Moderate Sedation

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Moderate Sedation Analgesia

• Lesson 1 Introduction
• Lesson 2 The Sedation Continuum
• Lesson 3 Guidelines Regulations

Erlinda C. Oracion, M.D., D.P.B.A Department of
Anesthesiology
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Introduction
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We watch while you sleep
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Course Rationale

• Sedation and anesthesia are important risk
  factors for morbidity and mortality during
  procedures.
• Giving sedation safely is critical to
• Help prevent negative outcomes
• Comply with regulations

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Course Rationale

• This course will teach you
• How moderate sedation relates to other types of
  anesthetic services, and how this relates to
  patient safety
• How The Joint Commission expects accredited
  facilities to manage moderate sedation

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Course Goals

• After completing this course, you should be able
  to
• List the levels of the continuum of sedation
• Identify key features of each level
• Recognize the significance of the continuum for
  sedation safety
• List the Joint Commission standards for moderate
  sedation
• Identify key requirements of each standard

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Over the last 15 years

• Administration of sedatives and analgesics for
  performance of procedures is a significant
  independent risk factor for morbidity and
  mortality both inside and outside the OR.

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• Although sedation is often offered as safer than
  general anesthesia,
• this may not be altogether correct.
• 1984- Natof studied 40 ambulatory centers (87,492
  patients)
• Complications 1 106 (LA with sedation) vs 1120
  (GA)

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Gastroenterology literature Walker
JA.Am J Gastroent 2003981744-50

• NAPS (Nurse Administered Propofol Sedation)
• 2000 patients- GI endoscopies (ASA 1 and 2)
• 3- laryngospam
• 11 desaturated lt90 spO2 despite 4L/min O2
• 4 desaturated lt85 spO2, were assumed apneic

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Course Outline

• Lesson 1
• provided the course rationale and goals
• Lesson 2
• will describe the sedation continuum
• Lesson 3
• will list and explain the Joint Commission
  standards for moderate sedation

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LESSON 2 THE SEDATION CONTINUUM
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• After completing this lesson, you should be able
  to
• List the levels of the sedation continuum
• Identify key features of each level
• Recognize the significance of the sedation
  continuum

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The Sedation Continuum

• Moderate sedation is on a continuum with other
  levels of sedation.
• The levels on this continuum are
• Minimal sedation (anxiolysis )
• Moderate sedation/analgesia (formerly conscious
  sedation)
• Deep sedation/analgesia
• General Anesthesia

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Minimal Sedation Anxiolysis

• Minimal sedation is also called anxiolysis.
• In this drug-induced state
• The patient feels relaxed .
• The patient responds normally to speech.
• Thinking and coordination may be affected.
• Breathing and heart function are not affected

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Moderate Sedation Analgesia

• In this drug-induced state
• The patient has depression of consciousness
• The patient will respond purposefully to spoken
  words, or spoken words with a light touch.
• The airway remains patent without help.
• The patients breathing is adequate.
• Heart function is usually maintained.

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Deep Sedation/Analgesia

• Deep Sedation/Analgesia is the next level on the
  continuum.
• In this drug-induced state
• The patient has depression of consciousness and
  is difficult to awaken.
• The patient will respond purposefully to repeated
  or painful stimulation. Reflex movement away
  from pain is not purposeful.
• The patient may need help to keep the airway
  open.
• The patients own breathing may not be adequate.
• Heart function is usually maintained.

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General Anesthesia

• General Anesthesia is the deepest form of
  sedation.
• In this drug-induced state
• The patient loses consciousness.
• The patient cannot be awakened, even by painful
  stimuli.
• The patient often needs assistance maintaining
  the airway and ventilation. This often requires
  positive pressure ventilation.
• Heart function may be impaired.

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Levels of Sedation
DEEP SEDATION
GENERAL ANESTHESIA
MODERATE SEDATION -conscious sedation
MINIMAL SEDATION -anxiolysis
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The Sedation Continuum Summary

• This table summarizes the sedation continuum.

Continuum of Depth of Sedation
Minimal Sedation (anxiolysis) Moderate Sedation/ Analgesia Deep Sedation/ Analgesia General Anesthesia
Responsiveness Normal response to speech Purposeful response to speech or touch Purposeful response to repeated or painful stimulation No response, even to pain
Airway Unaffected Remains open May need help to maintain airway Often needs help to maintain airway
Breathing Unaffected Adequate May not be adequate Often require ventilatory support
Heart Function Unaffected Usually maintained Usually maintained May be impaired
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Levels of Anesthesia and Sedation- Minimal
Sedation (Anxiolysis)

• A drug induced state during which patients
  respond normally to verbal commands. Although
  cognitive function and coordination may be
  impaired, ventilatory and cardiovascular
  functions are unaffected.

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Levels of Anesthesia and Sedation- Moderate
Sedation/Analgesia

• (conscious sedation) a drug-induced depression
  of consciousness during which the patients
  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.

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Levels of Anesthesia and Sedation- Deep
Sedation/ Analgesia

• is a drug-induced depression of consciousness
  during which patients cannot be easily aroused
  but respond purposefully following repeated or
  painful stimulation.
• The ability to independently maintain ventilatory
  function may be impaired. Patients may require
  assistance in maintaining a patent airway and
  spontaneous ventilation may be inadequate.
• Cardiovascular function is usually maintained.

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Levels of Anesthesia and Sedation- General
Anesthesia

• A drug-induced loss of consciousness- patients
  not arousable, even by painful stimulation.
• Ability to maintain ventilatory function is often
  impaired. Patients often require assistance in
  maintaining a patent airway, and positive
  pressure ventilation may be required because of a
  depressed spontaneous ventilation or drug-induced
  depression of neuromuscular function.
• Cardiovascular function may be impaired.

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Levels of Sedation
DEEP SEDATION
GENERAL ANESTHESIA
MODERATE SEDATION -conscious sedation
MINIMAL SEDATION -anxiolysis
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Monitored Anesthesia Care (MAC)

• MAC does not describe the continuum of depth of
  sedation
• a specific anesthesia service in which an
  anesthesia provider has been requested to
  participate in the care of the patient undergoing
  a diagnostic/ therapeutic procedure.

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• Sedation is a continuum- not always possible to
  predict how an individual patient will respond.
• Skill required ? ability to rescue from deep
  sedation levels

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The Sedation Continuum Summary

• This table summarizes the sedation continuum.

Continuum of Depth of Sedation
Minimal Sedation (anxiolysis) Moderate Sedation/ Analgesia Deep Sedation/ Analgesia General Anesthesia
Responsiveness Normal response to speech Purposeful response to speech or touch Purposeful response to repeated or painful stimulation No response, even to pain
Airway Unaffected Remains open May need help to maintain airway Often needs help to maintain airway
Breathing Unaffected Adequate May not be adequate Often require ventilatory support
Heart Function Unaffected Usually maintained Usually maintained May be impaired
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Significance of the Continuum

• Why is it important to understand the continuum
  of sedation?
• Because sedation is a continuum, the response of
  any one patient may be unpredictable.

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Significance of the Continuum

• Why is it important to understand the continuum
  of sedation?
• A moderately sedated patient may progress to deep
  sedation.
• Therefore, moderate sedation must be monitored
  just as carefully as deep sedation and anesthesia.

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Review

• The best description of moderate sedation is
• A risk-free treatment
• A point on the continuum of sedation
• A lesser form of sedation than minimal sedation
• A treatment entirely different from general
  anesthesia

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Summary

• You have completed the lesson on the sedation
  continuum.
• Remember
• Moderate sedation is a point on a continuum. It
  falls between minimal sedation and deep sedation.
• Because sedation is a continuum, the response of
  any patient is individual and may be
  unpredictable.

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Minimal sedation (anxiolysis) Moderate sedation/ analgesia (conscious sedation) Deep sedation/ analgesia General Anesthesia
Administering clinicians RN, Physicians Sedation trained RN, Credentialed physicians Anesthesiologist only Anesthesiologist only
Responsiveness 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
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Objectives of Moderate Sedation

• Blunting of anxiety and fear
• Elicit cooperation from the patient
• Afford amnesia for the patient
• Increase the pain threshold

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Individuals administering Moderate
Sedation/Analgesia (Conscious Sedation)

• should be able to
• -rescue a patient who enters a state of deep
  sedation
• -manage a compromised airway
• -provide adequate oxygenation and ventilation

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Lesson 3 Guidelines Regulations
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• Introduction Objectives
• Welcome to the lesson on guidelines and
  regulations.
• After completing this lesson, you should be able
  to
• List the The Joint Commission standards related
  to moderate sedation
• Identify key requirements of each standard

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JCAHO COMPARABLE CARE MANDATE

• "conscious sedation" for non-operating room
  procedures represents a dynamic continuum
  significantly overlapping monitored anesthesia
  care (MAC), this implies that such areas must
  have processes
• presedation assessment,
• intraprocedure monitoring,
• discharge criteria,
• facilities, equipment, and personnel similar to
  those utilized for MAC delivered by qualified
  anesthesia providers.

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JCAHO COMPARABLE CARE MANDATE

• mandates that sedation practices throughout the
  hospital be "monitored and evaluated by the
  Department of Anesthesiology"

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• Question Does the person administering sedation
  have to be qualified to monitor the patient if
  other staff who are present are qualified?
• Standard PC. 13.20 states, Sufficient numbers of
  qualified staff (in addition to the individual
  performing the procedure) are present to
  evaluate, monitor, administer medication, assist
  with the procedure if needed and recover the
  patient.

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The Joint Commission Standards

• The Joint Commission has several standards for
  anesthesia services, including moderate sedation.
• For Moderate sedation, these standards are
• Moderate sedation must be given by a qualified
  provider.
• Patients who will receive moderate sedation must
  be assessed ahead of time.
• Sedation options and risks must be discussed with
  the patient and family prior to the
  sedation/procedure.

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The Joint Commission Standards

• For Moderate sedation, these standards are
• The patient must be re-assessed immediately
  before the sedation is given.
• The patients oxygenation, ventilation and
  circulation must be monitored during sedation.
• The patient must be assessed in the post-sedation
  recovery area before discharge.
• A qualified provider must discharge the patient
  from the post-sedation recovery area, or
  discharge must be based on established criteria .

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Pre-sedation Assessment (1)

• All patients must be assessed before sedation.
• Hospitals with obstetric or emergency services
  should be able to perform an assessment quickly.
• These hospitals should be able to gather enough
  information to give moderate sedation safely
  within 30 minutes after deciding to sedate the
  patient.
• The patient must give informed consent before
  moderate sedation can be administered.

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Pre-Sedation Assessment (2)

• The pre-sedation assessment should include
  information about the procedure and the patient.
• The Assessment should include
• Indication for the procedure
• Determination that the patient is an appropriate
  candidate for sedation and the procedure

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Pre-Sedation Assessment (2)

• The Pre-sedation assessment should also include
• Patient historyshould include
• Allergies or adverse drug events
• Prior sedative or anesthesia experiences
• Potential for pregnancy

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Pre-Sedation Assessment (2)

• Pre-sedation assessment should also include
• Physical Historyshould include
• Baseline vital signs and oxygen saturation
• Weight
• Airway status
• Appropriate fasting interval
• Aspiration risk factors
• Status of cardiac, pulmonary, and neurologic
  systems
• Mental status and level of consciousness
• Appropriate lab tests
• ASA status

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Pre-Sedation Assessment (3)

• The patients ASA status should be determined.
• The ASA describe five physical status classes
• ASA Class I A normal healthy patient.
• ASA Class II A patient with mild systemic
  disease.
• ASA Class III A patient with severe systemic
  disease.
• ASA Class IV - A patient with severe systemic
  disease that is a constant threat to life.
• ASA Class V A moribund patient who is not
  expected to survive without the operation.
• ASA Class VI A declared brain-dead patient
  whose organs are being removed for donor
  purposes.

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Pre-Sedation Assessment (3)

• Patients in ASA classes I and II can be given
  moderate sedation.
• Medical consultation is suggested for class III
  patients.
• Patients in ASA classes IV and V should not be
  given moderate sedation by a non anesthesia
  provider.

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Pre-sedation Assessment (4)

• Conditions that will affect the use of moderate
  sedation

Indication for the procedure Altered mental status Atypical airway anatomy Obesity Pregnancy Sleep apnea Current medications Substance abuse Cardiovascular disease Respiratory disease Liver disease Kidney disease Central nervous system dysfunction
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Discussion of Options Risks

• Sedation options and risks may be discussed with
  the patient and family before giving moderate
  sedation.
• Patients must give informed consent for any
  treatment. This includes moderate sedation.
• Part of informed consent is a full understanding
  of the options and risks of treatment.
• Discussing the sedation procedure ahead of time
  can also help calm patient fears.

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Discussion of Options Risks

• Patient education also should include information
  on
• Resuming activity
• Consciousness checks
• Dietary restrictions
• When medications can be resumed
• Potential post-procedural complications
• Whom to contact for questions for help

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Sedation Care Plan

• The moderate sedation of each patient must be
  carefully planned.
• The Plan of Care should
• Take into account the physical status of the
  patient (ASA class)
• Meet any other patient needs identified during
  the pre-sedation assessment

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Sedation Care Plan

• All providers should be informed of
• The patients care needs
• The sedation plan of care
• The patient should be assessed again
• immediately before moderate sedation
• is given.

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• Question Are specific privileges to administer
  moderate sedation required?
• Standard PC. 12.20 EP 4 states that Individuals
  monitoring moderate or deep sedation are
  qualified and have the appropriate credentials to
  manage patients whatever level of sedation or
  anesthesia is achieved

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Qualified Provider (1)

• The qualified provider requirement covers the
  training and credentials of the provider who
  gives moderate sedation.
• A provider qualified to give moderate sedation
  must be trained in
• How to evaluate patients before sedation
• How to give drugs for moderate sedation
• How to monitor patients to keep them moderately
  sedated
• How to rescue patients from deep sedation

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Qualified Provider (1)

• The ability to rescue patients from deep
  sedation includes training in
• How to manage an airway
• How to give oxygen and ventilation
• How to deliver appropriate reversal agents

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Qualified Provider (2)

• Rescue of patients from sedation may also
  include the use of reversal drugs.
• Patients given reversal drugs must be monitored.
  Seizures or other heart and nervous system
  problems may occur.
• Note The effect of the reversal drug may wear
  off before the effect of the sedating drug.
  Extended monitoring will be needed.

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Qualified Provider (3)

• Moderate sedation procedures are performed by a
  licensed independent practitioner (LIP)
• The qualified provider requirement also covers
  the number of personnel during a procedure.

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Qualified Provider (3)

• In addition to the LIP, there must be enough
  other qualified personnel to
• Evaluate the patient before the sedation
• Give the sedation
• Perform the procedure
• Monitor the patient
• Recover and discharge the patient

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Monitoring

• Patients must be monitored during moderate
  sedation.
• The person monitoring the patient can not have
  additional assignments.
• Physiological monitoring is the only way to
  ensure that patients get the supportive treatment
  they need.

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Mandatory equipment

• Cardiac monitor
• Pulse oximeter
• Medications for sedation and reversal of effect
• Blood pressure determination unit
• Oxygen source and administration equipment
• Bag-valve-mask
• Standard emergency equipment and drugs for
  resuscitation
• Defibrillator
• Suction machine
• Stethoscope

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Monitoring

• The following need to be monitored in some or all
  patients
• Heart rate and oxygenationshould be continuously
  monitored by pulse oximetry.
• Respiratory rate-- pulmonary ventilation should
  be continuously monitored
• Blood pressureshould be measured at regular
  intervals.
• EKGshould be monitored
• If the patient has significant cardiovascular
  disease
• If cardiac arrhythmias are expected or detected.

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Post-Sedation Assessment Discharge

• Data from monitoring must be recorded in the
  patients medical record.
• After moderate sedation, patients must be
• Assessed in the post-sedation recovery area
• Discharged by a qualified LIP or according to
  established criteria
• Discharged home with a responsible adult
• Meeting discharge criteria should be documented
• in the medical record.

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Review

• MULTIPLE CHOICE INTERACTION
• A provider qualified to give moderate sedation is
  trained in
• How to evaluate patients before sedation
• How to rescue patients from deep sedation
• How to give drugs to achieve moderate sedation
• How to monitor patients to keep them moderately
  sedated
• All the above

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Review

• MULTIPLE CHOICE INTERACTION
• The physical status of a patient with
  well-controlled hypertension would be
• ASA class I
• ASA class II
• ASA class III
• ASA class IV
• ASA class V

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Summary

• Remember
• Patients must be assessed before moderate
  sedation. ASA class should be determined
• Sedation options and risks must be discussed with
  each patient.
• A sedation care plan must be developed for each
  patient.

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Summary

• Remember
• Moderate sedation must be given by a qualified
  provider.
• Patients must be monitored during sedation.
• Patients must be assessed after sedation.
• Note They may be discharged from the
  post-sedation recovery area only by a qualified
  LIP or according to established criteria.

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Moderate Sedation

• Course Glossary

Term Definition
1. Analgesia Pain relief
2. Anxiolysis The use of drugs to lessen anxiety without lessening awareness
3. Apnea Not breathing
4. ASA American Association of Anesthesiologists
5. Continuum On a scale progressing from the smallest to the greatest amount
6. Criteria Standards or measures used to make a judgment or decision
7. The Joint Commission Joint Commission of the Accreditation of Healthcare Organizations
8. Positive pressure ventilation Artificial breathing using positive pressure to maintain inflation of the lungs
9. Reversal drugs Drugs that neutralize the effects of the drugs used to sedate the patient
10. Sedation Sleepiness, or the act of cause sleepiness
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Objectives completed

• List the levels of the continuum of sedation
• Identify key features of each level
• Recognize the significance of the continuum for
  sedation safety
• List the Joint Commission standards for moderate
  sedation
• Identify key requirements of each standard

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THANK YOUFOR YOUR ATTENTION!