PROCEDURAL SEDATION

Dr. Mohammed NiyazPGY2

MIMS-K

Procedural sedation is the administration of sedatives or dissociative anesthetics to induce a depressed level of consciousness while maintaining cardiorespiratory function so that a medical procedure can be performed with little or no patient reaction or memory.

Examples: EGD, bronchoscopy, fracture/dislocation reduction, cardiac catheterization

SEDATION LEVEL

MINIMAL SEDATION Minimal sedation is characterized by anxiolysis but with normal, although

sometimes slowed, response to verbal stimuli.

Abscess incision and drainage Lumbar puncture Simple fracture reductions and laceration repair.

Ventilatory function- maintained Low risk of hypoxia or hypoventilation. Agents : Nitrous oxide, midazolam, fentanyl, pentobarbital, and low-dose ketamine.

MODERATE SEDATION Moderate sedation is characterized by a depressed level of consciousness and a

slower but purposeful motor response to simple verbal or tactile stimuli. “Conscious sedation.”

Incidence of hypoxia and/or hypoventilation : 10% to 30%.

Procedures : reduction of dislocated joints, thoracostomy tube insertion, and synchronized cardioversion.

Agents : propofol, etomidate, ketamine, methohexital, and the combination of fentanyl and midazolam.

DISSOCIATIVE SEDATION Dissociative sedation is a type of moderate sedation. Dissociation is a state in which the cortical centers are prevented from

receiving sensory stimuli, but cardiopulmonary activity and responses are preserved.

Ketamine is the agent most commonly used for dissociative sedation.

DEEP SEDATION

Deep sedation is characterized by a profoundly depressed level of consciousness, with a purposeful motor response elicited only after repeated or painful stimuli.

Procedures that are painful and require muscular relaxation with minimal patient reaction. The risk of losing airway patency or developing hypoxia or hypoventilation is greater with

deep sedation

Eg : reducing fracture dislocations, open fracture reductions, and burn wound care. Same agents as moderate sedation, but with larger or more frequent doses.

Richmond Agitation Sedation Scale (RASS) Score Term (not

included on documentation forms)

Description

+4 Combative Overtly combative, violent, immediate danger to staff

+3 Very agitated Pulls or removes tube(s) or catheter(s), aggressive

+2 Agitated Frequent, non-purposeful movement. Fights ventilator

+1 Restless Anxious, but movements not aggressive, vigorous

0 Alert and Calm-1 Drowsy Not fully alert, but has sustained awakening

(Eye-opening/eye-contact) to voice, ≥ 10 seconds-2 Light sedation Briefly awakens with eye-contact to voice, <10 seconds

-3 Moderate sedation

Movement or eye-opening to voice, (but no eye contact)

-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation

-5 Unarousable No response to voice or physical stimulation

NUMBER OF PHYSICIANS NEEDED : Two physicians, one to perform sedation and monitor the patient and the other to perform the procedure.

* The person performing the procedure (clinician) is to review objectives, risks, benefits and alternatives of Procedural Sedation (informed consent)

* This can be done at the same time as the procedure is explained

* Informed consent for the sedation does not require a patient signature.

Rather there is a check box on the Pre-Procedure/Pre-Sedation Assessment form.

If paper forms are not available, it is the responsibility of the clinician to document this in the pre- procedure note.

Informed Consent

RISK ASSESSMENT AND PATIENT SAFETY

American Society of Anesthesiologists’ physical status classification system.

Class I (healthy normal patient) and II (patient with mild systemic disease) is low, usually less than 5%.

The risk of an adverse procedural sedation and analgesia event is correspondingly higher in patients with an American Society of Anesthesiologists class of III (patient with severe systemic disease) or IV (severe systemic disease that is a constant threat to life).

Airway Inspect the airway to determine whether any

abnormalities (e.g., severe obesity, short neck, small mandible, large tongue, trismus) are present that might impair airway management.

Cardiovascular Disturbances in rhythm or other abnormalities. In patients with known cardiovascular disease, evaluate their

degree of reserve because most PSA agents can cause vasodilatation and hypotension.

Respiratory Obstructive lung disease and upper respiratory infections that

may predispose the patient to airway reactivity.

Oral Intake Guidelines Age does not matter – what they took orally is the issue.

Ingested Material Minimum Fasting Period Clear Liquids 2 hours Breast Milk 4 hours Infant Formula 6 hours Non-clear Liquids 6 hours Light Meal 6 hours

Options for the patient not within these guidelines: Cancel the Procedure

Postpone the Procedure

FASTING STATE : There is no primary evidence that the risk of aspiration during procedural sedation is increased with recent oral intake.

Thus recent food intake is not a contraindication.

If the risk of aspiration is concerning, waiting 3 hours after the last oral intake before performing procedural sedation is associated with a low risk of aspiration, regardless of the level of sedation.

Selecting agents that are less likely to produce vomiting, such as fentanyl instead of morphine or meperidine, may decrease the potential for aspiration.

Hepatic and Renal The implications of delayed metabolism or excretion of

PSA agents in infants younger than 6 months, in the elderly, and in patients with hepatic or renal abnormality should be considered.

EQUIPMENT Equipments for airway

management and resuscitation Oxygen, a bag-mask ventilation

device, suction, oral/nasal airway(s), and intubation equipment.

Defibrillator Reversal agents, such as opioid

receptor and benzodiazepine receptor antagonists

Prevent wrong site / wrong patient / wrong limb / wrong equipment

Site Verification / Marking “YES” on the procedure site Must be completed before the procedure starts Is the responsibility of the person performing the procedure (clinician) Should be a process which includes patient input / verification / understanding

TIME OUT! To be completed immediately before the first dose of sedation / start of the procedure. Is the responsibility of the clinician, although may be documented by the assistant Should be a group interaction (clinician, assistant, others present in the room) Includes four questions:

1. Is this the Correct Patient?2. Is this the Correct Procedure?3. Is this the Correct Site?

4. Is this the Correct Equipment?

The administration of morphine or fentanyl for analgesia during the procedure. Begin procedural sedation after the last dose of analgesic has reached its peak effect

(3 to 5 minutes for IV morphine and 2 to 3 minutes for IV fentanyl). Propofol or etomidate should be titrated separately

PREPROCEDURE PAIN MANAGEMENT

SEDATION MANAGEMENT After the patient has been evaluated, the appropriate sedation target

level is selected, the monitoring modalities are applied, and preparations are made for possible adverse events, then procedural sedation can begin

Pharmacokinetic Considerations- When selecting a sedative, the following

pharmacokinetic parameters should be considered to optimize response in a given situation.* Onset and Duration * Elimination Route * Accumulation * Drug interactions / potentiations* Cross-Tolerance (e.g. patients with prior opiate use may require higher doses of opiates; those with prior ethanol exposure may require larger doses or benzodiazepines, etc.)

Procedural orders * Given orally throughout procedure* Written orders required* If assistant is utilizing handwritten documentation, sign, time and date the bottom of monitoring form * If assistant is utilizing computer documentation, write orders for medications etc. in patient chart when writing post-procedure orders and notes.

Monitoring requirements* BP / P / RR / SpO2 documented every 10 minutes* Aldrete Score completed with each vital sign documentation

PROCEDURAL SEDATION MONITORING

Two types of monitoring are used for ED procedural sedation: interactive monitoring by dedicated observers and electronic monitoring with equipment connected to the patient.

The recommended extent of monitoring is determined by the level of sedation

INTERACTIVE MONITORING Direct observation of the patient To assess the depth of sedation and observe for

hypoventilation or apnea, upper airway obstruction, laryngospasm, vomiting, or aspiration.

Requires an unobstructed view of the patient’s face, mouth, and chest wall.

MECHANICAL MONITORING Pulse Oximetry Capnography ECG Monitoring BIS Monitoring :The

bispectral index (BIS) is a monitoring modality that uses a processed electroencephalogram signal to quantify the depth of anesthesia or sedation.

Normal capnogram.

The partial pressure of carbon dioxide detected at the nares during the respiratory cycle is represented by the carbon dioxide waveform (capnogram) that can be displayed on the monitor

Phase I: At the start of exhalation, carbon dioxide concentration in the exhaled gas is essentially zero, representing gas from the anatomic dead space that does not participate in gas exchange.

Phase II: As the anatomic dead space is exhaled, carbon dioxide concentration rises as alveolar gas exits the airway.

Phase III: For most of exhalation, carbon dioxide concentration is constant and reflects the concentration of carbon dioxide in alveolar gas.

Phase IV: During inhalation, carbon dioxide concentration decreases to zero as atmospheric air enters the airway.

Variations in the capnogram : apnea, upper airway obstruction, laryngospasm, bronchospasm, and respiratory failure.

A flat-line capnogram : apnea, upper airway obstruction, or complete laryngospasm.

Normalization of the waveform after airway alignment maneuvers (chin lift, jaw thrust, or oral airway placement) confirms that apnea was due to upper airway obstruction.

ALDRETE POST PROCEDURE RECOVERY SCORE Aldrete Post Procedure Recovery Score Base

Line Post

Procedure

D/C Activity Moves 4 Extremities voluntarily or on command Moves 2 Extremities voluntarily or on command Moves 0 Extremities voluntarily or on command

2 1 0

2 1 0

2 1 0

Circulation SBP ± 20 mmHg of Preprocedure Level ± 20-50 mmHg of Preprocedure Level ± 50 mmHg of Preprocedure Level Preprocedure BP / .

2 1 0

2 1 0

2 1 0

Respirations Able to deep breath or cough freely Dyspnea, shallow, or limited breathing Apneic or Mechanical Vent

2 1 0

2 1 0

2 1 0

Consciousness Awake (oriented, answers questions approp.) Arousable on calling (responds to voice) Non-responsive

2 1 0

2 1 0

2 1 0

Color Normal Pale, dusky, mottled, jaundiced, other Cyanotic

2 1 0

2 1 0

2 1 0

Discharge score must be a minimum of pre-procedure score minus one, with stable vital signs to meet discharge criteria.

TOTAL:

Baseline must be done before sedation initiated. This is what post-procedure Aldretes are

compared to.

Post Procedure is done at the end of the procedure, then every 10 minutes until patient meets recovery criteria

*A minimum of two consecutive Aldrete scores are baseline minus one with stable vital signs

* The patient’s room air oxygen saturation must be back to baseline

*Sufficient time (i.e., a minimum of 1 hour) should have elapsed after the last administration of reversal agents (naloxone, flumazenil).

*Patients who will be discharged to home and receive IV medications for relief of pain, nausea, vomiting etc. must be observed no less than two consecutive Aldrete / vital sign assessments following administration of such medication

Recovery criteria

* Vital signs stable* Swallow, cough * Able to ambulate (patient demonstrates ability to ambulate at pre-procedure level) * Nausea, vomiting, dizziness is minimal * Absence of respiratory distress * State of consciousness (patient is alert, oriented to time, place and person consistent with pre-procedure level of consciousness). * Level of comfort

* Post-procedure (oral and written) discharge instructions : purpose and expected effects of sedation, patient’s care, emergency phone number, medications, dietary or activity restrictions, and necessary precautions (e.g., no driving for 24 hours, avoid alcohol and use of power tools, etc.).

Discharge criteria

OUTCOME ASSESSMENT/COMPLICATIONS

Age >65 years Level of sedation Premedication with fentanyl, use of short-acting agents Procedural sedation and analgesia performed at night, When procedural sedation and analgesia could be administered by

physicians with varying levels of training and experience and when consultant-level supervision is not always physically present.

Serious adverse events include the need for assisted ventilation, endotracheal intubation, or treatment of hypotension or cardiac dysrhythmias.

Minor adverse events resolve spontaneously and include sedation to a deeper level than intended, transient hypoxia, or emesis.

SEDATING AGENTS

NITROUS OXIDE

50:50 mixture with oxygen, can be used alone for minimal sedation or as an adjunct with IV medications for moderate sedation

use of a demand delivery system triggered by the patient’s inspiratory force and a disposal or scavenger system to prevent accumulation of nitrous oxide in the room.

Rapid onset (1 to 2 minutes) and a rapid recovery (3 to 5 minutes)

cardiac depressant & pulmonary vasoconstrictor , relativedly CI in pulmonary hypertension.

Inhibitor of folate metabolism contraindicated in pregnant women. Promote expansion of internal gasfilled structures and should be avoided

in patients with pneumothorax, pneumocephalus, and vascular air embolism.

MIDAZOLAM short-acting benzodiazepine peak effect is seen within 2 to 3 minutes, and duration of retrograde amnesia is 20 to 30

minutes . combined with an opioid for moderate or deep procedural sedation, but when given

with an opioid, there is an increased risk of respiratory depression. Midazolam causes mild cardiovascular depression, and hypotension Paradoxical agitation and flumazenil can be given for reversal. Midazolam can be administered IV, PO, IM, PR, or intranasally. Intranasal midazolam irritates the nasal mucosa, which can be painful and provoke

anxiety.

FENTANYL AND ALFENTANIL

Potent, relatively short-acting opioid. Rapid onset of <1 minute, peak effect in 2 to 3 minutes, and duration of 30 to

60 minutes. alone for minimal sedation can be used in combination with midazolam for moderate and deep procedural

sedation and analgesia.

Rigid chest syndrome, a rare complication characterized by spasm of the respiratory muscles leading to respiratory depression or apnea, is seen when high doses (>5 micrograms/kg) of fentanyl are given by rapid IV bolus.

In small children, this syndrome may be precipitated by rapidly flushing the IV line.

Rigid chest syndrome is not reversible with opioid receptor antagonists.

Intubation with rapid-sequence induction and pharmacologic paralysis is usually required to ventilate the patient in this situation.

Slow administration of fentanyl (1 to 3 micrograms/kg over 5 minutes followed by slow and careful flushing of the IV line can prevent rigid chest syndrome.

Alfentanil is an effective agent but is associated with a 30% to 40% rate of airway and respiratory adverse effects, a rate typically higher than that seen with fentanyl or propofol alone

METHOHEXITAL Methohexital is an ultra-short-acting barbiturate

produces sedation within 1 minute of IV administration and has an effective duration of 3 to 5 minutes.

Methohexital is best used for brief moderate and deep sedation, such as that needed for joint dislocation reduction.

Adverse effect of methohexital is respiratory depression; the risk increases if additional boluses are given after the initial dose.

PENTOBARBITAL Pentobarbital is a short-acting barbiturate

Useful when the procedure itself is painless, but the associated circumstances may cause anxiety (e.g., radiologic procedures).

Pentobarbital produces sedation within 3 to 5 minutes of IV administration

Lasts approximately 15 minutes, and complete recovery occurs in 30 to 40 minutes.

KETAMINE Produces a state of dissociation characterized by profound analgesia,

sedation, and amnesia. Possesses both analgesic and anxiolytic properties. Effective agent for ED procedural sedation and for prehospital

analgesia At doses lower than a threshold, analgesia and sedation occur. Ketamine can be given either IV or IM. The IM route 40 minutes of

sedation, 10 minutes by the IV route.

Ketamine is the only sedative agent that typically preserves a patient’s ventilatory effort and has minimal effect on blood pressure.

Ketamine can induce hypersalivation. Anticholinergics, such as atropine 10 micrograms/kg IV or

glycopyrrolate 4 micrograms/kg IV, are often administered to counter this effect.

Other adverse effects also include laryngospasm, vomiting (most often in the late recovery phase), and emergence reactions.

Laryngospasm has been reported primarily in children, with reported rates of occurrence of <1.0% to 2.5%.

It is typically transient and responds to positive pressure ventilation with a bagvalve mask.

Emergence reactions are common with ketamine and range from mild agitation to recurrent nightmares and hallucinations.

Midazolam can be given along with ketamine to blunt the occurrence of emergence reactions.

Because of these emergence reactions, ketamine should not be used in patients with schizophrenia and psychosis.

Ketamine increases intracranial pressure

Ketamine does increase intraocular pressure and should be avoided in patients with eye injuries or glaucoma.

ETOMIDATE Nonbarbiturate sedative-hypnotic Rapid onset (15 to 30 seconds) and a short duration of effect

(3 to 8 minutes). causes less cardiovascular depression

Complication rate of 10% to 15%, most complications being minor.

Myoclonic jerking occurs in up to 20% of patients and can interfere

with the procedure for which the patient was sedated.

Causes suppression of the adrenal-cortical axis, and when used for rapid sequence induction in critically ill patients, it is associated with adrenal insufficiency and increased mortality.

PROPOFOL Moderate and deep procedural sedation

Fewer complications than etomidate or methohexital in patients who received multiple doses and is much easier to titrate.

Sudden respiratory depression and apnea.

Propofol can produce hypotension as a result of both negative inotropy and vasodilatation.

Hypotension is more common in hypovolemic patients and those with American

Societyof Anesthesiologists physical status scores of III or IV.

Hypovolemia should be corrected before propofol administration. at 10 micrograms/kg.

Sedation from propofol occurs within 30 to 60 seconds after injection and lasts for about 5 to 6 minutes.

healthy nonelderly adults is 0.5 to 1.0 milligram/ kg IV, followed by 0.5 milligram/kg IV every 3 minutes if needed.

Higher doses are associated with more respiratory depression.

Propofol is formulated in a soybean oil, glycerol, and egg lecithin emulsion and is contraindicated in patients who are allergic to eggs or soy protein.

Propofol causes local pain at the IV site during administration.

Methods to reduce the pain of propofol administration include placing a tourniquet proximal to the IV and injecting 0.05 milligram/kg of lidocaine through the IV approximately 60 seconds before injecting the propofol

KETAMINE AND PROPOFOL

Propofol is an excellent sedative, but respiratory depression and hypotension are its principal adverse events.

Ketamine causes emergence reactions and vomiting as adverse events, whereas propofol has antiemetic and hypnotic properties.

This combination is safe and effective for ED procedural sedation and analgesia. Published “ketofol”

Adding ketamine to propofol promotes hemodynamic stability, which is reassuring in patients with known or potentially reduced cardiac function.

ketofol provides less erratic sedation depth than propofol alone. The analgesic properties of ketamine preclude the need for and risks

of opioids administered with propofol.

The advantage of ketofol is that it may be able to achieve adequate sedation with lower total doses compared with when either drug alone is used

ketofol prolongs the duration of sedation more than propofol alone, which is useful for procedures anticipated to take more time, and without the need for additional doses of propofol

SPECIAL CIRCUMSTANCES PROCEDURAL SEDATION AND ANALGESIA IN CRITICALLY ILL PATIENTS Etomidate : hypotensive patients who require sedation for an emergency

procedure because it produces less cardiovascular suppression than other agents.

Etomidate : suppresses the adrenal-cortical axis, increased mortality Critically ill patients who require prolonged sedation should be referred for

general anesthesia in the operating room.

PROCEDURAL SEDATION AND ANALGESIA IN THE ELDERLY

Increased technical and pharmacologic adverse events.

Ventilatory drive and the ability to maintain a patent airway are reduced.

Remove false teeth or partial dentures before sedation to prevent aspiration of the devices.

Risk of pulmonary aspiration increases as a result of reduced gag reflex and gastroesophageal sphincter incompetence.

Underlying comorbidities or hepatic or renal insufficiency affect the response to sedatives.

Etomidate :minimal cardiovascular effects. For painful procedures, opioids may be necessary, as etomidate has no analgesic effect. In elderly patients with underlying clonus, etomidate should be avoided.

Propofol produces greater peak plasma concentrations after a specific IV bolus dose in the elderly, therefore producing a greater risk of respiratory depression and apnea.

To counteract this, the initial and subsequent doses should be 50% (0.25 to 0.5 milligrams/kg) of those recommended for younger adults, and more cautious titration is needed.

PROCEDURAL SEDATION AND ANALGESIA FOR EMERGENCYENDOSCOPY

Endoscopy increases the risk for vasovagal reactions, with bradycardia and hypotension.

Treatment with atropine should be reserved for persistent bradycardia.

Passage of the endoscope through the pharynx into the stomach can exacerbate the risks for hypoxia, apnea, and aspiration.

The endoscope can interfere with ventilation and can induce vomiting. Topical agents (benzocaine, lidocaine) are used for pharyngeal anesthesia.

The occurrence of methemoglobinemia after benzocaine topical spray can interfere with pulse oximetry monitoring.

Antiemetic agents used during the procedure, such as promethazine or droperidol, can cause complications during the performance of procedural sedation.

Promethazine exerts an α-adrenergic blocking effect and may produce hypotension. Sedative effect of promethazine may last >2 hours, prolonged recovery should be anticipated.

Droperidol increases the risk of transient hypotension and may also prolong the recovery phase (up to 3 to 6 hours).

Ondansetron is an antiemetic without these potential effects and is a reasonable alternative

QUESTIONS ???

Which of the following notation by the Assistant would best indicate your patient’s sedation is maintained at a moderate sedation level?

A. Opens eyes to sternal rub B. BP 128/68 C. Follows simple commands D. RR remains 14-16Answer: C

Question 1

Within 5 minutes of the end of the procedure, your patient is snoring loudly and occasionally appears to have sleep apnea. When you vigorously shake his shoulder and call his name loudly, he arouses and takes a deep breath. This description most accurately describes which of the following?

A. Anxiolysis B. Moderate sedation C. Deep sedation D. General anesthesia

Answer: C

Question 2

You have given Ms Gray Midazolam 3 mg IVP and Morphine 2mg IVP. She remains alert but states she feels more relaxed. Select the level of sedation this patient has received.

A. No sedation B. Light sedation (Anxiolysis) C. Moderate sedation D. Deep sedation

Answer: B

Question 3

What is an indication your patient may be dropping from moderate sedation to deep sedation?

A. BP drops from 128/62 to 118/56B. SpO2 drops from 99% to 90%C. Apnea developsD. The patient squeezes your hand on

command Answer: B

Question 4

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. This patient is an ASA PS classification of:

A. ASA IB. ASA IIC. ASA IIID. ASA IVE. ASA V

Answer: B

Question 5

A 71-year-old woman has a history of diabetes and CHF. She is on multiple medications from her physician including nitropaste, atenolol, lasix, and micronase. She lives a very sedentary life. She presents for an EGD for a work-up of her “guiaiac positive stools. On physical exam you hear rales ¼ of the way up on both lung fields. This patient is an ASA PS classification of:

A. ASA IB. ASA IIC. ASA IIID. ASA IVE. ASA V

Answer: D

Question 6

A 55-year-old man is to have a closed reduction of a fractured wrist. He had a MI a few years ago. He underwent a carotid endarterectomy last year. He reports that he does get a little tired after walking one block and has to rest after 1 flight of stairs. This patient is an ASA PS classification of:

A. ASA I EB. ASA IIC. ASA III ED. ASA IVE. ASA V E

Answer: C

Question 7

Required monitoring parameters during the procedure include:

A. Heart rate, blood pressure, and oxygen saturation

B. Heart rate, rhythm interpretation, blood pressure, respirations, oxygen saturation and level of sedation.

C. Heart rate, rhythm interpretation, blood pressure, oxygen saturation, capnography and respirations

D. Heart rate, blood pressure, respirations, oxygen saturation and level of sedation

Answer: D

Question 8

Informed consent needs to be obtained before conscious sedation is administered. Which of the following need not be included in Mr. Brown’s informed consent?

A. Medications planned for Moderate Sedation

B. Benefits of Moderate Sedation C. Alternatives to Moderate Sedation D. Risks of Moderate Sedation

Answer: A

Question 9

The clinician is responsible for:A. Sedation planB. Initiating the “Time Out”C. Completing the history and physicalD. All of the above

Answer: D

Question 10

Which of the following is required for all outpatients prior to the procedure?

A. Consent for sedation B. Airway assessment C. Presence of responsible adultD. All of the above

Answer: D

Question 11

During the procedure Mr.... Green’s vital signs should be documented at least:

A. Every 5 minutes B. Every 10 minutes C. Every 15 minutes D. Beginning and end of the procedure

Answer: B

Question 12

The assistant’s responsibilities DO NOT include:

A. Documentation of vital signsB. Patient comfortC. Leaving the room to get suppliesD. Assisting with short interruptible

tasks during the procedure.

Answer: C

Question 13

Jane Smith is a 79-year-old female otherwise healthy female who is to have a closed reduction of a right colles fracture under moderate Sedation. Pre-procedure assessment includes BP 142/74, P82, R18, T37.4, Sat 96% room air. Immediately after administration of the medications, Mrs. Smith’s BP drops to 108/56 and her heart rate rises to 98. What should be the first intervention you provide?

A. Fluid Bolus B. Romazicon 0.4 mg IVP C. Page for Anesthesia D. Cancel the procedure and reevaluate Mrs.

SmithAnswer: A

Question 14

You have planned moderate sedation. You anticipate the patient will achieve a RASS score of:

A. -1B. -2C. -3D. -4 Answer: C

Question 15

During a painful procedure, you order morphine 4 mg IV. Within a few minutes of the morphine administration the patient’s oxygen saturation is 92%. You should immediately:

A. Insert an oropharyngeal airway B. Stimulate the patient C. Apply non-rebreather mask at 12

L/min D. Give a fluid bolus

Answer: B

Question 16

After the procedure is completed, your patient’s saturation drops , and Romazicon is given. She is able to support her own airway and her saturations return to normal. The minimal time she needs to be monitored after the romazicon is given before returning her to the nursing unit is:

A. 30 minutes B. 1 hour C. 2 hours D. No more monitoring is necessary, the benzodiazepine is

reversed.Answer: B

Question 17

After the procedure, your patient states she’s ready to go home. Which of the following would indicate that she would need to stay a little longer?

A.Dizziness when first sitting up. B.Systolic BP 128-136 for the past hour C.Wrist pain, reported 3/10 D.Aldrete score 2 below pre-procedure

score.Answer: D

Question 18

Question 19What is the usual fentanyl onset time and what is the time interval

that should elapse before a second dose should be administered?

A. 30 seconds, 1 minuteB. 1-2 minutes, 2 minutesC. 8-10 minutes, 10 minutesD. 15 minutes, 15 minutes

Answer: B

Which of the following information should be included in the discharge instructions when a patient is discharged within 24 hours of receiving procedural sedation?

A. Return to your normal activitiesB. Avoid alcoholic beverages for the next 2 hoursC. Do not drive for 24 hours.D. Clear liquid diet for 24 hours.

Answer: C

Question 20

Question 21

What is the usual Midazolam onset time and what is the time interval that should elapse before a second dose should be administered?

A. 30 seconds, 5 minutesB. 1 minute, 1 minuteC. 3-5 minutes, 5 minutesD. 10 minutes, 20 minutes

Answer: C

Question 22

What is the expected duration of effect of asingle bolus of midazolam?

A. 20 minutesB. 1 to 2 hoursC. 4 hoursD. 6 hours Answer: A

Question 23What is the explanation for the prolonged

effect?

A. Drug-drug interaction B. Chronic renal insufficiencyC. Too high of doseD. None of the above

Answer: A

Question 24What alternative opioid agent should be

considered for moderate sedation?A. FentanylB. MorphineC. HydromorphoneD. B or C

Question 25What is the duration of effect of naloxoneand what is the minimum amount of timeafter the dose that the patient should bemonitored?

A. 30 min-1 hour, 30 minutesB. 30 min- 1 hour, 1 hourC. 1-2 hours, 1 hourD. 1-2 hours, 2 hours

Answer: B

Question 26What important history should be obtainedprior to meperidine administration?

A. Allergy history B. Seizure historyC. Medication historyD. All of the above

Answer: D