completes required documentation
•
Ensures patient/family education
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Procedural Sedation
4b. RN Qualifications / Requirements
•
Acts within hospital approved Scope of Practice
•
Has successfully completed:
• Current Basic Life Support (BCLS)
• Procedural Sedation Clinical Competency


•
Nursing Adult and Pediatric  RNS
Departmental Competencies as required
If Applicable, has successfully completed:
• Advanced Cardiac Life Support (ACLS)
• Neonatal Resuscitation Program (NRP)
• Pediatric Advanced Life Support (PALS)
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Procedural Sedation
4b. Respiratory Therapist Qualifications / Requirements
•
Acts within hospital approved Scope of Practice
•
Has successfully completed:
• Current Basic Life Support (BCLS)
• Procedural Sedation Clinical Competency

•
Departmental Competencies as required
If Applicable, has successfully completed:
• Advanced Cardiac Life Support (ACLS)
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Procedural Sedation
On COR Cart
5. Needed supplies and equipment
• Oxygen
• a positive pressure system that is capable of administering > 90%
Oxygen at a 15 liter per minute flow rate for > than one hour (2 E
cylinders)
• Face mask and/or nasal prongs
• Pulse oximeter
• Intravenous equipment
• Blood pressure equipment
• Bag valve mask (ambu)
• Oral/Nasal airway
• Defibrillator & Cardiac monitor
• Suction equipment
• Emergency Medications
• Atropine and reversal agents (i.e. Narcan and Flumazenil)
• Advanced airway management equipment
• laryngoscope handles and blades
• endotracheal tubes and stylets
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Procedural Sedation
6. Monitoring requirements
Parameter
During the Procedure
After the Procedure
Every 15 min
At least 20 minutes after
last dose of IV medication
and until discharge criteria are met,
OR
For at least 1 hour after the
last dose of a reversal agent
and until discharge criteria are met
Pain:
• Adult  1-10
• Neonatal Neonatal
Infant Pain Scale
(NIPS)
As needed
After the procedure
Cardiac Monitoring:
If needed, staff with
rhythm recognition
skills must be present
As needed
As needed
Vital Signs:
• BP
• Respiratory rate
• Oxygen saturation
• Heart rate
Responsiveness to
commands:
Richmond Agitation
Sedation Scale
The decision to monitor the cardiac rhythm is based on:
Clinical indicators, history of significant cardiac disease, likelihood
that procedure might result in
rhythm changes, physician’s discretion.
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Procedural Sedation
7. Abnormal assessment findings and when to notify a LIP
When patient is:
•
Exhibiting signs of deep sedation, purposeful response only to
repeated or painful stimuli
•
Rass score of –4 or –5
•
O2 Sat <92% during or > 30 min after last dose of medication
•
BP increase or decrease by 20% from baseline
•
Arrhythmias
•
Apnea
•
Any change in respiratory or circulatory parameter
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Procedural Sedation
General principles in administration of Sedatives & Analgesics
• Combination of sedatives and analgesics increase the risk of
respiratory depression and apnea
• Medications should be administered:
• one at a time
• in incremental doses
• with sufficient time to evaluate
(generally over 2 minutes and wait 2-5 minutes to evaluate)
• Titrate narcotics to obtain pain relief and sedatives to
decrease anxiety
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Procedural Sedation
8a. Age Specific Considerations for medication
AGE
Pediatric patients
Geriatric patients
CONSIDERATIONS
•
•
•
•
•
•
•
Medication dosage by weight
Preferred routes PO or IV
Knowledge of age specific vital sign normals/abnormals is essential
Oxygen desaturation occurs faster
Faster drug clearance due to increased renal/hepatic blood flow
Increased body fat therefore increased storage
Increased susceptibility to airway obstruction.
(S/S of respiratory distress includes cyanosis, grunting, retractions,
and nasal flaring.)
• Available airway equipment must be appropriate size
• Sniff position for infants
•
•
•
•
•
•
Increased sensitivity to medications, adjust dosage appropriately
Less oxygen reserve
Decreased drug metabolism from decreased renal and hepatic flow
Slower circulation time of medications
Decreased muscle tone (stiff neck)
Increased musculoskeletal disorders
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Procedural Sedation
8b. Disease Considerations for medication
DISEASE
CONSIDERATIONS
Renal/Liver patients
• Diminished drug clearance
Obesity
• Poor venous access
• Inaccurate blood pressure
• Hypertension
• Difficult airway management
• Respiratory insufficiency, diaphragm pushed up by abdomen
• Positioning difficulties
• Storage of medication in adipose tissue
• Co-morbidity: diabetes resulting in circulatory disorders
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Procedural Sedation
8c. Usual dosage for medication
Initial doses IV over 2 minutes unless indicated
MEDICATION
ADULT
PEDIATRIC
NEONATE
GERIATRIC
0.5-2 mg
0.01-0.02
mg/kg
0.01-0.02
mg/kg
0.5-1 mg
0.04 mg/kg
0.04 mg/kg
over 5 min
over 5 min
0.05mg/kg
0.02-0.05
mg/kg
0.01 mg/kg
0.05 mg/kg
Onset immediate
Duration 30-60 min
50-100
mcg
0.5-1 mcg/kg
0.5-1
mcg/kg
25-50 mcg
MORPHINE
2-5 mg
0.05-0.1 mg/kg
0.05-0.2
1-2 mg
over 5 min
over 5 min
over 5 min
over 5 min
MIDAZOLAM (VersedTM)
Onset 2-5 min
Duration 60-90 min
DIAZEPAM (ValiumTM)
Onset 2-5 min
Duration 6-8 hours
LORAZEPAM (AtivanTM)
Onset 5-10 min
Duration 4-6 hours
FENTANYL (SublimazeTM)
Onset 5 min
Duration 4-5 hours
KETAMINE (KetalarTM)
Onset 1-2 min
Duration 1-2 hours
2-5 mg
2 mg
1-2 mg/kg
over 2-3 min
Refer to policy for repeat doses and other vital information
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Procedural Sedation
8d. Considerations & precautions for meds
Considerations
• Reduce dosage if
used with narcotics
• Reversal agent is
flumazenil
• Lorazepam may
have longer onset
of action up to 10
minutes
• Will potentiate
effects of
benodiazepines
Precautions
• Major side effects and
respiratory depression
hypotension (averted if drug
administered slowly)
• Lorazepam injection must be
diluted with = amount of
diluent before IV use
• Caution use in patients with
asthma and/or COPD
• May need increased
dose of naloxone to
reverse CNS/resp.
effects of fentanyl
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Procedural Sedation
8d. Considerations & precautions for meds (continued)
Considerations
• Observe for
sedation for a
minimum of one to
two hours
• Monitor blood
pressure, heart rate,
respiratory rate.
• Close cardiac
monitoring for
patients with history
of hypotension or
cardiac
decompensation
Precautions
• Contraindicated in patients
with elevated intracranial
pressure, uncontrolled
hypertension, aneurysms,
thyrotoxicosis, CHF, angina
• Caution in patients with
coronary artery disease,
tachycardia
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ONLY for
ED and ICU use
Procedural Sedation
8c. Usually dosage for medications specific to the ED and ICU
Initial doses IV
MEDICATION
ETOMIDATE
Onset 30-60 sec
Duration 3-5 min
ADULT
PEDIATRIC
0.1-0.2 mg/kg
over 30-60 sec
Not
recommended
for Children
under 10
years,
0.1-0.2 mg/kg
over 30-60 sec
NEONATE
GERIATRIC
0.1-0.2 mg/kg
over 60 sec
Refer to policy for repeat doses and other vital information
9. RN administration MUST be under
direct supervision of credentialed
physician and RT or 2nd physician not
involved in the procedure. MUST be
monitoring airway.
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Procedural Sedation
ONLY for
ED and ICU use
8d. Considerations & precautions for medications specific to the ED & ICU
Considerations
• RN administration
restricted to ED and
ICU
• Monitor blood
pressure, heart rate,
respiratory rate
Precautions
• Caution in patients with
serious asthma, hypotension,
myoclonus, and
nausea/vomiting
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Procedural Sedation
Propofol is used in the GI Lab as
well as the ED and ICU
8c. Usually dosage for medications specific to the ED, ICU and GI Lab
Initial doses IV
MEDICATION
PROPOFOL
Onset 30 sec
Duration 3-10 min
ADULT
PEDIATRIC
0.5-1 mg/kg
slow
0.5 mg/kg slow
NEONATE
GERIATRIC
0.5-1 mg/kg
slow
Refer to policy for repeat doses and other vital information
9.
MUST be administered only by an
anesthesiologist.
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Procedural Sedation
10. Identify appropriate interventions if pt. progresses to deep sedation
11. Describe REVERSAL agents, their actions and criteria for use
Initial doses IV over 15 seconds
MEDICATION
FLUMAZENIL
(RomaziconTM)
Onset 30 sec
Duration 3-10 min
NALOXONE
(NarcanTM)
Onset 1-2 min
Duration 1-4 hours
ADULT
PEDIATRIC
NEONATE
GERIATRIC
0.2 mg
0.01 mg/kg
(Max initial =
0.2 mg)
0.002-0.01
mg/kg
0.2 mg
0.1-0.4
mg
0.1 mg/kg
0.1 mg/kg
0.1-2 mg
Refer to policy for repeat doses and other vital information
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Procedural Sedation
10. Identify appropriate interventions if pt. progresses to deep sedation
11. Describe REVERSAL agents, their actions and criteria for use
Considerations
Precautions
• Observe for re- • Caution in patients addicted to
benzodiazepines
sedation for a
minimum of one • Caution in patients with history of
to two hours
seizures
• Caution in patients with history of
panic attacks
• Observe for renarcotization
for a minimum
of one to two
hours
• Caution use in patients addicted to
narcotics
• Titrate to avoid
excessive
reduction in
analgesia
• Naloxone associated non-cardiogenic
pulmonary edema has been reported
throughout dose range
• May need higher doses with fentanyl
• May not reverse cardiovascular
effects of narcotics
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Procedural Sedation
12. Potential complications related to the procedure
Complication
Airway obstruction
Treatment
• Monitor pulse oximeter continuously
• Stimulate patient to breathe
• Position head appropriately
• Chin lift and jaw thrust
• Administer supplemental oxygen
• Administer reversal agents
• Oral or nasal airway
• Suction airway if needed
• Ventilate manually with bag valve mask
device
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Procedural Sedation
12. Potential complications related to the procedure
Complication
Bradycardia
(caused by
hypoxemia, vagal
stimulation)
Treatment
• Oxygen
• Medications as ordered and indicated
• If patient develops shortness of breath
or chest pain, obtain EKG
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Procedural Sedation
12. Potential complications related to the procedure
Complication
Tachycardia
(caused by pain,
anxiety, hypoxemia,
hypovolemia)
Treatment
• Notify MD of tachycardia
• Administer pain medication as ordered
by MD performing procedure
• Administer O2 as needed
• Administer IV fluids as ordered by MD
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Procedural Sedation
12. Potential complications related to the procedure
Complication
Other
dysrhythmias
Atrial dysrythmias,
PVC’s
(caused by
hypoxemia &
hypovolemia )
Treatment
• Notify MD of dysrhythmias
• Administer medication as ordered by MD
• Look for underlying causes such as
hypoxemia and hypovolemia and report
to MD
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Procedural Sedation
12. Potential complications related to the procedure
Complication
Treatment
Hypotension
(caused by preexisting condition,
response to
medications,
hypovolemia )
As indicated and ordered:
• Administer reversal medications
• Administer fluids
• Administer vasopressors
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Procedural Sedation
12. Potential complications related to the procedure
Complication
Hypertension
(caused by preexisting conditions,
pain, stress)
Treatment
As indicated and ordered:
• Administer additional sedation
• Administer analgesia
• Administer patient medications for
hypertension
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Procedural Sedation
13. Criteria for discharging a patient
• Stability of vital signs = BP and Pulse within 20 points for 3
consecutive observations (in the absence of significant hypertension
or hypotension. )
• SPO2 meets or exceeds oxygen saturation guidelines (greater than 90
% on room air or with supplemental oxygen or within baseline
measurements)
• Body temperature at or greater than 96.8 degrees
• Patient orientation to name, place and day or to similar orientation
present pre-procedure
• Patient able to move all four extremities on command or in a manner
similar to that present pre-procedure
• Absence, control or MD awareness of: Pain, nausea and vomiting,
wound drainage and bleeding
• Airway patency and respiratory function must be adequate and
appropriate for discharge
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Procedural Sedation
13. Criteria for discharging a patient (continued)
• Fluids balanced, taking into account previous NPO status and
underlying conditions
• Physician if needed and desired contacted prior to discharge
• Vital signs remain stable after oxygen has been removed for 15 to 20
minutes
• Patient will remain at least 20 minutes after IV analgesic, providing
other discharge criteria have been met
• Final nursing assessment and evaluation of patient condition will be
performed and documented
• Primary nurse will inform unit nurse, if applicable, in an organized
report of patient condition and procedural experience
• Patients not meeting pre-determined discharge criteria requires a
specific physician order for discharge (Nurses notes will explain
criteria not met and interventions)
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Procedural Sedation
13. Criteria for discharging a patient (continued)
Discharge to Patient Care Unit
Vital signs monitored every 15 minutes after procedure until:
• Patient has met specified criteria or per physician order
• Transfer order written by physician
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Procedural Sedation
13. Criteria for discharging a patient
Discharge from Hospital
•
•
•
•
•
•
•
•
•
•
When criteria for discharging a patient has been met
Control of pain acceptable to the patient
Control of nausea
Ambulation in a manner consistent with the procedure and previous
ability
Arrangements for safe transportation from the facility
Patient and responsible adult should verbalize an understanding of
instructions
Patients should be evaluated for the need for provision of additional
resources to contact if any problems arise
Patients are to be discharged per a physician’s order
A copy of the post procedure discharge instructions should
accompany the patient home
It is recommended that the patient have a responsible adult with
them for 24 hours post procedure
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Procedural Sedation
14. Documentation
ELECTIVE PROCEDURE
H&P
• An H&P must be in the patient chart prior to the procedure
• An H&P Update must be completed if the original H&P was done
prior to patient admission
• Appropriate Informed Consent for the procedure must be in the
patient chart
• Emergent procedures must contain appropriate physician
documentation
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Procedural Sedation
14. Documentation
DURING TREATMENT & POST-PROCEDURE RECOVERY
•
•
•
•
•
•
•
•
•
•
•
•
Amount of medication used, including dosage, route, and times given
Notation if supplemental oxygen was given
Monitors employed
Oxygen saturation and vital signs at required intervals
Any complication and subsequent management
Level of consciousness and general appearance
Any restraints or protective devices used
Use of reversal agents
Response to the procedure
Condition of any dressings, procedure sites, or drainage
Orders for transfer/discharge
Discharge instructions given if discharged from facility
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Procedural Sedation
14. Documentation
DURING TREATMENT & POST-PROCEDURE RECOVERY
Select appropriate areas for your department and complete Doc Flow Sheets
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Procedural Sedation
14. Documentation
DURING TREATMENT & POST-PROCEDURE RECOVERY
For charting vitals, select specific Intra-Procedural Doc Flow sheet for your area
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Procedural Sedation
14. Documentation
DURING TREATMENT & POST-PROCEDURE RECOVERY
Complete Vital Signs/Pain flow sheet, charting medications administered in the MAR
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Procedural Sedation
Conclusion
You have completed the training content for this lesson. You should now be able to:
1. Differentiate between procedural and deep sedation
2. Demonstrate correct timing and process of verification of provider credentials
3. Identify prerequisites tasks for the licensed independent practitioner (LIP)
4. Describe RN/RT prerequisite tasks
5. Describe needed supplies and equipment
6. Identify monitoring requirements
7. Recognize abnormal assessment findings and know when to notify a LIP
8. Describe usually dosage and age specific considerations for medication
9. Identify appropriate staff who must be in the room and who can supervise a RN
administering medications
10. Identify appropriate interventions if patient progresses to deep sedation
11. Describe reversal agents, their actions and criteria for use
12. List potential complications
13. Describe criteria for discharging a patient
14. Describe essential elements to document in the patient’s medical record
15. Evaluate the procedure by completing the procedure review form
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Procedural Sedation
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