What is Procedural Sedation?

Procedural SedationKEY POINTS IN ADMINSTRATION

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What is Procedural Sedation?

Procedural Sedation also referred to as “moderate sedation/analgesia” or “conscious sedation” ….“a drug-induced depression of consciousness during which individuals 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.”

Joint Commission, 2001

Complications of Procedural Sedation can include: Hypoventilation, allergic or adverse reaction, abnormal cardiac function, deterioration in mental status.

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Examples of Procedural Sedation

In a Moderate Procedural Sedation the patient’s level of consciousness is altered, though response to verbal commands is still possible.

For a Deep Sedation the patient’s consciousness is altered and cannot be easily aroused, but can respond to purposeful or painful stimulation.

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Procedural Sedation is DEFINED by Patient’s Level of Conscious

■ Minimal (Anxiolysis) LOC 2■ Drug induced state, patient responds normally to verbal commands.

■ Moderate (Procedural Sedation) LOC 1■ Drug induced depression of consciousness, patient responds

purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

■ Deep Sedation (requires special privileges!) LOC 0■ Drug induced depression of consciousness, patient cannot be easily

aroused, but respond purposefully following repeated or painful stimulation. (Limited to ED, and Pediatric Sub specialists)

■ Anesthesia LOC 0■ Drug induced loss of consciousness, patient is not arousable, even by

painful stimulation.

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Scoring Patient’s Level of Conscious

■ Procedure & Anesthesia Scoring System (PASS)■ Used before giving medication(s), during procedure, during recovery,

and before discharge■ Consists of 7 categories

Consciousness Activity Circulation Respiration O2 Sat

Pain Emetic

■ All are scored using a point scale of 2, 1, 0

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PASS Assessment Scale Physiologic Assessment Scoring System

PASS Scoring

1. Score prior to sedation (all 7 elements) as baseline

2. Score at the conclusion of procedure

3. Score prior to discharge

Note: Patient must meet pre-sedation PASS Score prior to discharge.

San DiegoRecovery/Level of Sedation Score

Consciousness Awake and alert, turns toward voiceArousable, but drifts back to sleep when not disturbedUnresponsive (except to painful/repeated stimuli)

210

Activity Appropriate for age or developmentWeak for age or developmentNo voluntary movement

210

Circulation Stable BP within 15% of pre-sedation level (baseline)BP within 30% of pre-sedation levelBP > 30% higher or <30% lower than baseline

210

Respiration Able to cough, breath deeply or cryDyspnea or limited breathingApnea/obstructed breathing requires assistance to maintain airway

210

Saturation Room air: O2 Sat > 95%Needs supplemental O2 to maintain O2 Sat > 95%O2 Sat < 95% with O2 supplementation

210

Readiness for Discharge Score

Pain None or mild painModerate or severe pain controlled with IV analgesicsPersistent severe pain

210

Emetic None or mild nausea with no vomitingTransient vomiting or retchingPersistent moderate to sever nausea or vomiting

210

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WHAT is NOT Procedural Sedation?

■ Providing for comfort■ Preventing predictable anxiety to a procedure or treatment by

utilizing narcotics and anxiolytics in dosages appropriate to relieve pain and/or anxiety without altering the LOC

■ Non-invasive and routine procedures (dressing changes)

■ Procedure that takes so little time to perform that the fear of the procedure is often worse than the actual process

■ One type dose medication administration to relieve anticipated pain or anxiety for a particular patient (no titrating dose to “effect”)

■ Patient in ICU, intubated, and mechanically ventilated (airway is protected)

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WHAT is NOT Procedural Sedation?

■ Pain and/or anxiety management that may be performed on all inpatient units

■ Repetitive procedures (e.g. once daily) and a patient who is on a standard dose, or combination of medication that provides comfort

■ A change in medication dose that would potentially induce pain and/or anxiety

Note: If patients have been on a medication regime in the ICU with Fentanyl/Versed, the physician should be consulted to determine if the choice of narcotics may be changed to an equianalgesic dosage of hydromorphone or morphine sulphate, and the midazolam changed to a non-amnesiac anxiolytic such as lorazepam or valium

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WHY Provide Procedural Sedation?

■ Allows patient to tolerate an unpleasant procedure while maintaining consciousness

■ Patient does not remember majority of procedure, awakens comfortable (depending on medications utilized)

■ Rapid return to presedation state

■ Uncomfortable and/or painful procedures can be performed safely utilizing procedural sedation

■ Patient safety during, and recovering from, sedation is VITAL!

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WHO can Provide Procedural Sedation?

■ Physicians must have current sedation privileges. An updated list can be accessed on the SD Credentialing Website: http://cred.zion.ca.kp.org

■ Residents may perform procedures only when the privileged attending physician is present

■ RNs with age-specific training in ACLS or PALS may administer Procedural Sedation and recover the patient

■ MD will complete the Procedural Sedation Record Physician documentation (Health Connect), including auscultation of heart and lungs and airway assessment

■ RN will complete the Procedural sedation Record RN documentation (Health Connect)

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Procedural Sedation SETTING

■ Emergency Medications, Equipment & Supplies■ Crash cart with defibrillator, O2, suction■ Reversal agents (naloxone, flumazenil)■ Pulse oximeter, blood pressure monitor

■ Endotracheal tube (ET) CO2 monitoring device

■ Physical Environment■ Emergency power outlets, or flash light■ Telephone

■ Transportation after Sedation■ By RN or MD

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ASA Status Risk Assessment

Class I Healthy patient

Class II Mild systemic disease, no functional limitation

Class III Severe systemic disease that limits activity (not incapacitating)

Class IV Incapacitating systemic disease that is a threat to life (Anesthesia consult)

Class E Emergent

Procedural Sedation Preparation

■ Consent needs to be obtained by physician for both the procedure and the sedation

■ Pre-sedation Assessment■ Evaluation of Risk (American Society of

Anesthesiologists ASA status)■ PASS Scores■ Sedation plan (medications ordered)

■ Time Out■ Team members discuss any risks■ Team members know roles and responsibilities

■ Patient Safety■ Identify patient (2 identifiers), must have arm

band■ Site/side verified

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Presedation Assessment

■ AMPLE ■ Allergies – medication, food, latex

■ Medications – presently taking

■ Past medical history

■ Last meal (NPO Guidelines)

■ Event leading to need for procedure

■ NPO GuidelinesAGE Solids & Non-Clear FluidsClear

0-6mo 4 hours 2-3 hours

6mo-3yrs 6 hours 2-3 hours

3yrs + 6-8 hours 2-3 hours

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Care During Sedation

■ Ensure Patient SAFETY ■ RN remains with patient at all times

■ RN responsibility is to monitor the patient – ensure safety

■ RN will NOT be expected to assist with the procedure

■ Maintain level of sedation that allows for continuous patent airway

■ Monitor patient’s response to medications■ Assess vital signs q 15 minutes ■ Sedation plan (medications ordered)

■ Document■ Use the Procedural Sedation Navigator

(Health Connect)

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Procedural Sedation DocumentationUse the Procedural Sedation Navigator (Health Connect)

From the patient’s open record, Click Action Procedural Sedation on the Main Menu.

Procedure Sedation Navigator AppearsFour (4) Main Topics

Navigate through each section to document your findings…

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1. Chloral Hydrate

2. Chlorpromazine (Thorazine)

3. Diazepam (Valium)

4. Fentanyl (Sublimaze)

5. Hydroxyzine (Vistaril)

6. Lorazepam (Ativan)

7. Meperidine (Demerol)

8. Midazolam (Versed)

9. Morphine Sulfate

10. Pentobarbital (Nembutal)

11. Promethazine (Phenergan)

Deep Sedation Agents

1. Alfentanil (Alfenta)

2. Etomidate (Amidate)

3. Ketamine (Ketalar)

4. Methohexital (Brevital)

5. Propofol (Diprivan)

6. Thiopental (Sodium Pentothal)

Moderate Sedation Agents

Common Sedation Agents

Procedural Sedation does not include:

Click Deep Sedation Agents for details

San DiegoADULT DRUG DOSAGE GUIDELINES for Moderate and Deep SedationDosages require adjustment based on patient's clinical condition Adapted from: Southern CA Regional Drug Information Services

BENZOIDIAZEPINES, DOSAGE ONSET DURATIONMidazolam (Versed): Slow IV: 0.5 - 1 mg (over 2 minutes) and titrate to desired effect by repeating doses every 2-3 minutes if neededPrecaution: Reduce dose for elderly or those that have COPD or receiving concomitant narcotics. Some pt’s respond to 1mg. Usual total dose: 2.5-5 mg

IV: 2-5 mins Peaks at 30 – 60 minutes.Duration: 2-6 hours

Lorazepam (Ativan): IV: 0.05 mg/kg, 1-4 mg IV every 10-20 mins. 4 mg max. PO: 1-2 mg initially. Usual dosing is 2-6 mg/day divided. May gradually increase to 10 mg daily in 2-3 divided dosesPrecaution: Monitor blood pressure and assess motor and autonomic responses

IV: 5-20 minsPO: 60 mins

IV, PO: 2 – 6 hours

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ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical conditionAdapted from: Southern CA Regional Drug Information Services

Diazepam (Valium): IV: 2.5-5 mg incremental doses of 2.5 mg can be given in 3-4 minute intervals. Usual total 2-10 mg.PO: 2-10 mg 2-4 times/dayPrecaution: incompatible with most medications. Potential complications: hypotension, confusion, drowsiness & apnea

IV: 2-5 minsPO: 30 mins

Peaks at 60-90 minutes Elimination half-life 36hours

IV = intravenous; IM = intramuscular; IN = intranasal; PO = by mouth; PR = by rectum; and SC = subcutaneous

San DiegoADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation

Dosages require adjustment based on patient's clinical condition

NARCOTICS, DOSAGE ONSET DURATION

Morphine: IV: 1-5 mg every 2-15 minutes. 2-5 mg IV every 5-15 minsPrecaution: Itching & hypotension may occur

IV: 5-10 mins/ 15-60 mins

IV: 2 – 4 hours

Fentanyl (Sublimaze): IV: 1 - 4 mcg/kg. Typical dose is 25-50 mcg; may repeat every 5-15 minutes. Usual total 50-200mcgPrecaution: 100 times more potent than morphine. Rapid administration causes skeletal muscle & chest wall rigidity

IV: 30-60 sec Peaks in 5-15 minsIV: 30-60 min

Meperidine (Demerol): IV: 12.5-50 mg every 15 minutes. Usual dose is 50-100mg.

IV: 5-10 mins IV: 2-4 hours

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ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical condition

Adapted from: Southern CA Regional Drug Information Services

OTHER AGENT, DOSAGE ONSET DURATIONDiprivan (Propofol): IV: 0.5-1.5mg/kg. May repeat 0.5mg/kg boluses every 3-5 mins as needed for continued sedation

Note: Injectable Emulsion for adults & children >2years. Adhere to strict aseptic technique during handling. A soy based product containing egg lecithin with no preservatives, can support growth of microorganismsPrecaution: rapid bolus injection can result in undesirable cardiorespiratory depression (apnea and hypotension). Discard unused portions at the end of the procedure or at 6 hours. Flush IV every 6 hours & at the end of the procedure to remove residual from the line

IV: 1-2 mins IV: 3-10 minutes

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ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical condition


REVERSAL AGENTS, DOSAGE ONSET DURATION

Naloxone (Narcan): Narcotic antagonistIV: 0.2-0.4 mg every 2-3 minutes as neededPrecaution: rapid reversal may cause nausea, hypertension

IV: 1-2 mins

IV: 30-60 mins short half- life- 30-81 mins; may require repeat in 1-2 hours

Flumanzenil (Romazicon):Benzodiazepine antagonistIV: 0.2 mg every minute up to max of 1mg. Most patients respond to 0.6-1 mg; up to 3 mg has been reportedPrecaution: may induce seizures in pt’s with seizure history

IV: 1-3 mins

IV: 30-60 mins short half-life- 41-79 mins; may repeat 20 min intervals

San DiegoPediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mosDosages require adjustment based on patient's clinical condition Consider Adult dosing guidelines for patients greater than 50 kg

Midazolam (Versed), DOSAGE ONSET DURATION

IV: 0.05 mg/kg, maximum of 5 mg titrated over one hour IM: 0.1 mg/kgIN: 0.2-0.4 mg/kg, maximum dose 7.5 mgPO: 0.25-0.5 mg/kg; maximum total dose 12 mg

Precaution: Three times more potent than diazepam. Used with opiates can cause overdosage and complications(IV = intravenous; IM = intramuscular; IN = intranasal; PO = by mouth; PR = by rectum; and SC = subcutaneous)

IV: 1-2 minIM: 5-15 minIN/PO:10min

IV, IM: 30–60 min

IN/PO:1–2 hours


San DiegoPediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mosDosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg

BARBITUATES, DOSAGE ONSET DURATION Pentobarbital (Nembutal) * IV: 1-3 mg/kg; may repeat up to 6 mg/kg IM: 2-5 mg/kg PO: 2-3 mg/kg

IV: 1-5 minIM: 5-15 minPO: 15-60 min

IV:15–60 minIM, PO: 2–4 hours

Methohexital (Brevital) *

PR: 20-30 mg/kg

PR: 5-15 min PR: 30–90 min

*These agents are restricted to practitioners with deep sedation privileges operating under guidelines approved by the Medical Executive Committee



OTHER AGENTS, Dosage:

ONSET DURATION

Chloral hydrate; PO, PR: 25-100 mg/kg; maximum 2 g Precaution: May necessitate ongoing monitoring

PO, PR: 15-30 min

PO,PR: 2–3 hours

Ketamine (Ketalar): *IV: 0.5-2 mg/kg IM: 3-4 mg/kgAdverse Effects: Increased systemic, intracranial, & intraocular pressures; hallucinogenic emergence reactions; laryngospasm; & excessive airway secretions

IV: 1-2 min

IM: 3-10mins

IV, IM:

15–60 min

Diprivan (Propofol) *IV: 0.5-1mg/kg. May repeat 0.5mg/kg boluses every 3-5 mins as needed for continued sedation. Precaution: rapid bolus injection can result in undesirable cardiorespiratory depression (apnea and hypotension). Discard unused portions at the end of the procedure or at 6 hours. Flush IV every 6 hours & at the end of the procedure to remove residual from the line * Agents restricted to practitioners with deep sedation privileges


IV: 1-2 min IV: 3-10 min


NARCOTICS, DOSAGE ONSET DURATION

Morphine IV: 0.05-0.1 mg/kgPrecaution: Itching & hypotension mayoccur

IV: 5-10 mins IV: 2-4 hours

Fentanyl (Sublimaze) IV: 1-4 mcg/kgPrecaution: one hundred times morepotent than morphine. Rapid administration causes skeletal muscle & chest wall rigidity

IV: 2-3 mins IV: 20–60 mins



REVERSAL AGENTS: DOSAGE ONSET DURATION

Naloxone (Narcan): Narcotic antagonist IV, IM,: 0.1 mg/kg (20kg or less) – max 2mg; if above 20kg 2 mg; may repeat in 5min to effectPrecaution: rapid reversal may cause nausea, Hypertension

IV: 1-2 minsIM: 2-5mins

45mins,may be shorter than duration of opiate

Flumanzenil (Romazicaon): Benzodiazepineantagonist IV: 0.01 mg/kg; Max. single dose 0.2 mg; may repeat every minute up to a maximum total dose of 1 mg Precaution: may induce seizures in pt’s with seizure history

IV: 1-3 min 45-60 mins, may be shorter than duration of the benzodiazepine


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Medication Administration Requirements

Clinical Library

To find out more information about medications, visit KP’s Clinical Library at http://cl.kp.org. This resource includes information on medication:

■ Dosages

■ Routes

■ Therapeutic range

■ Pharmacologic classification

■ Mechanism of action

■ Safe use of clinical practice guidelines formularies

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Post Sedation Recovery and Care

Ensure Patient SAFETY ■ RN remains with patient at all times■ RN is responsible to monitor the patient – until

pt. achieves his/her presedation LOC ■ If transferring the patient, the RN administering

sedatives must accompany the patient, give a complete, concise report to the receiving RN responsible for further patient care

■ Monitor patient’s vital signs and pulse oximetry q 15 minutes until stable

■ Reorient patient to time and place■ Limit stimuli to the patient (loud noises)

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Discharge Requirements

Patient Must■ Be discharged by a physician■ Have adequate respiratory function and stable vital signs ■ Meet their preprocedural LOC, and return to their

preprocedural status■ Have their pain under control, and site stable without

evidence of bleeding■ Not be discharged for 20-30 minutes after last

medication, longer if reversal agents given■ Be discharged to a responsible driver and advised not to

drive or use heavy machinery for at least 24 hours■ Receive post-procedural written discharge instructions ■ Verbalize understanding of instructions and education

(and/or responsible caregiver)

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Patient Safety Special Considerations

Patient Special Considerations

■ Elderly patient’s may need more time for monitoring

■ Ensure a good intact gag reflex especially in children

■ Evaluate each INDIVIDUAL patient based on a number of considerations, not just meeting these outline criteria

■ Document time patient leaves the facility

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PROCEDURAL SEDATION POST TEST

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Procedural Sedation Post Test

1. Which treatment is an example of procedural sedation?A. Preventing anxiety prior to treatment without altering the patient’s level of consciousness.B. Providing comfort measures to the patient.C. Performing a simple dressing change.D. Administering medication to alter the level of consciousness prior to a procedure.

2. A Physician prescribes a one-time dose of Morphine and Ativan to reduce the patient’s pain and anxiety during a dressing change. This is considered procedural sedation.

A. TrueB. False

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3. To prepare for procedural sedation, the RN must: A. Obtain patient consent for both the procedure and the sedation. B. Confirm auscultation of heart, lungs, and airway assessment was performed by MD C. Be aware of sedation plan D. Perform patient identification and a “Time-Out” E. Perform a baseline PASS assessment. F. All of the above

4. To perform procedural sedation, the RN must: A. Have age-specific resuscitative equipment. B. Have a physician privileged in Procedural Sedation present in the room. C. Receive age specific advanced life support certification. D. Provide a cardiac monitor, O2 monitoring, and ET CO2 monitoring. E. Follow all of the above.

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5. When performing procedural sedation, it is satisfactory to have the physician be available by pager during the procedure. A. TrueB. False

6. The nurse providing moderate sedation should remain with the patient at all times.A. TrueB. False

7. Before a procedural sedation patient can be discharged, they need to be observed for a minimum of 30 minutes after the last dose of sedative or analgesic was administered. Longer periods of observation are required if reversal agents are used.A. TrueB. False

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8. To discharge a patient following procedural sedation, a post-procedural assessment must be conducted (by a credentialed practitioner privileged in this procedure), the patient needs to receive written discharge instructions, and a responsible adult/driver must be identified.

A. TrueB. False

9. A “time-out” is performed prior to the start of the procedure and typically includes:A. A description of the nature of the procedure, the patient’s condition, details of any

abnormal history or condition, and any special patient needs.B. Use of two patient identifiers – patient name and medical record on arm band.C. Verification of the site, both physically and verbally, and if required, marking of the

site.D. A review of the expected course of the procedure and recovery.E. All of the above

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10. Development of chest wall rigidity (“wooden chest”) may result in serious respiratory compromise and is most often seen with the rapid administration of:

A. Fentanyl (Sublimaze)B. MorphineC. Ketamine (Ketalar)D. Flumazenil (Romazicon)

11. The reversal agent and initial dose preferred for a 300-pound 18 year-old who has had Diazepam, Midazolam, and Lorazepam during a procedure is:

A. Flumazenil (Romazicon) 0.2 mg, repeat every 1-2 minutes as neededB. Naloxone (Narcan) 0.4 mg, repeat every 2-3 minutes as neededC. Both a and b

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12. During conscious sedation, vital signs and oxygenation status are recorded at least every ______ minutes.A. 1B. 5C. 15

13. To verify a physician’s privileges to perform procedural sedation: A. Call the house supervisor B. Go to the Kaiser Permanente Credentialing web site C. Call the MD to see if they are privileged

14. Complications of procedural sedation can include: A. Abnormal cardiac function and deterioration B. Hypoventilation and allergic or reverse reaction C. Hypoventilation, allergic or adverse reaction, abnormal cardiac function, and

deterioration in mental status

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15. A 60 year-old male patient with coronary artery disease undergoes a pacemaker implant under IV sedation. During the procedure, the patient’s oxygen saturation decreases to 84%. The patient is snoring and responds to vigorous stimulation. You should:A. Lift the chin and jaw, attempt to provide a better airway, notify the physician

immediately after the change in the patient's condition, increase oxygen delivery, call for assistance and consider reversal agents.

B. Continue to monitor for further changes; reduce the next dose of sedation medication by half.

C. Document the patient's status on the assessment form; notify the MD at the conclusion of the procedure.

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16. After receiving Morphine and Valium for sedation and analgesia, your patient loses consciousness and becomes dusky in appearance, and the oxygen saturation

decreases rapidly from 95% to 75%. What is the appropriate nursing action?A. Ambu bag delivery of oxygenB. Nasal cannula delivery of oxygenC. Be ready to give IV Narcan and RomaziconD. A and C

17. During a procedure in which you are administering procedural sedation, respirations suddenly become stridorous and you notice a red rash occurs on the patient’s hands. The appropriate nursing action is to:

A. Intubate B. Do nothing C. Stop the medication and treat per the physician’s order D. Call a code blue

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18. Emergency equipment which must be immediately accessible during IV sedation includes:

A. Emergency cart with defibrillator, cardiac monitor, airways, bag-valve mask, and intubation equipment, including ET CO2 monitor

B. Emergency drugs including reversal agentsC. Oxygen and suction with tubingD. All of the above

19. The reversal agent and initial dose preferred for a 44-pound (20-kg) child who has had Morphine during a procedure is:A. Flumazenil (Romazicon) 0.1 mg – 0.2 mgB. Naloxone (Narcan) 0.01 mg/kgC. None of the above

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20. A patient whose PASS score is “1” for consciousness is: A. Presumed to be moderately sedated B. Presumed to be minimally sedated C. Presumed to be deeply sedated

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What is Procedural Sedation?