Procedural sedation in

Emergency Medicine

Dr . Venugopalan. P.P

DA,DNB,MNAMS,MEM[GWU]

Director Emergency Medicine

PG Teacher in EM , NBE

Founder & Executive director ,ANGELS

Aster DM Health care

India

Objectives

What does it mean

What needs to be considered.

What do we normally use it for.

Review commonly used agents

Briefly discuss alternatives to PSA

Overview

DISCLAIMER….

This is a very simplified overview of a

complex topic.

It is not a substitute for in-depth research,

background knowledge and training.

AcknowledgementPresentations by

Deon Stoltz ,Dr Garry Clearwater and

Barnes-Jewish Hospital

What is

Procedural

Sedation?To reduce patient anxiety

and awareness

To facilitate a painful medical procedure

Patient maintains their airway & breathing

“Conscious sedation”“Deep sedation”

What is Procedural Sedation?

• Procedure (n) A series of steps taken to accomplish an end. Examples: EGD, bronchoscopy, fracture/dislocation reduction, cardiac catheterization

• Sedation (n)

Reduction of anxiety,

stress, irritability, or

excitement by

administration of a

sedative agent or

drug. Procedural Sedation (n) Reducing anxiety or stress with medications in order to perform a procedure. These medications may include, but are not limited to Opiates (e.g., morphine, fentanyl) and Benzodiazepines (e.g., midazolam, lorazepam).

The goals of PSPatient safety & welfare the first priority.

Adequate analgesia, anxiolysis, sedation and amnesia during the performance of painful diagnostic or therapeutic procedures in the ED.

Minimize the adverse psychological responses

Control motor behaviour that inhibits the provision of necessary medical care.

Return the patient to a state in which safe discharge is possible.

Procedural

Sedation PositivesAvoids the discomfort associated with local or regional anaesthetictechniques.Doesn’t affect anatomyRelatively simple technique

NegativesConsumes resourcesGeneral anaesthesia in the ED is frowned upon…

How low should you go?

Depth of Procedural Sedation

Minimal Sedation (Anxiolysis)

Moderate Sedation/Analgesia

Deep Sedation/Analgesia

General Anaesthesia

Normal LOC

Sedation Continuum Moving from one state of conscious to

another is a dose-related continuum that depends on patient

response NOT type, dose or route of medication, or any other

external factors.. MINIMAL

SEDATION

(ANXIOLYSIS)

MODERATE

SEDATION

DEEP

SEDATION

ANESTHESIA

Response Normal

response to

verbal

stimulation

Purposeful

response to

verbal or

tactile

stimulation

Purposeful

response

following

repeated or

painful

stimulation

Unarousable

even with

painful

stimulus

Airway Unaffected No

intervention

required

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

Uses Reduction of dislocations:

Shoulder, elbow, hip, patella, ankle

Reduction of fractures: Wrist, ankle Washout compound

fracture

Paediatric injuries: Wound inspection,

closure, suturingAbscess I&D

Considerations for PS in the

ED

Environmen

tal

Patient Agent

Patient

Case – Mr. F. B.

Case

A 40 yo

man

presents

with a

painful,

swollen

right wrist

after a fall.

You do an

x-ray…

So what about our patient?Allergies:

Eggs

Medications:

Enalapril

Salbutamol

Flovent

Past Medical History:

Asthma

Obstructive sleep apnea

Hypertension

DM II

• Last Meal:

– 30 minutes ago

• Events:

– Patient came immediately to the

hospital after falling.

AMPL

E

To sedate or not to sedate…

86 yo female with a dislocated hip

Allergies: NKDA

Meds: MetoprololNitroglycerin patch

Enalapril

Lasix

ASA

Last meal:NPO for 4 hours

• PMHx:– MI x 2 (multi-vessel

CAD)

– Angina with minimal activity

– PVD

– HTN

– CVA

– CRF

• Events:– Pt felt a pop while

trying to get up from a chair.

To sedate or not to sedate…

22 yo intoxicated male with an ankle fracture

Allergies: NKDAMeds: unknownPMHx: unknownLast meal:

Smells like EtOHUnknown

Events:No one really knows

To sedate or not to sedate…

28 yo female with a fractured wrist

What risks

are

associated

with sedation

during

pregnancy?

Patient

Assessment

The AMPLE historyAllergiesMedicationsPast medical

historyLast mealEvents before &

after the incident

Physical ExamAirway

assessmentRespiratory

examCardiovascular

exam

ASA Physical Status

ClassificationI. Healthy Patient

II. Mild systemic disease – no functional limitation

III. Severe systemic disease –definite functional limitation

IV. Severe systemic disease that is a constant threat to life

V. Moribund patient that is not expected to survive with the operation

ASA PS (physical status) classification

Definition Details Examples

ASA

PS 1 A

normal

healthy

patient

Healthy individual with no

systemic disease, undergoing

elective surgery. Patient not at

extremes of age. (Note: Age

is often ignored as affecting

operative risk; however, in

practice, patients at either

extreme of age are thought to

represent increased risk.)

Fit patient with inguinal

hernia.

Fibroid uterus in an

otherwise healthy woman

ASA

PS 2 A

patient

with

mild

systemic

disease

Individual with one system,

well-controlled disease.

Disease does not affect daily

activities. Other anesthetic

risk factors, including mild

obesity, alcoholism, and

smoking can be incorporated

at this level.

Non-limiting or only

slightly limiting organic

heart disease.

Mild diabetes, essential

hypertension, or

anemia.

ASA PS (physical status) classification continued

Definition Details Examples

ASA

PS 3 A

patient

with

severe

systemic

disease

Individual with multiple

system disease or well

controlled major system

disease. Disease status

limits daily activity.

However, there is no

immediate danger of

death from any

individual disease.

Severely limiting organic heart

disease. Severe diabetes with

vascular complications.

Moderate to severe degrees of

pulmonary insufficiency.

Angina pectoris or healed

myocardial infarction.

ASA

PS 4 A patient

with

severe

systemic

disease

that is a

constant

threat to

life

Individual with severe,

incapacitating disease.

Normally, disease state

is poorly controlled or

end-stage. Danger of

death due to organ

failure is always present

Organic heart disease showing

marked signs of cardiac

insufficiency, Persistent

anginal syndrome, or active

myocarditis. Advanced

degrees of pulmonary, hepatic,

renal, or endocrine

insufficiency.

ASA PS (physical status) classification continued

Definition Details Examples

ASA PS 5 A

moribund

patient not

expected to

survive (24

hrs)

Patient who is in

imminent danger of death.

Operation deemed to be a

last resort attempt at

preserving life. Patient not

expected to live through

the next 24 hours. In some

cases, the patient may be

relatively healthy prior to

catastrophic event, which

led to the current medical

condition.

Burst abdominal

aneurysm with

profound

shock.

Major cerebral

trauma with rapidly

increasing

intracranial

pressure.

Massive pulmonary

embolus.

ASA PS 6 A declared

brain-dead

patient /

organ

donor

“It’s only a little chest pain”

ASA Scores & PSA• The ASA classification is not validated

outside of the OR.

• Malviya et al showed an increased risk

of adverse sedation-related events in

paediatric patients with an ASA > 2.

“The patient’s ASA status should be

determined. For non-emergent

procedures, ED sedation and

analgesia should be limited to ASA

class 1 or 2 patients.”Class B, Level III

Procedural sedation and analgesia in the emergency department

Canadian Consensus Guidelines

The Last Supper

Fasting & PSA

ANZCA recommendations for healthy elective GA patients:

2 h NPO for liquids

6 h NPO for solids

The risk of aspiration during PSA is extremely low.

There is no evidence that fasting improves outcome during procedural sedation and analgesia.

One large paediatric study of ED procedural sedation showed no increase in the number of adverse events in patients that were not fasting.

Starved for how long…?

Controversial.

Probably not as rigid as anaesthetic guidelines for GA...

Depends on degree and duration of sedation

Starship CED paediatric guideline:

Clear fluids: at least 2 hours

Non-clear fluids and solids: at least 4 hours

Oral Intake

GuidelinesAge 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 6hours

Non-clear Liquids 6 hours

Light Meal 6 hours

Options for the patient not within these guidelines:

Cancel the Procedure

Postpone the Procedure

Emergent

Procedures

Emergent Procedures : life- or organ (i.e., CNS) saving procedures (consult anesthesiology)

Urgent procedure are those which need to be done in 2-4 hrs

•Document why it is urgent; •Assess the need for sedation and preferably administer none•Consider postponing or consult anesthesiology•Monitor the patient's airway closely •Look for active or silent regurgitation and aspiration.

PATIENT SELECTION

Can you hold the fort if something goes wrong?

BREATHING & CIRCULATION:

Lung disease?

Stable cardiac status?

BP stable?

Medications

Allergies (e.g. watch out for soy, eggs: Propofol)

Airway Assessment

Can you bag?

Can you

Intubate?

Predictors of Difficult BVM Ventilation

Beard

Obesity

Old (age > 55 yrs)

Toothless

Snores

Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000; 92:1229-36.

The LEMON Method of Airway

Assessment• Look for external characteristics known to causes

problems with BVM or intubation.

• Evaluate the 3-3-1 Rule:

Mouth opening > 3 fingers

Hyoid – chin distance > 3 fingers

Anterior low jaw subluxation > 1 finger

• Mallampati Score

• Obstruction – any pathology within or surrounding the

upper airway

• Neck Mobility - full flexion & extension

Considerations for PS in the

ED

Environmen

tal

PatientAgent

Choosing appropriate

medications

• Agents should be chosen

based on the desired

pharmacological

response. Depending on

the particular agent one,

two or all three of these

below effects can be

achieved:

Adverse effects -

The potential side

effects of any

medication in a

particular patient

must by

considered.

Many sedative

agents can

produce cardiac

or respiratory

depression.

Analgesi

aAmnesi

a

Pharmacokineti

c

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.

-

The Perfect

Drug

Provides adequate

sedation and analgesia

for:

Patient comfort

Easy completion of the

procedure

Maintains airway

reflexes

Does not affect

hemodynamics

Does not affect

respiratory function

Commonly

Used Agents Propofol

Fentanyl

Ketamine

Midazola

m

Commonly Used

Agents

Propofol

Category

Sedative-Hypnotic

What is it?

2,6-diisopropofol, an alkylphenol oil in an emulsion

How does it work?

Potentiates GABA activity

How much do you need?

Starting dose of 0.5 -1 mg/kg

Commonly Used

Agents

Propofol

What else does it do?

CNS: Mild analgesic properties; euphoria

CVS: Myocardial depressant; vasodilation

Resp: Respiratory depressant

GI: Antiemetic

MSK: Myoclonus

What does the body do with it?

Rapid redistribution

Hepatic and extrahepaticmetabolism

Commonly Used

Agents

Propofol

Pros

Shown to be safe for

ED PSA use

Rapid onset and

recovery

Cons

Must be combined with

an analgesic agent

May cause apnea &

loss of airway reflexes

Myocardial depressant

and vasodilator

Commonly Used

Agents

Fentanyl

CategoryAnalgesic agent

What is it?Synthetic opioid

How does it work?Decreases conduction along nociceptivepathways and increases activity in pain control pathways in the brain.

How much do you need?

Starting dose of 1-2 mcg/kg

Commonly Used

Agents

Fentanyl

What else does it do?

CNS: Euphoria (or dysphoria)

Resp: Respiratory depressant; chest wall rigidity

CVS: May decrease HR

GI: Decreased motility

What does the body do with it?

Hepatic metabolism (inactive metabolite)

Renal excretion

Commonly Used

Agents

Fentanyl

Pros

Good hemodynamic

stability

Rapid onset and

recovery

Cons

Must be combined with

an amnestic agent

May cause bradycardia

May cause chest wall

rigidity

May cause apnea &

loss of airway reflexes

Commonly Used

Agents

MidazolamCategory

Amnestic

What is it?

Benzodiazepine

How does it work?

Bind to benzodiazepine receptors which up-regulate GABA activity

How much do you need?

0.02 – 0.1 mg/kg IV

Commonly Used

Agents

Midazolam

What else does it do?

CNS: Anxiolysis

CVS: Slight decrease in

PVR & decreased

contractility.

Resp: Respiratory

depression

What does the body do

with it?

Hepatic metabolism

(active metabolite)

Renal excretion

Commonly Used

Agents

KetamineCategory

Dissociative Amnestic

What is it?

Derivative of phencyclidine with some opioid properties.

How does it work?

Stimulates the limbic system while inhibiting the thalamus & cortex (dissociation)

Binds to NMDA and opioid receptors

Commonly Used

Agents

Ketamine

What else does it do?

CNS: Emergence reactions

CVS: Increased contractility, HR and PVR through sympathetic stimulation. Direct myocardial depressant.

Resp: Laryngospasm, bronchodilation, increased secretions

What does the body do with it?

Hepatic metabolism

Renal excretion

• Frequency is reported to

be anywhere from <1% to

50% in adults.

• Treatment with

benzodiazepines is the

most effective way to

prevent emergence

reactions.

But won’t it give him nightmares?

Ketamine & Emergence Reactions

Commonly Used

Agents

Ketamine How much do you

need?

1 – 2 mg/kg IV

How much

midazolam?

0.7 mg/kg given at

the time of

ketamine injection.

Mix & Match

Commonly used combinations:

Propofol + Fentanyl

Fentanyl + Midazolam

Propofol + Midazolam + Fentanyl

Ketamine + Midazolam

Ketamine + Propofol

“Ketofol”

If respiratory depression and/or hemodynamic instability

occurs, consider use of reversal agents.

Naloxone

(Narcan®) Opioid antagonist

Dosing: 0.4–2 mg q 2-3

min, up to 10 mg

Onset time: 1-2 min

Duration of effect: 30-60

min

Adverse effects:

precipitate withdrawal,

pulmonary edema

Flumazenil

(Romazicon®) Benzodiazepine

antagonist

Dosing: 0.2 mg q 1 min,

up to 1 mg

Onset time: 1-2 min

Duration of effect: 30-90

min

Adverse effects: seizures

Reversing BZD-induced

hypoventilation

How low should you go?

Depth of Procedural Sedation

Minimal Sedation (Anxiolysis)

Moderate Sedation/Analgesia

Deep Sedation/Analgesia

General Anaesthesia

Normal LOC

Considerations for PS in the

ED

Environmen

tal

PatientAgent

Environmenta

l

PREPARATIO

N

Prepare for the worst….

What can go wrong?

Unexpected drug

reaction or anaphylaxis

Vomit and aspirate

Obstructed airway (e.g.

laryngospasm, tongue)

Apnoea, respiratory

arrest

Profound hypotension

PREPARATIO

N

Not quite the worst …

What can go wrong?

Disinhibition / agitation

Terrors, nightmares

Unexpected drug

reactions: dystonias

Inadequate sedation

Unsuccessful

procedure… still needs

GA

PREPARATIO

N

ACEM POLICY

DOCUMENT -

USE OF

INTRAVENOU

S SEDATION

FOR

PROCEDURE

S IN THE

EMERGENCY

DEPARTMENT

© ACEM. 5 December

2001

PREPARATION

Environment

Separate space to perform the procedure

A recovery space: ideally quiet, available for 1-2 hours, easily observed.

PREPARATIO

N

ENVIRONMENT

The procedure must be performed in a suitable clinical area with facilities for:

Monitoring,

Oxygen

Suction

Immediate access to emergency resuscitation equipment, drugs and other skilled staff.

PREPARATIO

NENVIRONMENT

Readily available equipment must include:

Resuscitation trolley

Defibrillator

Bag-Valve-Mask device for ventilation

PREPARATIO

N

MONITORING

Cardiac rhythm,Non-

invasive blood

pressure, Pulse

oximetry must be

monitored “throughout

the procedure and

recovery period”

PREPARATIO

N

PERSONNEL

The involvement of at least two clinical staff is required:

PERSON PERFORMING PROCEDURE

must understand the procedure and its potential complications.

PERSON GIVING DRUGS AND MONITORING PATIENT - must have training and experience of resuscitation, emergency drugs and …. (details of) the drugs used.

This person is not involved in the performance of the procedure but is dedicated to care and monitoring of the patient.

PREPARATIO

N

PATIENT PREPARATION

Explanation

Consent

Secure IV access

is mandatory.

Informed Consent

* 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.

* If the person who will monitor the patient (assistant) finds that the patient has

additional questions, the person performing the procedure (clinician) will be

contacted to answer these questions before sedation is given.

Assistant Responsibilities

– Patient assessment and

appropriate documentation

throughout the procedure

– Reassure patient and monitor

patient awareness.

– Provide comfort measures as

needed

– Notify clinician of changes /

concerns.

– Documentation of required

parameters.The Assistant is not to leave patient bedside for any

reason during the procedure (although may assist

the clinician with short, interruptible tasks) The

assistant must be able to drop those tasks if the

patient needs attention)

Documentations

Don’t forget …..

Must ….

Pre-Procedure/Pre-Sedation Assessment form (required

for all procedural sedation) includes documentation of the

following:

Review of Systems:

*Can be completed by nursing or medical staff. If completed by nursing,

must

be reviewed by the clinician completing the pre-procedure

assessment.

Focused Assessment:

Must be completed by a licensed independent practitioner according

to

Medical Staff Bylaws. It includes procedure-specific parameters, and

addresses any new or pertinent data seen on the Review of Systems.

Airway Assessment:

* Aim is to plan for airway management if that would be necessary.

* Assessment parameters may include

* Assessing dentures, loose teeth, partials, etc.

* When the patient opens his/her mouth, how easily can the cords

and

pharynx be visualized should intubation be necessary.

* Are there physical limitations, which would impede proper

positioning

Pre-Procedure/Pre-Sedation Assessment form

(required for all procedural sedation) includes

documentation of the following:

Risk Assessment (ASA PS Score)

*To be completed by clinician, even if you’re not Anesthesia

personnel

Risks/Benefits/Alternatives for Sedation

*Required discussion with patient should be documented

either on outpatientforms, or in procedure note

Risks/Benefits/Alternatives for Procedure

*As above, with the addition of signature on procedural

consent

Sedation Plan:

*The level of sedation that was presented to, and accepted by

the patient. This must be documented before initiation of the

procedure.

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?

Intra-procedure Monitoring requirements

*BP, Pulse, Respiratory Rate, SpO2

Immediately before the procedure / first dose of sedation, monitored

frequently and documented every 10 minutes throughout the

procedure and recovery period.

*Mechanical noninvasive blood pressure is preferred, however may

use manual (cuff) method.

*Continuous Pulse Oximetry

*Sedation

*Assessed and documented with vital signs

*RASS Sedation Scale

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

Intra-procedure Monitoring requirements

EKG monitor

*Assistants may not be able to perform rhythm

interpretation

*Identify when more in depth patient assessment

is required

1). For example: heart rate drops, assistant

may stimulate

patient, check BP, or other

2). Another example: heart rate accelerates,

assistant may ask patient about comfort level.

*Assistants should notify the clinician for any

noticeable changes in rhythm, rate, or other

concerns noted on monitor for further medical

direction.

Intra-procedure Monitoring

requirements

Capnography?

*Although not essential this indicates if

patient is ventilating

adequately.

*This will indicate hypoventilation

before pulse oximetry.

*Currently available to intubated

patients only

Responsible Individual

for discharge planning

• The person who will provide the patient’s ride home and be

available to the patient after the procedure will be identified

before the procedure begins.

• This person may be an adult, or someone in their late teens that

the patient feels comfortable with.

• If the patient is an outpatient, this person frequently

accompanies the patient to the hospital

• If the responsible individual is not present, hospital staff need to

verify the individual by telephone.

• If the patient is an inpatient, it may not be necessary to identify

this individual pre-procedure.

• If the inpatient is discharged within 24 hours of the

procedure, the patient must be discharged to a responsible

individual.

Responsible individual?

• For outpatients: If either the clinician (person performing

the procedure) or the assistant (person monitoring the

patient) feels the individual present would not be

appropriate in this role, or the patient has no one

identified, the clinician needs to determine:

– Can the procedure be cancelled (or postponed) until a

responsible individual is available?

– Should the procedure be completed and the patient

kept an additional 4 hours after discharge criteria are

reached, then released with appropriate

transportation?

Discharge to Responsible Person

Guidelines:

Best Practice: Patient accompanied by Responsible

Adult

If no responsible adult present at patient admission,

staff should

-Verify via phone the responsible adult who will be

present at discharge

-Or

-Identify a responsible individual to whom the patient

can be reasonably transported after the procedure

-Or

-Cancel the Procedure!

How do I know the

person is

responsible?

Use your

professional

judgment.

If no responsible adult present after the procedure is completed,

observe the patient for 4 hours after completion of the recovery

period, then discharge (patient must not drive for 24 hours after

sedation).

READY TO GO…

ExplainPre-oxygenateIV Access and IV fluid runningSplints or plaster or equipment all

ready to goHand over your phone or pager…

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 3 aldrete scores must be completed before the

patient can be identified as “recovered” When recovery criteria are met, the last

(frequently the third) Aldrete can be the D/C score.

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) to ensure

that

the patient does not become resedated after reversal effects have

abated.

* 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

Discharge criteriaVital signs stable (Vital signs include BP, HR, R,& O2 Sat. The VS are

determined to be stable if they are consistent with the patient’s age and with the

patient’s pre-operative VS)

Swallow, cough present (patient demonstrates ability to swallow fluids and

is able to cough

Able to ambulate (patient demonstrates ability to ambulate at pre-procedure

level)

Nausea, vomiting, dizziness is minimal

Absence of respiratory distress (patient’s respiratory effort consistent

with pre-procedure status)

State of consciousness (patient is alert, oriented to time, place and person

consistent with pre-procedure level of consciousness).

Level of comfort (Pain controlled as per BJH pain policy)

Post-procedure (oral and written) discharge instructions are

given to the patient and/or significant other regarding the following: 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.).

Phone a friend…

Consider sending the at-risk patient

to the OR.

Questions?

Key Points

Be

prepared

Know

your drugs

and your

drug

interactions

Consider

all your

options

Thank you so much…

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. True

Procedural Sedation Post Test

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.

Procedural Sedation Post Test

5. When performing procedural sedation, it is satisfactory to have the

physician be available by pager during the procedure.

A. True

B. False

6. The nurse providing moderate sedation should remain with the patient

at all times.

A. True

B. 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. True

B. False

Procedural Sedation Post Test8. 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. True

B. 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

Procedural Sedation Post Test

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. Morphine

C. 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

needed

B. Naloxone (Narcan) 0.4 mg, repeat every 2-3 minutes as needed

C. Both a and b

Procedural Sedation Post Test

12. 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.