Conscious Sedation March, 2012

Moderate Sedation Patient maintains: Airway Spontaneous ventilation Responds to verbal commands or light tactile stimulation “Ramsey 3” Cardiovascular function maintained Drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

Deep Sedation Patients response May need assistance to maintain airway Stimulation to elicit a response may need repeated to obtain purposeful response (Ramsey 4, 5, 6) Sometimes the patient may go from moderate to deep sedation Cardiovascular function is usually maintained Drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. Ability to independently maintain ventilatory function may be impaired.

Procedures that require sedation per Lake Health policy Moderate sedation: Transesphogeal echocardiogram Endoscopy PEG placement

Procedures that require sedation per Lake Health policy Deep sedation: Elective cardioversion

Preprocedure Preparation Current H&P Physician assessment of airway and ASA status (American Society of Anesthesiology) Any previous problems with intubation, sleep apnea, and/or complications with anesthesia Informed consent IV access NPO status

During the procedure Ongoing monitoring of level of consciousness, vital signs, oxygenation/ventilation, ECG, pain Nurse monitoring patient stays in the room during the procedure

Post Procedure Monitor; LOC and emotional state Oxygenation/ventilation Vital signs ECG Pain assessment

Post procedure cont. BP, HR, RR within +/- 20% of patient’s normal range O2 sat >95% or within 5% of patient’s baseline Arouses easily and when aroused is able to respond appropriately for his/her age Significant complications related to the specific procedure are absent, have been controlled, or have been evaluated Wound drainage, N & V, Bladder distention, compromised neurovascular status.

Documentation Conscious sedation record is used Assessment parameters are documented at 5 minute intervals during the procedure and for 30 minutes post procedure at the minimum If patient does not return to baseline cont. every 15 minutes VS until patient back to baseline or physician determines patient is stable

Documentation cont. IF DEEP SEDATION is planned, Anesthesia uses the Anesthesia record for the history, medications and airway assessment.

Important to remember If you are performing an elective cardioversion you must have anesthesia present prior to starting the procedure

TIME OUT A time out MUST be performed with all involved parties present and is documented on the Conscious Sedation Record!!!!!

Most common Medications used during the procedure Midazolam Hydrochloride (Versed) Morphine Demerol Fentanyl Diazepam Propofol (Diprivan)

Dosing for medications during the procedure Versed (midazolam) for moderate sedation: 0.5 mg – 2.5 mg Versed for deep sedation: 0.5 mg -3.5 mg in incremental doses until desired level of sedation

Dosing for medication during procedure (con’t) Fentanyl: 25-100 ug (0.3-1.5 ug/kg) Diazepam: 1-10 mg

Dosing for medications during the procedure: Morphine: 2-10 mg (0.3-1.5 mg/kg) Demerol: 25mg – 100mg (0.3-1.5mg/kg) Diprivan (propofol): Variable doses administered by the anesthesiologist during deep sedation

Medications to treat overdose Narcan: used to treat opiod/narcotic overdose Usual dosing: 0.1mg to 0.2mg IV, IM repeat dose every 2 minutes until patient responds not to exceed 10mg Romazicon: used for benzodiazepine overdose Usual dosing: 0.2mg over 15 seconds May repeat every 1 minute with 0.2mg over 15 seconds times 3

1. During moderate sedation patient maintains: Airway, spontaneous ventilation, responds to verbal commands, cardiovascular function Needs mechanical ventilation Responds to painful stimuli, needs respiratory support Maintains no function

2. Prior to conscious sedation pre-procedure preparation includes: No consent needed Patient had breakfast Current H&P, physician assessment of airway, informed consent, IV access, NPO status No preparation

3. During procedure nurse must stay in room with patient to monitor True False

4. Post Procedure nurse will monitor: Pain assessment LOC, oxygenation, vital signs, ECG, pain assessment LOC only BP & Pulse only

5. Documentation includes: Neuro flowsheet ADL’s flowsheet Use of conscious sedation form None of the above

6. A time out must be performed prior to conscious sedation True False