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Conscious Sedation

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Title: Conscious Sedation


1
Conscious Sedation
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2
Case Presentation
  • ?xx, 74 year-old age man. C.CPET whole body
    scanThe area of increased FDG uptake at the
    hepatic flexure of the colon can be due tumor
    involvement or normal bowel activity
  • Further evaluation with CT scan is recommended
  • CREAT. 4.3 mg/dl
  • S-SCOPE BX 91/06/27 unpleasant

3
Unpleasant endoscopy
  • Unsedated endoscopy (43 refusal rate for upper
    GI endoscopy with no sedation, 65-83 refusal
    rate for unsedated colonoscopy )
  • Whereas other patients will need prolonged, more
    stimulating therapeutic endoscopic procedures
    that require total patient compliance.
  • Zaman A. A randomized trial of peroral versus
    transnasal unsedated endoscopy using an ultrathin
    videoendoscope. Gastrointest Endosc 1999
    49279-284
  • Early DSPatient attitudes toward undergoing
    colonoscopy without sedation. Am J Gastroenterol
    1999 941862-1865

4
Patient factors affecting tolerance of unsedated
endoscopy
  • 509 patients undergoing unsedated diagnostic
    gastroscopy aided by topical pharyngeal
    anaesthesia
  • Gag reflex, young age, a high level of anxiety,
    poor tolerance of previous examinations and
    female sex
  • Rex DK Patients willing to try endoscopy
    without sedation associated clinical factors and
    results of a randomized controlled trial.
    Gastrointest Endosc 1999 49554-559.

5
GI endoscopy complication
  • Bleeding, perforation, and infection
  • 0.1 for upper endoscopy
  • 0.2 for colonoscopy
  • Cardiopulmonary complications 21,011 procedures
    5.4 per 1000 procedures
  • Aspiration
  • Oversedation
  • Hypoventilation
  • Vasovagal episodes
  • Airway obstruction
  • Rankin GB. Indications, contraindications and
    complications of colonoscopy. In
    Gastroenterologic Endoscopy 1989

6
Endoscopic design and intubation route
  • Ultrathin (5-6 mm) endoscopes
  • Less traumatic and easier to tolerate for
    patients having UGIE without sedation
  • Nasal route provides a direct route to the
    esophagus avoiding sensitive oropharyngeal
    structures with less stimulation of the gag
    reflex

7
  • Routine administration of sedation , The
    incidence of unplanned absence from work the day
    after outpatient colonoscopy has been shown to be
    4

8
What is Conscious Sedation?
  • Altered state of consciousness
  • Minimizes pain and discomfort through the use of
    pain relievers and sedatives
  • Able to speak and respond to verbal cues
    throughout the procedure
  • Communicating any discomfort they experience to
    the provider.
  • Amnesia may erase any memory of the procedure.

9
Depth of Sedation Definition of General
Anesthesia and Levels of Sedation/Analgesia
10
Non-Anest Practice Guidelines for Sedation and
Analgesia byNon-Anesthesiologists
hesiologists Anesthesiology 2002 96100417
11
Who Can Administer Conscious Sedation?
  • Qualified providers
  • Certified Registered Nurse Anesthetists (CRNAs)
  • Anesthesiologists
  • Physicians
  • Dentists
  • Oral surgeons are qualified providers of
    conscious sedation

12
When is Conscious Sedation Administered?
  • In hospitals, outpatient facilities, e.g.,
    ambulatory surgery centers, doctors offices
  • Breast biopsy
  • Vasectomy
  • Minor foot surgery
  • Minor bone fracture repair
  • Plastic/reconstructive surgery
  • Dental prosthetic/reconstructive surgery
  • Endoscopy (example diagnostic studies and
    treatment of stomach, colon and bladder )

13
Definition of Terms
  • Sedation and Analgesia describes a state that
    allows patients to tolerate unpleasant procedures
    while maintaining adequate cardiorespiratory
    function and the ability to respond purposefully
    to verbal command and/or tactile stimulation.
  • Monitoring is the measurement of physiologic
    parameters, including the use of mechanical
    devices as well as clinical observations. The RN
    may delegate this function.
  • Assessment is the continuous, systematic
    collection, validation, and communication of
    patient data for the purpose of planning,
    implementing, and evaluating nursing care.
    Assessment is directed toward the attainment of
    specific patient outcomes. The RN should not
    delegate this function.
  • Assistive personnel are staff without a nursing
    license (e.g., GI assistants, medical
    technicians, respiratory therapists) who have
    direct patient care responsibility and are
    supervised by an RN.

14
Preprocedure evaluationPatient Evaluation
  • strongly agreehistory, physical examination
    increases the likelihood of satisfactory sedation
    and decreases the likelihood of adverse outcomes
    for both moderate and deep sedation
  • (1) abnormalities of the major organ systems
  • (2) previous adverse experience with
    sedation/analgesia as well as regional and
    general anesthesia
  • (3)drug allergies, current medications, and
    potential drug Interactions
  • (4) time and nature of last oral intake and
  • (5) history of tobacco, alcohol, or substance use
    or abuse

15
Preprocedure Preparation
  • Strongly agree that appropriate preprocedure
    counseling of patients regarding risks, benefits,
    and alternatives to sedation and analgesia
    increases patient satisfaction
  • Guidelines for Preoperative Fasting
  • (1) the target level of sedation
  • (2) whether the procedure should be delayed
  • (3) whether the trachea should be protected by
    intubation

Preprocedure Fasting Guidelines
16
Problems with sedation (sedation and
procedure-related complications )
  • Desaturation
  • Arrhythmias
  • Myocardial ischemic episodes
  • O2 saturation less than 95
  • premorbid cardio-respiratory disease
  • Continuous electronic monitoring (oxygen
    saturation, electrocardiogram (ECG), non-invasive
    blood pressure (NIBP)
  • Froelich F, Thorens J, Schwizer W -- Gastrointest
    Endosc 1997 451-9
  • Alcain G, Guillen P. Predictive factors of oxygen
    desaturation during upper gastrointestinal
    endoscopy in nonsedated patients. Gastrointest
    Endosc 1998 48143-147

17
Airway Assessment Procedures for Sedation
andAnalgesia
18
Monitoring
  • strongly agree monitoring level of
    consciousness reduces risks for both moderate and
    deep sedation
  • be avoided if adverse drug responses are detected
    and treated in a timely manner i.e., before the
    development of cardiovascular decompensation or
    cerebral hypoxia
  • Pulmonary Ventilation
  • Oxygenation
  • Hemodynamics

19
Recording of Monitored Parameters
  • (1) before the beginning of the procedure
  • (2) after administration of sedative
  • analgesic agents
  • (3) at regular intervals ( 5-min) during the
  • procedure
  • (4) during initial recovery
  • (5) just before discharge

20
Pulmonary Ventilation
  • Capnography, measurement of carbon dioxide
    retention, may be useful in prolonged cases

21
Oxygenation
  • strongly agree early detection of through the
    use of oximetry
  • hypoxemia more likely to be detected by oximetry
    than by clinical assessment alone
  • pitch beepalarms
  • Supplemental Oxygen

22
Hemodynamics
  • Blunt the appropriate autonomic compensation for
    hypovolemia and procedure-related stresses or
    inadequate (hypertension, tachycardia)
  • Response to verbal commands control his airway
    and take deep breaths
  • young children, mentally impaired or
    uncooperative patients, oral surgery, upper
    endoscopy
  • Continously EKG
  • Blood pressure

23
Arrhythmias -- sedation in the endoscopy
  • five- to sixfold higher in patients with
    pre-existing cardiac disease
  • endoscope size
  • the presence of hypoxemia
  • premorbid cardiorespiratory disease

24
Emergency Equipment for Sedation andAnalgesia
(1)
25
Emergency Equipment for Sedation andAnalgesia(2)
26
Availability of Emergency Equipment
  • Suction, appropriately sized airway equipment,
    means of positive- pressure ventilation
  • Intravenous equipment, pharmacologic antagonists,
    and basic resuscitative medications
  • Defibrillator immediately available for patients
    with cardiovascular disease

27
Training of Personnel
  • Strongly agree education and training
  • (1) potentiation of sedative-induced respiratory
  • depression by concomitantly administered
    opioids
  • (2)inadequate time intervals between doses of
    sedative or analgesic agents, resulting in a
    cumulative overdose
  • (3) inadequate familiarity with the role of
    pharmacologic antagonists for sedative and
    analgesic agents
  • ACLS,BLS

28
Combinations of SedativeAnalgesic Agents
  • Equivocal regarding moderate sedation
  • Deep sedation, satisfactory Intravenous
    combinations of sedativeanalgesic agent
  • Fixed combinations of sedative and analgesic
    agents may not allow
  • Appropriately titrated strongly agree that
    incremental drug administration improves patient
    comfort and decreases risks

29
Drugs used in conscious sedation for endoscopy
30
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31
Benzodiazepines
  • the majority of endoscopic procedures
  • relaxation , cooperation and anterograde amnesia
  • titrated
  • respiratory depression
  • synergistically increased with the use of
    intravenous opiates, the midazolam dose should be
    reduced by 30
  • 0.5-2 mg given slowly intravenously
  • repeating doses every 2 to 3 minutes
  • total dose is 2.5 to 5 mg

32
Midazolam-Induced Sedation for Upper
Gastrointestinal Endoscopy Assessment of
Endoscopist and Patient Satisfaction
  • 352 patients upper gastrointestinal endoscopy
    were sedated with midazolam given
  • Ages of the patients ranged between 16 and 79
    years (average 41.6 12.7 years).
  • Anterograde memory was found in 310 (88.0)
  • 342 patients (98.0) cooperated well
  • Side effects were rarely seen (3.6), and
    included nausea, vertigo, and vomiting
  • Acceptability of further endoscopy in 338
    (96.0)
  • No significant cardiopulmonary problems
  • Gastroenterology Nursing Volume 26(4)
    July/August 2003 pp 164-167

33
  • Most patients and endoscopists prefer some form
    of premedication be given (Bell, 1990)
  • Intravenous diazepam or midazolam have been used
    by the majority of endoscopists (Wille et al.,
    2000)
  • Midazolam quickly gained popularity after it was
    introduced in the mid-1980s (Zakko, Seifert,
    Gross, 1999)
  • Many endoscopists prefer midazolam for conscious
    sedation because it has short duration of action
    and efficient amnesic effect (Whitwam,
    Al-Khudhairi, McCloy, 1983Wille et al., 2000)
  • Midazolam was accused of more than 40
    sedation-related deaths, which made its safety in
    the setting of conscious sedation questionable
    (Zakko et al., 1999). These adverse events may
    have been related to the fact that when midazolam
    was first used

34
Opiates --Fentanyl
  • Pain threshold, alters pain reception, and
    inhibits ascending pain pathways
  • Sedation is 25 to 50 µg, repeated every 1 to 2
    minutes
  • Total dose is 50 to 200 µg
  • Half-life is 2 to 4 hours

35
Opiates --Meperidine
  • pain threshold, alters pain reception, and
    inhibits ascending pain pathways
  • sedation is routine procedures is 50 to 100 mg

36
Reversal Agents
  • Naloxone and flumazenil available whenever
    opioids or benzodiazepines administered

37
Special Considerations
  • Age gt60 years
  • Inability to cooperate
  • Significant developmental delay
  • Severe comorbidity (e.g., cardiac, pulmonary,
    hepatic, renal, or central nervous system
    disease)
  • Morbid obesity
  • History of sleep apnea
  • History of drug or alcohol abuse
  • Pregnancy
  • Emergency procedure with lack of patient
    preparation
  • Airway anomalies

38
Recovery Criteria after Sedationand Analgesia
  • 1. Medical supervision of recovery and discharge
    after moderate or deep sedation is the
    responsibility of the operating practitioner or a
    licensed physician.
  • 2. The recovery area should be equipped with, or
    have direct access to, appropriate monitoring and
    resuscitation equipment
  • 3. Patients receiving moderate or deep sedation
    should be monitored until appropriate discharge
    criteria are satisfied .The duration and
    frequency of monitoring should be individualized
    depending on the level of sedation achieved .the
    overall condition of the patient, and the nature
    of the intervention for which sedation/analgesia
    was administered. Oxygenation should be monitored
    until patients are no longer at risk for
    respiratory depression

39
Recovery Criteria after Sedationand Analgesia
  • 4.Recovery area once vital signs are stable and
    the patient has reached an appropriate level of
    consciousness. Level of consciousness, vital
    signs, and oxygenation (when indicated) should be
    recorded at regular intervals.
  • 5. A nurse or other individual trained to monitor
    patients and recognize complications should be in
    attendance until discharge criteria are
    fulfilled.
  • 6. An individual capable of managing
    complications (e.g. establishing a patent airway
    and providing positive pressure ventilation)
    should be immediately available until discharge
    criteria are fulfilled

40
Guidelines for discharge
  • 1. Patients should be alert and oriented infants
    and patients whose mental status was initially
    abnormal should have returned to their baseline
    status. Practitioners and parents must be aware
    that pediatric patients are at risk for airway
    obstruction should the head fall forward while
    the child is secured in a car seat.
  • 2. Vital signs should be stable and within
    acceptable limits.
  • 3. Use of scoring systems may assist in
    documentation of fitness for discharge.
  • 4. Sufficient time (up to 2 h) should have
    elapsed after the last administration of reversal
    agents (naloxone, flumazenil) to ensure that
    patients do not become resedated after reversal
    effects have worn off.
  • 5. Outpatients should be discharged in the
    presence of a responsible adult who will
    accompany them home and be able to report any
    postprocedure complications.
  • 6. Outpatients and their escorts should be
    provided with written instructions regarding
    postprocedure diet, medications, activities, and
    a phone number to be called in case of emergency.

41
Discharge criteria after sedation
42
Evidence-Based Medicine
  • A focused history and physical is required prior
    to the administration of moderate sedation. (C)
  • Routine monitoring of the patients pulse rate,
    blood pressure, oxygen saturation are useful in
    identifying early problems. (B)
  • Monitoring of EKG recordings may be helpful in
    selected cases. (C)
  • Capnography, measurement of carbon dioxide
    retention, may be useful in prolonged cases. (A)
  • The use of benzodiazepines and/or opiates will
    result in a satisfactory outcome in nearly all
    patients. (B)
  • Endoscopists prefer the combination of these
    drugs, but it adds little benefit from the
    patient's viewpoint. (A)
  • (A), Prospective controlled trials.
  • (B), Observational studies.
  • (C), Expert opinion

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