Guideline Update: Moderate Sedation/Analgesia Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission

Guideline Update: Moderate Sedation/Analgesia

Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

Mary is a senior perioperative practice specialist at AORN. Her primary responsibility is authoring guidelines (Care of the Patient Receiving Moderate Sedation/Analgesia, Care of the Patient Receiving Local Anesthesia, Complementary Care Interventions, Electrosurgery, Laser Safety, Sharps Safety, Ambulatory Supplements). Her other responsibilities include providing professional, technical, and management consultative services regarding perioperative nursing practice. She creates products and education materials that support the perioperative professional’s safe workplace practice including AORN tool kits and videos for sharps safety, surgical smoke evacuation, workplace safety, cultural competence, and safe patient handling and movement in the perioperative setting.

Developed and originally presented by Mary J. Ogg, MSN, RN, CNOR

Mary has practiced in management and clinical roles in multiple settings, including hospital-based operating rooms, ambulatory surgery centers, and office-based operating rooms. Prior to employment at AORN, Mary was the Ambulatory Surgical Services Manager at Inova Surgery Center in Falls Church, Virginia. Mary has worked as a staff nurse and RN first assistant in California, Maryland, Virginia, Florida, Hawaii, Kentucky, New Mexico, and Colorado. She is a member of the Epsilon Zeta Chapter of Sigma Theta Tau.

These slides were taken from the webinar Guideline Update: Moderate Sedation/Analgesia, presented November 18, 2015. To listen to the webinar, visit http://www.aorn.org/education/individuals/education-webinars. These slides are made available for educational use. Slides may be personalized for your facility and presentation. HOWEVER, THE VIEWS EXPRESSED IN THESE SLIDES ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO, AORN.

• Discuss changes in AORN’s Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia• Describe the evidence supporting the Guideline for Care of the

Patient Receiving Moderate Sedation/Analgesia• Discuss the perioperative RN’s scope of practice as it relates to

caring for the patient receiving moderate sedation/analgesia

Objectives


• Drug-induced, mild depression of consciousness – achieved by the use of sedatives or a combination of sedatives and analgesics– most often administered by IV – titrated to achieve a desired effect

• The Patient – has a mildly depressed level of consciousness – has an altered perception of pain– retains the ability to respond appropriately to verbal or tactile stimulation– maintains protective reflexes – may experience some degree of amnesia

• Desired effect – level of sedation with or without analgesia – enables the patient to tolerate diagnostic, therapeutic, and invasive procedures – relief from anxiety and pain

What is Moderate Sedation/Analgesia?


American Society of Anesthesiologists Continuum of Depth of Sedation


• Assessment– obstructive sleep apnea– difficult mask ventilation– acuity level

• Monitoring– capnography– bispectral index (BIS)

• Emerging technology– CAPS

What is new?


Recommendation I• Consult with your state board of nursing• Verify that administering the medications for moderate

sedation/analgesia is within your scope of nursing practice – eg, propofol, ketamine, nitrous oxide• Administer moderate sedation/analgesia under the supervision

of the licensed independent practitioner

Scope of Practice


Is administering propofol within your state board of nursing’s scope of practice?

1. Yes

2. No

3. Not sure

Polling question


• Select your state at the link below to learn about legislation that may affect you and about your state’s nurse practice act.

http://www.aorn.org/community/government-affairs/my-state

What’s Happening in My State?

Preoperative nursing assessment

Recommendation II• Use a physical status

classification tool to determine patient acuity– example

• ASA Physical Status Classification System

• Need for IV access – level of sedation intended– route of medication administration– organizational policy, procedure, and

protocol.


Difficult mask ventilation– age > 55 years– BMI > 30 kg/m2

–missing teeth– history of snoring, stridor, or sleep apnea– presence of a beard– short neck– limited neck extension

Assessment


Difficult mask ventilation– jaw abnormalities– nonvisible uvula– history of problems with anesthesia or sedation– advanced rheumatoid arthritis– chromosomal abnormality– tonsillar hypertrophy– small mouth opening

Assessment


Obstructive sleep apnea• sleep-related breathing disorder • characterized by periodic, partial, or complete obstruction of

the upper airway during sleep • repeated arousals from sleep to restore airway patency

Assessment


Assessment

Obstructive sleep apnea (OSA)• estimated incidence of OSA ranges from 2% to 26% • affects men more frequently than women • estimated undiagnosed range of moderate to severe OSA • number of patients with OSA is likely to increase • surgical patients


Obstructive sleep apnea (OSA)• Screening tools– Examples -STOP-BANG, ASA checklist for OSA, Berlin questionnaire

• Consultation with an anesthesia professional if OSA is severe• Additional precautions

Assessment


OSA Screening for Pediatric Patients– higher weight (ie, 95th percentile for age

and sex)– intermittent vocalization during sleep– parental report of restless sleep, difficulty

breathing or struggling respiratory effort during sleep

– night terrors– unusual sleep positions

Assessment


OSA Screening for Pediatric Patients– new onset enuresis– somnolence – easily distracted– overly aggressive– irritability– difficulty concentrating

Assessment


Do you assess your patients for obstructive sleep apnea?

1. Yes

2. No

Polling question


When to seek a consult?

• Previous difficulties with anesthesia or sedation• History– respiratory or hemodynamic instability– coagulation abnormality– neurologic or cardiac disease– renal or liver disease

• One or more significant comorbidities• Multiple drug allergies• Multiple medications with potential for drug interaction


• Severe sleep apnea or airway issues• Current substance abuse • Pregnancy• Inability to – cooperate– communicate

• ASA physical status classification of unstable ASA III• ASA physical status classification of ASA IV or above

When to seek a consult?


• The RN in collaboration with the licensed independent practitioner develops and documents the sedation plan.

• Sedation plan– medications & route of administration– predetermined depth of sedation– length of the procedure & sedation – recovery time

Assessment


Recommendation III

Baseline & intraoperative monitoring end-tidal CO2 by capnography

• Adequate ventilation– movement of gases in and out of the lungs

• Respiration– diffusion of gases across the alveolar

membranes

– requires the exchange of O2 and CO2

Monitoring


• Effective respiration– oxygen uptake – carbon dioxide removal by exhalation

• Normal blood concentration of CO2 = 35 mm Hg - 45 mm Hg

Monitoring


• Poor ventilation– CO2 may not be fully exhaled, resulting in hypercarbia

– Small increases in CO2 of 1 mm Hg - 15 mm Hg

• Not usually harmful

• Hypercarbia– Arterial blood concentration of CO2 > 45 mm Hg

– Large increases → acidosis, somnolence & respiratory arrest

– CO2 > 65 mm Hg - 70 mm Hg → sedation

• Synergy in patients already sedated with benzodiazepines & narcotics → respiratory arrest

Monitoring


Pulse oximetry– measures the percentage of blood oxygen levels

Capnography– monitors the concentration of exhaled carbon dioxide – assesses physiologic status– determines the adequacy of ventilation– provides a continuous, noninvasive measurement and graphical display of

end-tidal carbon dioxide – provides an immediate picture of patient condition

Monitoring


• Presence of exhaled CO2 verifies ventilation is occurring

• Earlier detection of abnormalities– bradypnea, hypoventilation, and apnea – quicker than pulse oximetry

Why monitor exhaled CO2 ?


• Evidence supporting monitoring end-tidal CO2 during moderate sedation– Beitz et al concluded that early intervention based on the additional

capnographic monitoring of ventilatory activity • reduced the incidence of oxygen desaturation and hypoxemia during sedation

• Evidence against– Slagelse et al concluded that capnography • reduced the number and duration of hypoxic events • has limited clinical benefit to increase safety • is associated additional costs

Evidence for Capnography


Do you currently monitor end-tidal carbon dioxide with capnography when administering moderate sedation/analgesia?

1. Yes

2. No

Polling question


• Assess and document depth of sedation – objective scale • ASA Continuum of Sedation Scale• Ramsay Sedation Scale• Modified Ramsay Sedation Scale• Modified Observer’s Assessment of Alertness/Sedation Scale

• Assess the patient’s level of consciousness – patient’s ability to respond purposefully to• verbal commands• light tactile stimulation

Monitoring


BIS – direct measure of the effects of

anesthetics and sedatives on the brain– integrated measure of cerebral

electrical activity, derived from the electroencephalogram (EEG)

– values range on a scale of zero to 100, with the numbers correlated to level of sedation

Adjunct technology for monitoring

Value Description

0 Coma, absence of cerebral electrical activity

0-40 Deep hypnotic state

40-60 General anesthesia

60-90 Varying levels of conscious sedation (ie, minimal to deep sedation)

90-100

Awake


• The RN caring for the patient receiving moderate sedation/analgesia should have no competing responsibilities that would compromise continuous monitoring and assessment of the patient during the administration of moderate sedation

• Two perioperative RNs should be assigned to care for the patient receiving moderate sedation/analgesia. – One RN administers the sedation medication and monitors the patient – One RN performs the circulator role

Staffing


• Is in constant attendance with unrestricted immediate visual and physical access to the patient• May perform short, interruptible tasks to assist the

perioperative team while remaining within the OR– Examples• opening additional suture• tying a gown

– May not perform other tasks when administering propofol

The RN providing moderate sedation


How do you staff for a procedure when moderate sedation/analgesia is administered?

1. One RN to circulate and monitor the patient

2. Two RNs—an RN circulator & an RN to administer sedation

3. Not sure

Polling question


Recommendation IV

Before administration• RN verifies– licensed independent practitioner’s order– correct dosing parameters

• RN identifies patient-specific maximum dose– medication formulary– pharmacist– licensed independent practitioner– product information sheet

• RN adjusts doses of sedatives and analgesics for an older adult– as directed by the licensed independent practitioner

Medication administration


• IV medications– administered one at a time– incremental doses– titrated to desired effect

• Non-intravenous route– allow sufficient time– drug absorption– onset

Medication administration


• Supplemental oxygen – immediately available– under the direction of the supervising licensed independent practitioner

• Patient’s optimal level of oxygen saturation – measured with pulse oximetry– necessity – method– flow rate

Medication Administration


• Emerging technology • Designed to administer propofol • Based on the patient’s

physiological response & monitoring • To achieve and maintain

minimal to moderate sedation/analgesia

Adjunct technologyComputer-assisted personalized sedation (CAPS)


CAPS

• An anesthesia professional must be immediately available for assistance or consultation.• The health care organization should define and

determine “immediate availability” of an anesthesia professional.• Should be used according to the manufacturer’s

instructions for use and the US Food and Drug Administration labeling.

Adjunct technology


Recommendation V• Medical supervision of patient recovery and discharge – responsibility of the operating practitioner or licensed independent practitioner

• Qualified provider – defined by and authorized under the health care organization’s guidelines &

policies – available in the facility to discharge the patient in accordance with the health

care organization’s discharge criteria

• RN – must give the patient and caregiver verbal and written discharge instructions– copy of the written discharge instructions must be placed in the patient’s

medical record

Discharge


• Return to baseline mental status• Stable vital signs• Sufficient time interval since the last administration of an

antagonist• Objective patient assessment discharge scoring system• Absence of protracted nausea

Discharge readiness criteria


• Intact protective reflexes• Adequate pain control• Return of motor/sensory control• Ability to remain awake for at least 20 minutes• Arrangement for safe transport from the facility

Discharge readiness criteria


• Prolonged– receives a medication with a long half-life – only one responsible adult is accompanying the child

• Infant or toddler riding home in a car safety seat– careful observation of the child’s head position to avoid airway

obstruction – care of two responsible adults

Pediatric patient discharge


Recommendation VI• Patient selection & assessment criteria• Monitoring equipment• Pharmacology of the medications • Compromised airway• Basic dysrhythmia recognition and management

Education & Competency


• Emergency response and management• ACLS and PALS • Recognition and management of complications• Review policies and procedures • Knowledge of airway anatomy and physiology

Education & Competency


Do you use simulation for education and competency verification of moderate sedation/analgesia?

1. Yes

2. No

Polling question


Recommendation VII

Based on• state’s medical practice act• state nurse practice act• regulatory requirements• practice guidelines• professional organizations’ statements• accreditation requirements

Policies & Procedures


• Developed by a multidisciplinary team• Directors of anesthesia services in hospitals must be

responsible for all anesthesia services– topical or local anesthesia – minimal sedation – moderate sedation/analgesia– rescue capacity throughout the hospital, including all departments, all

campuses, and all off-site locations – Medicare/Medicaid-participating organizations



• Assessment parameters• Patient selection criteria • Patient risk assessment and criteria for consultation (eg,

anesthesia)• Fasting guidelines• IV access requirements



• Monitoring• Permitted moderate sedation/analgesia medications and dosage

guidelines• Recovery and discharge criteria• Documentation (eg, parameters, frequency)• Emergency equipment, medications, and procedures



• Staffing requirements• Licensed independent practitioner’s qualifications, education,

& competency requirements for administering or supervising moderate sedation/analgesia • RN qualification, education & competency requirements • Alternative care arrangements when the patient’s acuity or level

of care required is outside the perioperative RN’s capabilities or scope of practice



Fasting requirements

SUBSTANCES TIME EXAMPLES

Clear liquids 2 hours Water, fruit juices without pulp, carbonated beverages, clear teas, and black coffee

Breast milk 4 hours

Infant formula 6 hours

Solids (eg, light meal)Nonhuman milk

6 hours Toast accompanied by a clear liquid

Fried or fatty foods 8 hours


Questionsand Answers


• Guideline for care of the patient receiving moderate sedation/analgesia. In: Guidelines for perioperative practice. Denver, CO: AORN, Inc; 2016.

Reference


Documents

Guideline Update: Moderate Sedation/Analgesia Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission