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Moderate Sedation

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Title: Moderate Sedation


1
Moderate Sedation
2
PowerPoint
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3
Description of Course
  • This course is designed to provide the health
    care professional with information needed to
    manage a patient receiving moderate sedation
    during a procedure at Tulare Regional Medical
    Center.
  • Information for both Adult and Pediatric Sedation
    will be included.

4
Objectives
  • Identify the purpose of procedural sedation.
  • Explain the criteria for the proper level of
    sedation on the sedation continuum.
  • Differentiate between the different levels of
    sedation (example procedural vs. deep).
  • Discuss common medications used for sedation,
    including the desired effect, side effects and
    reversal agents.
  • Articulate the elements of respiratory depression
    and airway compromise including techniques to
    rescue.
  • Explain TRMC policy for Procedural Sedation.

5
Introduction
  • Moderate sedation (often referred to as conscious
    sedation or procedural sedation) is a drug
    induced depression of consciousness during which
    a patient is able to respond purposefully to
    verbal commands or light tactile stimulation. No
    interventions are required to maintain a patent
    airway and spontaneous ventilation is adequate.
    Cardiovascular function is usually maintained
    (Cote et al, 2006).

6
Introduction continued
  • A growing number of outpatient procedures,
    advances in medical technology, and increasing
    population has lead to an increasing number of
    procedures being performed under moderate
    sedation.
  • Basic life support equipment and trained
    personnel should always be immediately available
    when procedural sedation is performed (ASA,
    2002).

7
Definitions
  • Local Anesthesia
  • Elimination of pain and other sensations in one
    body location utilizing the topical application
    or regional injection of a drug.
  • No modification of memory or affect and no
    alteration or loss of consciousness occurs.

8
Definitions cont
  • Minimal Sedation (Anxiolysis)
  • A drug induced state during which patients
    respond normally to verbal commands.
  • Cognitive function and coordination may be
    impaired ventilation and cardiovascular
    functions are unaffected.
  • Light sedation occurs following the
    administration of medication for reduction of
    anxiety or pain and allows the patient to
    maintain normal respiration, eye movements, and
    protective reflexes.
  • NOTE Medication used for this purpose and for
    sedation of mechanically ventilated patients or
    for urgent/emergent endotracheal intubation is
    not considered moderated sedation therefore not
    part of this module.

9
Definitions cont
  • Procedural/Moderate Sedation
  • A state of altered consciousness resulting in
    relaxation, euphoria, and amnesia.
  • Procedural/Moderate sedation/analgesia is a state
    of depressed consciousness, controlled by drugs,
    allowing protection reflexes to be maintained.
  • Patient independently maintains a patient airway
    and appropriately responds to physical
    stimulation and/or verbal commands. The patients
    cardiovascular system is not usually impaired.
  • Procedural/Moderate sedation is not the use of IV
    analgesics for pain control when no procedure is
    being conducted.
  • NOTE Procedural sedation is not eh use of IM
    sedatives with or with IM analgesics even if an
    invasive procedure is performed.

10
Definitions cont
  • Deep Sedation/Analgesia
  • A state of depressed consciousness or
    unconsciousness controlled by drugs which may
    result in the partial or complete loss of
    protective reflexes.
  • Patients ability to independently maintain a
    patient airway frequently requires airway and
    ventilatory support while cardiovascular function
    is usually maintained.
  • The patient ability to respond purposefully to
    physical stimulation or verbal commands is
    compromised.

11
Definitions cont
  • Analgesia
  • Consists of general anesthesia, as well as spinal
    or major regional anesthesia but no local
    anesthesia.
  • General anesthesia is a state of unconsciousness,
    controlled by drugs, resulting in the complete
    loss of protective reflexes.
  • Patients ability to maintain an airway
    independently and respond purposefully to
    physical stimulation or verbal command is absent.
  • Cardiovascular function may be affected.
  • Loss of Protective Reflexes
  • Absence of gag reflex and/or ability to maintain
    a patient airway

12
Informed Consent
  • Informed consent from the patient (or parent or
    guardian for pediatric patients) must be obtained
    prior to the onset of moderate sedation. Usually
    it is obtained in conjunction with the consent
    for the planned procedure. The pediatric patient
    can be informed with age appropriate expectations
    and directions, but, informed consent can only be
    obtained from a parent or guardian. Important
    elements of informed consent included
  • Objectives of Moderate Sedation
  • Anticipated Changes in Behavior before and after
    sedation
  • Name of anticipated medication to be used and
    side effects
  • Post Moderate Sedation limitation of activity

13
  • Moderate Sedation Consent form used at TRMC

14
Sedation Continuum
  • The American Society of Anesthesiologists (ASA)
    has adopted a continuum for the levels of
    sedation and analgesia from minimal sedation
    (anxiolysis) through general anesthesia. The
    American Academy of Pediatrics (AAP) has adopted
    the continuum and the ASAs recommendations into
    their practice guidelines. This continuum
    provides an easy to follow guide. It is important
    for the clinician to realize the sedation course
    is sometimes unpredictable. It should be noted
    not all patients will follow the continuum in
    exactly the same way and sedation/analgesia must
    be customized for each patient. The clinician
    must take into account each patients age, body
    habitus, developmental status, co-morbidities,
    medications, allergies, and fasting status to
    determine if moderate sedation is the best plan
    of care for that patient. Staging on the
    continuum is based upon the patients
    responsiveness, airway self preservation,
    spontaneous ventilation and cardiovascular
    function. It is important to point out that any
    practitioner should have the capabilities to
    rescue a patient from one level deeper than the
    intended level of sedation (ASA, 2002).

15
ASA Sedation Continuum
16
ASA Sedation Continuum
17
TRMC Policy
  • Tulare Regional Medical Center recommends
    procedural/moderate sedation be limited to the
    following areas
  • ED, ICU, PICU, OR, Endoscopy, MI, Cath Lab
    (CCVL), Bronchoscopy and Pediatrics.

18
Physician Requirements
  • Physician credentialed for administration of
    sedation according to the guidelines established
    and approved by medical staff.
  • Must be able to manage complications that may
    occur including rescue from deep sedation.
  • Successful completion of TRMC sedation module.
  • ACLS certification for adult sedation
  • PALS certification for pediatric sedation
    (exception to ACLS/PALS requirement - Certified
    Emergency Medicine Physician and/or Cardiologist
    with documentation of ACLS equivalent of airway
    management skills)
  • Other specific criteria available with the
    Medical Staff Office for credentialing
    requirements.

19
Registered Nurse Requirements
  • RNs assisting with a procedure requiring moderate
    sedation will be ACLS certified for adult
    sedation and/or PALS certified for pediatric
    sedation and have appropriate competency
    documentation including completion of TRMC
    sedation module.
  • Note an RN does not have the authority to
    administer medications which would result in deep
    sedation and/or loss of consciousness.

20
Respiratory Therapist Requirements
  • Respiratory Therapists assisting with a
  • procedure requiring
  • moderate sedation will be
  • ACLS certified for adult
  • sedation and/or PALS
  • certified for pediatric sedation and have
  • appropriate competency documentation including
    completion of TRMC sedation module.



21
TRMC Policy cont.
  • An anesthesiologist will be available 24 hours a
    day, 7 days a week as consultants for the
    implementation of sedation.
  • Anesthesia will respond to calls requesting
    consultation or resuscitation efforts, should
    they become necessary.
  • Anesthesiology can be reached through the
    Operating Room (OR), the Nursing Supervisor, or
    via their pagers.

22
Pharmacology
  • The goal of moderate sedation is to allow the
    practitioner to perform the procedure with
    minimal pain and discomfort to the patient.
    Previously sleep deprivation was encouraged as a
    synergistic technique to help with pediatric
    sedation. Recent evidence suggests routine use of
    sleep deprivation may not be beneficial (Shields
    et al, 2004).

23
Pharmacology
  • The goal for the pediatric patient receiving
    sedation at TRMC is to maintain safety/ comfort,
    control anxiety/stress, modify behavior/movement,
    minimize psychological trauma, and maximize the
  • potiential for amnesia.

24
Pharmacology
  • There is no standard recipe for moderate
    sedation, however, a combination of
    benzodiazepines and opioids is used most often.
  • TRMC policy 12-1054 Policy and Procedure for
    Procedural/Moderate Sedation-Analgesia has a
    table of recommended medications for Moderate
    Sedation (see following 2 slides)

25
Medications for Moderate Sedation
26
Medications for Moderate Sedation
27
Medications for Moderate Sedation
28
Medications for Moderate Sedation
29
Pharmacology
  • Medications for pediatric sedation should be
    based upon their effects, duration of action,
    ease of reversal, and relative safety.
  • It is important to keep in mind the widely varied
    individual patient response to medications and
    the synergistic effect they have when used
    together.
  • Regardless of the choice of medications they
    should be carefully titrated with adequate time
    to exert their maximal effect (AAP, 2006)

30
Benzodiazepines
  • Diazepam can also be used but is longer lasting
    and may lengthen the recovery time.
  • Benzodiazepines are synergistic with opioids and
    IV sedatives. In the pediatric patient, the
    combination of fentanyl and midazolam appear to
    result in a greater risk of respiratory
    depression.
  • Benzodiazepines are the most commonly used class
    of drugs in sedation.
  • Midazolam is preferred due to its quick onset,
    short duration and lack of residual metabolites.
    Midazolam also provides better amnesic properties
    than other benzodiazepines.

31
Opioids
  • Opioids are commonly used as an adjunct in
    moderate sedation in order to provide analgesia
    in combination with benzodiazepines or IV
    sedatives. Fentanyl and meperidine are the most
    commonly used opioids during moderate sedation.
  • Meperidine has a greater synergistic effect with
    midazolam, while fentanyl carries a greater risk
    of respiratory depression than the analgesic
    effect it provides. Meperidine also produces
    more nausea and may cause the accumulation of
    metabolites in those with renal insufficiency.
  • Side effects of Opioids include respiratory
    depression, pruritis, nausea/vomiting,
    bradycardia, hypotension, muscle rigidity,
    urinary retention, and biliary spasms.
  • Contraindications and precautions include use in
    patients with increased intracranial pressure,
    decreased respiratory capacity, allergy, and it
    may impair a persons mental judgment.

32
Chloral Hydrate
  • Chloral hydrate is a sedative hypnotic agent
    first introduced into clinical practice in the
    middle 1800s. The drug may be administered orally
    or rectally and was first described as an
    anxiolytic adjunct for dental procedures or as a
    single or combined sedative agent for painless
    diagnostic studies. It is not indicated as a
    first-line sedative for ages greater than 2 years
    (decreased efficacy rated).

33
Other Agents
  • IV sedative agents such as
    propofol, etomidate, and ketamine are not
    commonly used in moderate sedation, and are
    generally considered beyond the scope of
    procedural sedation.
  • Use of these anesthetics are usually associated
    with deep sedation or general anesthesia.

34
Propofol
  • There has been significant controversy over the
    use of propofol for nurse administered sedation.
    Many states have laws preventing nurses from
    administering propofol outside an intensive care
    sedation setting. It is the position of the ASA
    and the manufacturers of propofol that the
    medication not be used by anyone other than
    properly trained and credentialed anesthesia
    providers (ASA, 2009) (FDA 2006).

35
Reversal Agents
  • An important aspect in the selection of
    pharmacological agents in moderate sedation is
    the ability to reverse the agents if the patient
    needs to be rescued from a deeper level of
    sedation.

This is one of the reasons agents such as
ketamine, propofol and etomidate are not used
with moderate sedation.
36
Reversal Agents
  • Opiates can be reversed using an opioid
    antagonist such as naloxone (Narcan).
  • Benzodiazepines can be reversed using flumazenil
    (Romazicon).
  • Important Antagonists may have shorter half
    lives than the agonists being reversed.
    Additional doses may be needed to prevent
    re-sedation.

37
Evaluation
  • Appropriate patient selection criteria are
    important factors in moderate sedation.
  • The patient must be evaluated and the assessment
    of the risk must be performed.
  • The ASA has devised a patient categorization
    system based upon patient co-morbidities and risk
    of adverse events.

38
ASA physical Status
  • As the ASA physical status increases, the risk of
    complication from anesthesia increases.
  • Moderate sedation is not recommended for
    patients with an ASA
    status class greater than 3.

39
ASA Classification
  • Class I Normal healthy patient
  • Class II Mild systemic disease (e.g. controlled
    reactive airway disease, essential hypertension
    medication)
  • Class III Severe systemic disease (e.g. active
    wheezing, stable coronary artery disease)
  • Class IV Severe systemic disease that is
    constant threat to life (e.g. active myocarditis)
    NOTE No class 4 will be performed on an
    outpatient basis.
  • Class V Moribund patient not expected to
    survive 24 hours.
  • Class VI patient declared brain dead whose
    organs are being removed for donation.
  • E (suffix) Emergency (e.g. otherwise healthy
    patient presenting for fracture reduction)

40
Airway evaluation
  • Special attention must be given to the patients
    airway. A difficult airway is an airway where
    mask ventilation or orotracheal intubation is
    difficult to establish by a trained airway expert
    (anesthesiologist). In a closed claims review
    respiratory compromise accounted for the single
    largest class of adverse outcomes (Cheney FW et
    al, 1991).
  • At TRMC if the patient is found to be ASA class
    4, the physician will contact the
    anesthesiologist and the patient will only be
    sedated as an inpatient (no class 4 shall be
    sedated on an outpatient basis).

41
Pediatric Airway
  • The pediatric airway differs from the adult
    airway in many ways. The pediatric airway is
  • Smaller
  • Proportionally larger head relative to body size
  • Relatively larger tongue
  • Shorter, narrower, softer, floppier, and
    horizontally placed epiglottis
  • Cephalad larynx (C2-3 versus C4-5 in adult)
  • Shorter, narrower trachea
  • Funnel shaped versus cylindrical shaped airway
  • Cricoid cartilage is the narrowest part

42
Difficult Airway
  • There is no one evaluation which will determine
    whether a patient will have a difficult airway.
    Any of the following conditions may be considered
    a potential difficult airway
  • Macroglossia
  • -Downs Syndrome (Trisomy 21)
  • -Children have larger tongue compared to adults
  • -Mucopolysaccharidosis
  • Mandibular Hypoplasia
  • -Pierre-Robin Syndrome
  • -Crouzon Disease
  • -Goldenhar Syndrome
  • -Treacher-Collins Syndrome

43
Difficult Airway continued
  • Limited Alanto-occipital motion
  • -Goldenhar Syndrome
  • -Klippel-Feil Syndrome
  • -Juvenile Rheumatoid Arthritis
  • -Scoliosis
  • External/Internal compression
  • -Hemangiomas
  • -Tumors
  • -Abscesses
  • -Vascular Rings
  • -Cysts
  • Unstable Alanto-occipital motion
  • -Downs Syndrome
  • Tonsillar and Adenoid
  • Hypertrophy
  • Obesity
  • Facial Trauma

44
Difficult Airway continued
  • Adult patients who have difficulty extending
    their necks, have lt 3 finger breadths of
    distance between upper and lower incisors, or lt 3
    finger breadths distance between their hyoid bone
    and mental process, may all be potiential
    difficult airways.
  • The Mallampati airway classification system (used
    at TRMC) is an important tool in evaluating the
    patients airway.
  • To classify the patient have the patient extend
    their neck, fully open their mouth and stick out
    their tongue to observe the hard palate, soft
    palate, uvula, faucial pillars and pharynx.
    Depending upon what is visualized, the patient is
    classified according to the chart on the next
    slide.

45
Difficult Airway continued
  • Class I soft palate, uvula, faucial pillars
    visualizedClass II soft palate, faucial pillars
    visualized, portion of uvula Class III soft
    palate, base of uvulaClass IV hard palate only,
    soft palate not visualized

46
Paperwork
  • Prior to the procedure requiring Moderate
    Sedation, the physician will complete a
    Pre-Procedure Patient Evaluation of the airway.
  • Those involved in bedside sedation procedures
    will complete the Universal Protocol and Fire
    Risk Assessment for Bedside Procedure form.
  • During the procedure a Moderate Sedation Record
    will be completed.
  • Samples of forms used at TRMC are on the
    following slides

47
  • Pre-Procedure
  • Patient Evaluation/
  • Sedation Record used at TRMC
  • (completed by physicians)

48
  • Universal Protocol Fire Assess-ment for
    Bedside Procedure Record

49
  • Universal Protocol Fire Assess-ment for
    Bedside Procedure (back side)

50
  • Procedural Sedation Record (with sedation scale)
    used at TRMC form 1023.

51
NPO Guidelines
  • Aspiration pneumonia is a risk anytime a patient
    is to undergo a procedure with moderate sedation.
    As the patient is sedated he or she may lose the
    reflexes that protect their airway allowing
    gastric contents to flow up the esophagus and
    down into the lings. This can lead to aspiration
    pneumonitits, respiratory failure, and even
    death.
  • Factors that have shown to increase risk of
    aspiration are increasing ASA physical status,
    emergency procedures, parturients, obesity, and
    those with gastric esophageal reflux disease.
  • Guidelines for fasting periods should generally
    follow those created by the ASA for general
    anesthesia (Cote et al, 2006)

52
NPO Recommendations
  • Ingested Material Minimum NPO Time Description
  • Clear liquids 2 hours water, fruit juice,
    carbonated beverages,
    clear tea, black coffee
  • Breast Milk 4 hours
  • Infant Formula 6 hours
  • Non-Human Milk 6 hours
  • Light Meal 6 hours toast, clear liquids, no
    meats or fatty foods (prolong gastric
    emptying time)

53
Rescue
  • The concept of rescue is essential to safe
    sedation. Practioners must have the skills to
    rescue the patient from a deeper level than
    intended for the procedure (Cote et al, 2006).
    The ability to manage an airway in this
    circumstance should not be overlooked and
    appropriately sized emergency airway equipment
    such as an oral airway and bag valve mask should
    be immediately available anytime moderate
    sedation is being performed (ASA, 2002).

54
Monitoring
Monitoring will include ECG, BP, EKG (HR), RR,
Pulse Oximetry, LOC.
  • The purpose of monitoring is to provide a trend
    and early warning system for treatment of the
    patient to avoid complication from sedation. The
    patient should be observed continuously with
    recording of vital signs and other indicated
    parameters on an intermittent basis. The period
    of vital sign monitoring should be adjusted for
    the condition of the patient and the procedure
    being performed. It is suggested the frequency of
    the vitals not be more than 5 minutes.

55
Monitoring continued
  • Cote et al, recommends adding EtCO2 monitoring
    when respirations cannot be visualized, when
    sedation becomes deep, or with pediatric
    sedation.
  • The person monitoring the patient status should
    not be the same person performing the procedure
    (ASA, 2002).

56
Monitoring continued
  • Consciousness is a major monitoring parameter.
    Patients undergoing moderate sedation should
    maintain the ability to respond to simple verbal
    or tactile stimulation. If the patient fails to
    respond or it takes repeated stimuli in order to
    elicit a response the patient has moved into deep

sedation criteria and should be rescued back
into moderate sedation (ASA, 2002).
57
Monitoring continued
  • End Tidal Carbon Dioxide monitoring (EtCO2) or
    capnography will detect the concentration of
    carbon dioxide in the patients exhaled breath by
    drawing a sample of the breath into the monitor
    and using an infrared beam or gas chromatography
    to measure the concentration.

58
Monitoring continued
  • The results are then displayed as either a
    numerical value or more usefully as a graph
    plotted against time. Careful monitoring of this
    waveform can lead to the detection of respiratory
    insufficiency, apnea, or airway obstruction often
    before desaturation is detected in pulse
    oximetry.
  • Disadvantages of this technology are the cost of
    the monitor and possible distorted reading when
    using high flow oxygen.

59
Monitoring continued
  • According to Vargo et al, the use of EtCO2
    monitoring was more successful in detecting apnea
    and hypoventilation, more than both pulse
    oximetry and visual observation during procedural
    sedation.
  • Miner et al, found EtCO2 monitoring during
    procedural sedation in the emergency room may add
    to the safety of the sedation by detecting
    episodes of hypoventilation.
  • The use of expired carbon dioxide monitoring
    devices is encouraged for sedated children,
    particularly in situations where other means of
    assessing the adequacy of ventilation are limited
    (Cote et al, 2006).

60
Capnography
  • Normal EtCO2
  • Asthma EtCO2
  • Obstructive EtCO2

61
Capnography continued
  • The previous images show a normal, small airway
    obstruction (asthma), and large airway
    obstruction.
  • A normal airway pattern has a gentle but sharp
    upstroke, a gentle increasing top and a gentle
    but sharp down stroke.
  • The slope of the top and higher number indicate
    an asthmatic or small airway obstruction.
  • Irregular patterns or the absence of a pattern
    indicates and obstructed airway.
  • Capnography is an early detector of inadequate
    respiratory function. Respiratory events leading
    to death occurred twice as often when patients
    were sedated outside the operating room (Cravero
    JP, et al 2004).

62
Capnography continued
  • In October 2010 the American Society of
    Anesthesiologists (ASA) committee on Standards
    and Practice Parameters updated the anesthetic
    standards of monitoring to include exhaled carbon
    dioxide monitoring not just for endotracheal tube
    or laryngeal mask general anesthetics (3.2.2) but
    expanded for moderate and deep sedation cases.
  • During moderate or deep sedation the adequacy of
    ventilation shall be evaluated by continual
    observation of qualitative clinical signs and
    monitoring for the presence of exhaled carbon
    dioxide unless precluded or invalidated by the
    nature of the patient, procedure or equipment
    (3.2.4). This became effective July 1, 2011.

63
Discharge Criteria
  • Patients receiving procedural/moderate sedation
    are to be monitored by a Registered Nurse until
    discharge criteria are satisfied.
  • Patients are to be monitored for a minimum of 30
    minutes from the last dose of medication or until
    the Aldrete score is 8 or greater or until the
    patient reaches his/her pre-procedure baseline
    score.
  • If a reversal agent is given to the patient the
    RN must monitor the patient for 90 minutes from
    the time the reversing agent is given.
  • Post procedural documentation shall include
    minimally
  • Vital signs within 5 minutes and reassessment
    every 5-15 minutes
  • Assessment of patients level of comfort
  • LOC / mental status
  • Intact protective reflexes
  • Aldrete Score
  • Discharge education

64
Discharge Criteria continued
  • The patient must meet all discharge criteria
    (Physician order)
  • Aldrete Score gt or 8, or at pre-procedure level
  • Documented BP is within 20mm/Hg of the admitting
    BP
  • Respirations unlabored and patient able to deep
    breathe and cough freely or at pre-procedure
    levels
  • Absence of respiratory distress
  • Alert and oriented or LOC returned to
    pre-procedure level
  • Tolerates fluids with minimal nausea and vomiting
    (notify the physician if the patient is actively
    vomiting)
  • Pain is adequately managed, and pain is
    appropriate for procedure
  • Swallow, cough and gag reflex present, protective
    reflexes intact.
  • Dressing (if applicable) dry/intact or with
    minimal drainage appropriate for procedure
  • Reference Policy 20-20,002 Standardized
    Procedure Discharge of Patients from Ambulatory
    Care Unit by an RN

65
Pediatric Discharge Criteria
  • After a procedure, adequate time must be allowed
    for the patient to recover from the effects of
    moderate sedation. Recommended guidelines for how
    long a pediatric patient should be monitored is
    as follows
  • 2 hours for infants lt 5.5 kg
  • 4 hours for infants lt 4.5 kg
  • 2 hours for infants lt 6-12 months
  • 4 hours and overnight admission for
  • ex-premature infants lt50 52 weeks
  • post-conception age

66
Pediatric Discharge Criteria
  • With outpatient sedation, the American Academy of
    Pediatrics has developed the following discharge
    criteria
  • Cardiovascular function and airway patency are
    satisfactory and stable
  • Patient is easily arousable and protective
    reflexes are intact
  • Patient can talk (if age appropriate)
  • Patient can sit up unaided (if age appropriate)
  • The state of hydration is adequate
  • For a very young or handicapped child incapable
    of the usual expected responses, the pre-sedation
    level of responsiveness or a level as close a
    possible to the normal level for that child
    should be achieved.

67
  • TRMC Recovery (Phase II and Phase III with
    Aldrete Score) Record
  • form 1019.

68
TRMC Pediatric Sedation
  • Policy 12-1054 contains additional information
    concerning Pediatric Sedation at TRMC. In
    conjunction with previous standards, keep the
    following in mind
  • Age criteria for Pediatric patients at TRMC is
    2-3 days old through 13 years of age (Pediatric
    Scope of Service).
  • Continuous (Blood Pressure) BP monitoring may be
    altered or suspended if BP interferes with the
    completion of the procedure. The reason for
    omission must be documented in the patient
    record. In this circumstance continuous heart
    rate, respiratory rate, and pulse oximetry will
    not be interrupted. BP monitoring will resume
    post procedure.

69
TRMC Pediatric Sedation cont.
  • Pediatric patients receiving oral medication for
    sedation purposes and have no prior cardiac
    history, may be monitored with continuous pulse
    oximetry and heart rate only. EKG monitoring may
    or may not be used according to patient tolerance
    and risk of procedure.
  • The physician/pediatrician must be present for
    pediatric oral sedation procedures (TJC 2010).

70
TRMC Pediatric Sedation cont.
  • Orally sedated out-patients in the Pediatric Unit
    may or may not have IV access dependent on
    physician orders, assessment risk, and risk of
    procedure.
  • Emergency Department pediatric patients receiving
    moderate sedation will have IV assess
    established.

71
Quality Improvement at TRMC
  • Outcomes of patients undergoing moderate and deep
    sedation are collected and analyzed in order to
    identify opportunities to improve care throughout
    the institution.
  • Data will be reported as a component of the
    organization-wide performance improvement
    program.
  • The following data are gathered following the
    administration of sedation in any site within the
    facility
  • Unplanned admission or transfer to a higher level
    of care
  • Administration of reversal agent
  • Drop in O2 saturation lt92 for 5-7 minutes
  • Failure to conform to documentation requirements

72
Summary
  • As the demand for sedation in hospital areas
    increase, the need for non-anesthesia trained
    sedation will continue to increase. Patients
    scheduled to undergo moderate sedation will be
    given a basic thorough health history and
    physical. Special attention should be given to
    any conditions which may interfere with
    respiratory or cardiovascular function. If
    concerns arise, some conditions may warrant
    consultation with an anesthesia professional.
  • The patients NPO status and preoperative
    medication regimen should also be reviewed.
  • Proper monitoring by trained personnel not
    performing the procedure will be provided with
    baseline values recorded. Monitoring will be
    continued until the patient returns to his or her
    baseline status.

73
Summary Continued
  • Proper sedation agents should be used and
    titrated slowly, to effect, and in small doses
    (especially with pediatric sedation) paying
    careful attention to established ranges and
    maximums of dosing.
  • If deep sedation is encountered ventilatory
    and/or cardiovascular assistance will be rendered
    by trained personnel and correct reversal agents
    should be administered to return the patient to
    moderate sedation level.
  • As new technologies and evidence based practice
    continue to emerge the provider should continue
    his or her education into moderate sedation
    trends.

74
References
  • American Society of Anesthesiologists (2002).
    Practice guidelines for sedation and analgesia by
    non-anesthesiologists. Anesthesiology,
    96,1004-17.
  • American Society of Anesthesiologists (2009).
    Practice guidelines for propofol use with
    sedation. Anesthesiology
  • American Academy of Pediatrics (2006). Dedicated
    to the Health of all Children.
  • Cheney FW, Posner KL, Caplan RA. (1991). Adverse
    respiratory events infrequently leading to
    malpractice suits A closed claims analysis.
    Anesthesiology, 75932-939.
  • Colson, J. (2005). The Pharmacology of sedation.
    Pain Physician, 8, 297-308.
  • Cote C, Wilson S. (2006). Guidelines for
    monitoring and management of pediatric patients
    during and after sedation for diagnostic and
    therapeutic procedures an update. Pediatrics,
    118(6), 2587-2601.
  • Cravero J, Blike G. (2004). Review of pediatric
    sedation. Anesthesia and Analgesia, 99,
    1355-1364.

75
References continued
  • Hata K, Andoh A, Klyoyuki H, Ogawa A, Nakahara T,
    Tsujikawa T, Fujiyama Y, Saito Y. (2009)
    Usefulness of Bispectoral Monitoring of Conscious
    Sedation during Endoscopic Mucosal Dissection.
    World Journal of Gastroenterology. 15(5)595-598.
  • Shields C, Johnson S, Knoll J, Chess C,
    Goldberg D.(2004). Sleep deprivation for
    pediatric sedated procedures not worth the
    effort. Pediatrics, 113(5), 1204-1208.
  • TRMC Policy 12-1054, Policy and Procedure for
    Procedural/Moderate Sedation-Analgesia.
  • TRMC Policy 20-20,002, Standardized Procedure -
    Discharge of Patients from Ambulatory Care Unit
    by an RN.
  • TRMC Procedural Moderate Sedation Record 1023
    Phase II and Phase III Procedure Recovery Record
    1019 Pre-Procedure Patient Evaluation/Sedation
    Plan Universal Protocol Fire Assessment for
    Bedside Procedure Record 1781.

76
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