Moderate Conscious Sedation

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• Moderate Conscious Sedation

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Objectives
Upon completion of this learning module, the
nurse should be able to

• 1. Define moderate conscious sedation.
• 2. Identify nursing responsibilities before,
  during, and after a procedure involving moderate
  conscious sedation.
• 3. Review medications commonly used in moderate
  sedation.

The purpose of this self learning study is to
review and update the nurse on moderate
conscious sedation.

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Definition

• A drug induced depression of consciousness during
  which 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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Moderate Sedation is used for diagnostic,
therapeutic, and invasive procedures

• Bone marrows
• Bone reduction
• EGD/colonoscopy
• Chest tube insertion
• Wound debridement
• Heart lab procedures (ie. heart cath, TEE, EP
  studies, etc)
• Minimally invasive surgical procedures
• Cardioversion

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Moderate Conscious Sedation does not apply to

• Patients who are mechanically ventilated or whose
  cardiovascular and respiratory status are
  continuously monitored and documented in an ICU
  or PACU.
• Patients who receive anxiolytic or analgesic
  agents that are routinely administered to
  alleviate pain and agitation.
• Management of seizures.

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Staff Qualifications

• Conscious sedation is the responsibility of a
  licensed independent practitioner (LIP)
  privileged in moderate sedation.
• LIP must be qualified and have the appropriate
  credentials as defined by the medical staff to
  manage patients at whatever level of sedation or
  anesthesia is achieved, either intentionally or
  unintentionally.
• Sufficient numbers of qualified personnel are
  present to assist and document.

Physicians exempt from providing proof of
training for moderate conscious sedation are
intensivists, emergency medicine physicians, and
anesthesiologists.
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Moderate sedation is administered in the
following units

• Operating Room
• Pediatrics
• Heart Lab
• Oncology
• Stepdown Units
• Intensive Care Units

• Outpatient services
• Radiology
• Pain Management
• Emergency Department

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Equipment

• Appropriate equipment for monitoring including
  heart, blood pressure, respiratory rate, and
  oxygenation using pulse oximetry
• Cardiac arrest resuscitative equipment, reversal
  agents, and a code cart must be in the department
  where the procedure is performed
• EKG is monitored as ordered by the physician for
  patients with heart disease or if arrhythmias are
  present or anticipated

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Documentation
Documentation of Moderate Sedation is completed
on form 202120
Post-procedure vital signs And Aldrette scoring
Post-procedure and discharge
Pre-procedure and Intra-procedure
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Pre-Procedure ResponsibilitiesPhysician

• History and Physical including airway assessment
• Plan for moderate sedation and post procedure
  care
• Current medications
• Documents NPO status
• -Adults should be NPO for 4 hours
• -Pediatric patients should have no
  solids or non-human
• milk for 4 hours prior to the procedure
• Obtains and documents informed consent for
  procedure and sedation

In extreme emergencies the physician may
determine it to be necessary to proceed with an
intervention without completing the above steps.
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Pre-Procedure ResponsibilitiesHospital Staff
and Nursing

• Verifies informed consent, HP, and reassessment
  has been done prior to procedure.
• Verifies availability of emergency equipment,
  including O2 and suction.
• Establishes venous access.
• Assess patients VS, O2 sat, LOC, and Aldrete
  score and document on the moderate sedation flow
  sheet.
• If the patient is an outpatient- complete
  outpatient nursing assessment record.

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Intra-Procedure ResponsibilitiesPhysician

• Assumes full responsibility for the
• management of the procedure and sedation

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Intra-Procedure ResponsibilitiesHospital Staff
and Nursing Role

• Conducts and documents time out with physician
  present as well as the procedure team.
• Monitors and documents the patients VS and O2
  sat every 5 minutes or more frequently prn.
• Continuous assessment and documentation while
  assessing for changes in condition.

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Post Procedure ResponsibilitiesPhysician

• Documents a post procedure/anesthesia note,
  including pre and post procedure diagnosis,
  procedure findings, complications, blood loss or
  specimen removed, plan of care, and discharge
  instructions

EBL
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Post Procedure ResponsibilitiesHospital Staff
and Nursing Role

• Monitors and documents the patients VS and O2
  sat immediately post procedure and every 15
  minutes post procedure until it is a minimum of
  30 minutes post narcotic/sedative dose, the
  patients Aldrete score is 12 or equivalent to
  his/her pre procedure Aldrete score, or by
  physician order

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Aldrete Scoring System
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Post Procedure ResponsibilitiesHospital Staff
and Nursing Rolecontinued

• If the patient has received a reversal agent,
  monitor VS q 15 min. for 2 hours.
• Notify the physician immediately if the patient
  doesnt meet the Aldrete score after 1 hour post
  procedure or if there is a significant variation
  in the patients physiological parameters.

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Discharge Criteria
Discharge to hospital unit
Discharge from the hospital

• Aldrete score of 12, or pre procedure status, or
  by physician order
• Minimal nausea
• At least 1 hour from last dose of narcotic,
  hypnotic, antiemetic
• At least 2 hours from the last dose of reversal
  agent
• Pain rated less than 4, equal to the pre
  procedure score, or tolerable for the patient
• Accompanied by a responsible adult

• Minimum 30 minutes since the last dose of
  narcotic or sedative
• Aldrete score of 12, or pre procedure status, or
  by physician order

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Medications used for Moderate Conscious Sedation

• Individualize dose per recommendations.
• Do not give by rapid or single bolus IV
  administration.
• Use small increments to achieve the appropriate
  level of sedation.
• Titrate medication and dose to patient response.
  Expect to vary with age, physical status,
  concomitant medications.
• Allow time for drug to circulate and to have an
  effect after each incremental dose.
• Consider routine medications the patient has
  taken pre procedure they may potentiate and
  prolong the effects of the medications used for
  conscious sedation.

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Opiods
Drug IV Dosing Guidelines Onset, Peak, and Duration Comments
Morphine 2-4 mg. increments q 5 min. max dose of 10-20 mg. Peds 0.1-0.2mg/kg Onset- 1-3 min. Peak- 20 min. Duration- 2-4 hrs. Slower onset and longer duration than Fentanyl Histamine release assoc. with hypotension and itching
Fentanyl (Sublimaze) 1-3 mcg/kg, given in increments of 25-50 mcg max of 250 mcg Peds 1-2 mcg/kg total dose- given in increments up to 50 mcg max dose Onset- 1-2 min. Peak- 10-15 min. Duration- 30-60 min. Advantages include quick onset and short duration Causes less histamine release and less side effects as compared with morphine but 100 times more potent
Demerol (Meperidine) 10-25 mg increments max of 150 mg Peds 1-2 mg./kg. Onset 1-5min. Peak 1-3 hrs. Duration- 2-4 hrs. Nausea and vomiting common Risk of seizures
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Sedatives
Drug IV Dosing Guidelines Onset, Peak, and Duration Comments
Versed (Midazolam) 1-3 mg increments every 2-3 min. Max of 5 mg. Peds 0.02-0.1 mg/kg IV or IM Give in increments total dose not to exceed 0.4mg/kg Onset- 1-3 min. Peak- 5-7 min. Duration- 20-30 min. (may need to redose) Quick onset and short duration Retrograde and antegrade amnesia
Valium (Diazapam) 1-2 mg increments Max of 10 mg. Peds 0.1-0.2 mg/kg Onset 1-5 min. Duration 2-8 hrs. Respiratory depression with narcotics Irritates veins Long duration
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Reversal Agents
Drug IV Dosing Guidelines Onset, Peak, and Duration Comments
Narcan (Nalaxone) 0.1- 0.2 mg IV q 2-3 minutes prn Peds 0.005 -0.01 mg q 2-3 minutes prn Onset- 1-2 min. Duration- 30 min. when given IV Reverses narcotics only Reversal effect may not outlast narcotic Give slowly
Romazicon (Flumazenil) 0.2 mg over 15 seconds. After an interval of 45 seconds, a second dose of 0.2 mg may be given. Repeat at 60 second intervals until 1 mg. total. Peds 0.01mg/kg IV over 15 seconds, may repeat in 45 seconds Onset- 1-2 min. with peak effect within 10 min. Duration- 30-60 min. Reverses Benzodiazapines - ie. Versed - not narcotics Reversal may not out last sedative, monitor for 1 hr. after reversal
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Questions?

• The Interpretive Guidelines for Moderate Sedation
  (updated June 2010) are available through the
  Ohio Board of Nursing at http//www.nursing.ohio.
  gov/PDFS/Practice/IG-Mod-Sedation.pdf
• You may also call Cindie Berbari at 35341 or
  email at cberbari_at_aultman.com

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References

• Reed, Lynn. (2007, October). Aultman Moderate
  (Conscious) Sedation/Analgesia Policy.
  http//sharepoint/aultman/
• Volles, D. (2005, March) Adult and Geriatric
  Sedation/Analgesia for Diagnostic and Therapeutic
  Procedures. www.healthsystem.virginia.edu
• Comparing the duration of action of opiods,
  sedatives, and reversal agents. American Society
  of Anesthesiologists. www.asahq.org/clinical/toolk
  it/CS20Hand1.doc

Cindie Berbari RN, BSN