What is Procedural Sedation? Procedural Sedation also referred to as “moderate sedation/analgesia” or “conscious sedation” …. “a drug-induced depression of consciousness during which individuals 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.” Joint Commission, 2001 Complications of Procedural Sedation can include: Hypoventilation, allergic or adverse reaction, abnormal cardiac function, deterioration in mental status.

Examples of Procedural Sedation In a Moderate Procedural Sedation the patient’s level of consciousness is altered, though response to verbal commands is still possible. For a Deep Sedation the patient’s consciousness is altered and cannot be easily aroused, but can respond to purposeful or painful stimulation.

Procedural Sedation is DEFINED by Patient’s Level of Conscious Minimal (Anxiolysis) LOC 2 Drug induced state, patient responds normally to verbal commands. Moderate (Procedural Sedation) LOC 1 Drug induced depression of consciousness, patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Deep Sedation (requires special privileges!) LOC 0 Drug induced depression of consciousness, patient cannot be easily aroused, but respond purposefully following repeated or painful stimulation. (Limited to ED, and Pediatric Sub specialists) Anesthesia LOC 0 Drug induced loss of consciousness, patient is not arousable, even by painful stimulation.

Scoring Patient’s Level of Conscious Procedure & Anesthesia Scoring System (PASS) Used before giving medication(s), during procedure, during recovery, and before discharge Consists of 7 categories Consciousness Activity Circulation Respiration O2 Sat Pain Emetic All are scored using a point scale of 2, 1, 0

PASS Assessment Scale Physiologic Assessment Scoring System PASS Scoring Score prior to sedation (all 7 elements) as baseline Score at the conclusion of procedure Score prior to discharge Note: Patient must meet pre-sedation PASS Score prior to discharge.

Consciousness Activity Circulation Respiration Saturation Pain Emetic Recovery/Level of Sedation Score Consciousness Awake and alert, turns toward voice Arousable, but drifts back to sleep when not disturbed Unresponsive (except to painful/repeated stimuli) 2 1 Activity Appropriate for age or development Weak for age or development No voluntary movement Circulation Stable BP within 15% of pre-sedation level (baseline) BP within 30% of pre-sedation level BP > 30% higher or <30% lower than baseline Respiration Able to cough, breath deeply or cry Dyspnea or limited breathing Apnea/obstructed breathing requires assistance to maintain airway Saturation Room air: O2 Sat > 95% Needs supplemental O2 to maintain O2 Sat > 95% O2 Sat < 95% with O2 supplementation Readiness for Discharge Pain None or mild pain Moderate or severe pain controlled with IV analgesics Persistent severe pain Emetic None or mild nausea with no vomiting Transient vomiting or retching Persistent moderate to sever nausea or vomiting

WHAT is NOT Procedural Sedation? Providing for comfort Preventing predictable anxiety to a procedure or treatment by utilizing narcotics and anxiolytics in dosages appropriate to relieve pain and/or anxiety without altering the LOC Non-invasive and routine procedures (dressing changes) Procedure that takes so little time to perform that the fear of the procedure is often worse than the actual process One type dose medication administration to relieve anticipated pain or anxiety for a particular patient (no titrating dose to “effect”) Patient in ICU, intubated, and mechanically ventilated (airway is protected)

WHAT is NOT Procedural Sedation? Pain and/or anxiety management that may be performed on all inpatient units Repetitive procedures (e.g. once daily) and a patient who is on a standard dose, or combination of medication that provides comfort A change in medication dose that would potentially induce pain and/or anxiety Note: If patients have been on a medication regime in the ICU with Fentanyl/Versed, the physician should be consulted to determine if the choice of narcotics may be changed to an equianalgesic dosage of hydromorphone or morphine sulphate, and the midazolam changed to a non-amnesiac anxiolytic such as lorazepam or valium

WHY Provide Procedural Sedation? Allows patient to tolerate an unpleasant procedure while maintaining consciousness Patient does not remember majority of procedure, awakens comfortable (depending on medications utilized) Rapid return to presedation state Uncomfortable and/or painful procedures can be performed safely utilizing procedural sedation Patient safety during, and recovering from, sedation is VITAL!

WHO can Provide Procedural Sedation? Physicians must have current sedation privileges. An updated list can be accessed on the SD Credentialing Website: http://cred.zion.ca.kp.org Residents may perform procedures only when the privileged attending physician is present RNs with age-specific training in ACLS or PALS may administer Procedural Sedation and recover the patient MD will complete the Procedural Sedation Record Physician documentation (Health Connect), including auscultation of heart and lungs and airway assessment RN will complete the Procedural sedation Record RN documentation (Health Connect)

Procedural Sedation SETTING Emergency Medications, Equipment & Supplies Crash cart with defibrillator, O2, suction Reversal agents (naloxone, flumazenil) Pulse oximeter, blood pressure monitor Endotracheal tube (ET) CO2 monitoring device Physical Environment Emergency power outlets, or flash light Telephone Transportation after Sedation By RN or MD

Procedural Sedation Preparation Consent needs to be obtained by physician for both the procedure and the sedation Pre-sedation Assessment Evaluation of Risk (American Society of Anesthesiologists ASA status) PASS Scores Sedation plan (medications ordered) Time Out Team members discuss any risks Team members know roles and responsibilities Patient Safety Identify patient (2 identifiers), must have arm band Site/side verified ASA Status Risk Assessment Class I Healthy patient Class II Mild systemic disease, no functional limitation Class III Severe systemic disease that limits activity (not incapacitating) Class IV Incapacitating systemic disease that is a threat to life (Anesthesia consult) Class E Emergent

Presedation Assessment AMPLE Allergies – medication, food, latex Medications – presently taking Past medical history Last meal (NPO Guidelines) Event leading to need for procedure NPO Guidelines AGE Solids & Non-Clear Fluids Clear 0-6mo 4 hours 2-3 hours 6mo-3yrs 6 hours 2-3 hours 3yrs + 6-8 hours 2-3 hours

Care During Sedation Ensure Patient SAFETY Document RN remains with patient at all times RN responsibility is to monitor the patient – ensure safety RN will NOT be expected to assist with the procedure Maintain level of sedation that allows for continuous patent airway Monitor patient’s response to medications Assess vital signs q 15 minutes Sedation plan (medications ordered) Document Use the Procedural Sedation Navigator (Health Connect)

Procedural Sedation Documentation Use the Procedural Sedation Navigator (Health Connect) From the patient’s open record, Click Action  Procedural Sedation on the Main Menu. Procedure Sedation Navigator Appears Four (4) Main Topics Navigate through each section to document your findings…

Common Sedation Agents Moderate Sedation Agents Deep Sedation Agents Click Deep Sedation Agents for details Chloral Hydrate Chlorpromazine (Thorazine) Diazepam (Valium) Fentanyl (Sublimaze) Hydroxyzine (Vistaril) Lorazepam (Ativan) Meperidine (Demerol) Midazolam (Versed) Morphine Sulfate Pentobarbital (Nembutal) Promethazine (Phenergan) Alfentanil (Alfenta) Etomidate (Amidate) Ketamine (Ketalar) Methohexital (Brevital) Propofol (Diprivan) Thiopental (Sodium Pentothal) Procedural Sedation does not include: Click the Deep Sedation tab for details. Toggle between both tabs using the back and forward arrows in slide view.

ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical condition Adapted from: Southern CA Regional Drug Information Services BENZOIDIAZEPINES, DOSAGE ONSET DURATION Midazolam (Versed): Slow IV: 0.5 - 1 mg (over 2 minutes) and titrate to desired effect by repeating doses every 2-3 minutes if needed Precaution: Reduce dose for elderly or those that have COPD or receiving concomitant narcotics. Some pt’s respond to 1mg. Usual total dose: 2.5-5 mg IV: 2-5 mins Peaks at 30 – 60 minutes. Duration: 2-6 hours Lorazepam (Ativan): IV: 0.05 mg/kg, 1-4 mg IV every 10-20 mins. 4 mg max. PO: 1-2 mg initially. Usual dosing is 2-6 mg/day divided. May gradually increase to 10 mg daily in 2-3 divided doses Precaution: Monitor blood pressure and assess motor and autonomic responses IV: 5-20 mins PO: 60 mins IV, PO: 2 – 6 hours

ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical condition Adapted from: Southern CA Regional Drug Information Services Diazepam (Valium): IV: 2.5-5 mg incremental doses of 2.5 mg can be given in 3-4 minute intervals. Usual total 2-10 mg. PO: 2-10 mg 2-4 times/day Precaution: incompatible with most medications. Potential complications: hypotension, confusion, drowsiness & apnea IV: 2-5 mins PO: 30 mins Peaks at 60-90 minutes Elimination half-life 36hours IV = intravenous; IM = intramuscular; IN = intranasal; PO = by mouth; PR = by rectum; and SC = subcutaneous

ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical condition NARCOTICS, DOSAGE ONSET DURATION Morphine: IV: 1-5 mg every 2-15 minutes. 2-5 mg IV every 5-15 mins Precaution: Itching & hypotension may occur IV: 5-10 mins/ 15-60 mins IV: 2 – 4 hours Fentanyl (Sublimaze): IV: 1 - 4 mcg/kg. Typical dose is 25-50 mcg; may repeat every 5-15 minutes. Usual total 50-200mcg Precaution: 100 times more potent than morphine. Rapid administration causes skeletal muscle & chest wall rigidity IV: 30-60 sec Peaks in 5-15 mins IV: 30-60 min Meperidine (Demerol): IV: 12.5-50 mg every 15 minutes. Usual dose is 50-100mg. IV: 5-10 mins IV: 2-4 hours

ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical condition Adapted from: Southern CA Regional Drug Information Services OTHER AGENT, DOSAGE ONSET DURATION Diprivan (Propofol): IV: 0.5-1.5mg/kg. May repeat 0.5mg/kg boluses every 3-5 mins as needed for continued sedation Note: Injectable Emulsion for adults & children >2years. Adhere to strict aseptic technique during handling. A soy based product containing egg lecithin with no preservatives, can support growth of microorganisms Precaution: rapid bolus injection can result in undesirable cardiorespiratory depression (apnea and hypotension). Discard unused portions at the end of the procedure or at 6 hours. Flush IV every 6 hours & at the end of the procedure to remove residual from the line IV: 1-2 mins IV: 3-10 minutes

ADULT DRUG DOSAGE GUIDELINES for Moderate and Deep Sedation Dosages require adjustment based on patient's clinical condition Adapted from: Southern CA Regional Drug Information Services REVERSAL AGENTS, DOSAGE ONSET DURATION Naloxone (Narcan): Narcotic antagonist IV: 0.2-0.4 mg every 2-3 minutes as needed Precaution: rapid reversal may cause nausea, hypertension IV: 1-2 mins IV: 30-60 mins short half- life- 30-81 mins; may require repeat in 1-2 hours Flumanzenil (Romazicon): Benzodiazepine antagonist IV: 0.2 mg every minute up to max of 1mg. Most patients respond to 0.6-1 mg; up to 3 mg has been reported Precaution: may induce seizures in pt’s with seizure history IV: 1-3 mins IV: 30-60 mins short half-life- 41-79 mins; may repeat 20 min intervals

Midazolam (Versed), DOSAGE ONSET DURATION Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mos Dosages require adjustment based on patient's clinical condition Consider Adult dosing guidelines for patients greater than 50 kg Midazolam (Versed), DOSAGE ONSET DURATION IV: 0.05 mg/kg, maximum of 5 mg titrated over one hour IM: 0.1 mg/kg IN: 0.2-0.4 mg/kg, maximum dose 7.5 mg PO: 0.25-0.5 mg/kg; maximum total dose 12 mg Precaution: Three times more potent than diazepam. Used with opiates can cause overdosage and complications (IV = intravenous; IM = intramuscular; IN = intranasal; PO = by mouth; PR = by rectum; and SC = subcutaneous) IV: 1-2 min IM: 5-15 min IN/PO:10min IV, IM: 30–60 min IN/PO: 1–2 hours Adapted from: Southern CA Regional Drug Information Services

Pentobarbital (Nembutal) * IV: 1-3 mg/kg; may repeat up to 6 mg/kg Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mos Dosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg BARBITUATES, DOSAGE ONSET DURATION Pentobarbital (Nembutal) * IV: 1-3 mg/kg; may repeat up to 6 mg/kg IM: 2-5 mg/kg PO: 2-3 mg/kg IV: 1-5 min IM: 5-15 min PO: 15-60 min IV:15–60 min IM, PO: 2–4 hours Methohexital (Brevital) * PR: 20-30 mg/kg PR: 5-15 min PR: 30–90 min *These agents are restricted to practitioners with deep sedation privileges operating under guidelines approved by the Medical Executive Committee Adapted from: Southern CA Regional Drug Information Services

Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mos Dosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg OTHER AGENTS, Dosage: ONSET DURATION Chloral hydrate; PO, PR: 25-100 mg/kg; maximum 2 g Precaution: May necessitate ongoing monitoring PO, PR: 15-30 min PO,PR: 2–3 hours Ketamine (Ketalar): * IV: 0.5-2 mg/kg IM: 3-4 mg/kg Adverse Effects: Increased systemic, intracranial, & intraocular pressures; hallucinogenic emergence reactions; laryngospasm; & excessive airway secretions IV: 1-2 min IM: 3-10mins IV, IM: 15–60 min Diprivan (Propofol) * IV: 0.5-1mg/kg. May repeat 0.5mg/kg boluses every 3-5 mins as needed for continued sedation. Precaution: rapid bolus injection can result in undesirable cardiorespiratory depression (apnea and hypotension). Discard unused portions at the end of the procedure or at 6 hours. Flush IV every 6 hours & at the end of the procedure to remove residual from the line * Agents restricted to practitioners with deep sedation privileges Adapted from: Southern CA Regional Drug Information Services IV: 3-10 min

Precaution: Itching & hypotension may occur IV: 5-10 mins Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mos Dosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg NARCOTICS, DOSAGE ONSET DURATION Morphine IV: 0.05-0.1 mg/kg Precaution: Itching & hypotension may occur IV: 5-10 mins IV: 2-4 hours Fentanyl (Sublimaze) IV: 1-4 mcg/kg Precaution: one hundred times more potent than morphine. Rapid administration causes skeletal muscle & chest wall rigidity IV: 2-3 mins IV: 20–60 mins Adapted from: Southern CA Regional Drug Information Services

Pediatric Guidelines for Moderate and Deep Sedation Guidelines do not apply to neonates or ex-premature infants up to 6 mos Dosages require adjustment based on patient's clinical condition. Consider adult dosing guidelines for patients greater than 50 kg REVERSAL AGENTS: DOSAGE ONSET DURATION Naloxone (Narcan): Narcotic antagonist IV, IM,: 0.1 mg/kg (20kg or less) – max 2mg; if above 20kg  2 mg; may repeat in 5min to effect Precaution: rapid reversal may cause nausea, Hypertension IV: 1-2 mins IM: 2-5mins 45mins, may be shorter than duration of opiate Flumanzenil (Romazicaon): Benzodiazepine antagonist IV: 0.01 mg/kg; Max. single dose 0.2 mg; may repeat every minute up to a maximum total dose of 1 mg Precaution: may induce seizures in pt’s with seizure history IV: 1-3 min 45-60 mins, may be shorter than duration of the benzodiazepine Adapted from: Southern CA Regional Drug Information Services

Medication Administration Requirements Clinical Library To find out more information about medications, visit KP’s Clinical Library at http://cl.kp.org. This resource includes information on medication: Dosages Routes Therapeutic range Pharmacologic classification Mechanism of action Safe use of clinical practice guidelines formularies

Post Sedation Recovery and Care Ensure Patient SAFETY RN remains with patient at all times RN is responsible to monitor the patient – until pt. achieves his/her presedation LOC If transferring the patient, the RN administering sedatives must accompany the patient, give a complete, concise report to the receiving RN responsible for further patient care Monitor patient’s vital signs and pulse oximetry q 15 minutes until stable Reorient patient to time and place Limit stimuli to the patient (loud noises)

Discharge Requirements Patient Must Be discharged by a physician Have adequate respiratory function and stable vital signs Meet their preprocedural LOC, and return to their preprocedural status Have their pain under control, and site stable without evidence of bleeding Not be discharged for 20-30 minutes after last medication, longer if reversal agents given Be discharged to a responsible driver and advised not to drive or use heavy machinery for at least 24 hours Receive post-procedural written discharge instructions Verbalize understanding of instructions and education (and/or responsible caregiver)

Patient Safety Special Considerations Patient Special Considerations Elderly patient’s may need more time for monitoring Ensure a good intact gag reflex especially in children Evaluate each INDIVIDUAL patient based on a number of considerations, not just meeting these outline criteria Document time patient leaves the facility

PROCEDURAL SEDATION POST TEST

Procedural Sedation Post Test 1. Which treatment is an example of procedural sedation? A. Preventing anxiety prior to treatment without altering the patient’s level of consciousness. B. Providing comfort measures to the patient. C. Performing a simple dressing change. D. Administering medication to alter the level of consciousness prior to a procedure. 2. A Physician prescribes a one-time dose of Morphine and Ativan to reduce the patient’s pain and anxiety during a dressing change. This is considered procedural sedation. A. True B. False

Procedural Sedation Post Test 3. To prepare for procedural sedation, the RN must: A. Obtain patient consent for both the procedure and the sedation. B. Confirm auscultation of heart, lungs, and airway assessment was performed by MD C. Be aware of sedation plan D. Perform patient identification and a “Time-Out” E. Perform a baseline PASS assessment. F. All of the above 4. To perform procedural sedation, the RN must: A. Have age-specific resuscitative equipment. B. Have a physician privileged in Procedural Sedation present in the room. C. Receive age specific advanced life support certification. D. Provide a cardiac monitor, O2 monitoring, and ET CO2 monitoring. E. Follow all of the above.

Procedural Sedation Post Test 5. When performing procedural sedation, it is satisfactory to have the physician be available by pager during the procedure. A. True B. False 6. The nurse providing moderate sedation should remain with the patient at all times. 7. Before a procedural sedation patient can be discharged, they need to be observed for a minimum of 30 minutes after the last dose of sedative or analgesic was administered. Longer periods of observation are required if reversal agents are used.

Procedural Sedation Post Test 8. To discharge a patient following procedural sedation, a post-procedural assessment must be conducted (by a credentialed practitioner privileged in this procedure), the patient needs to receive written discharge instructions, and a responsible adult/driver must be identified. A. True B. False 9. A “time-out” is performed prior to the start of the procedure and typically includes: A. A description of the nature of the procedure, the patient’s condition, details of any abnormal history or condition, and any special patient needs. B. Use of two patient identifiers – patient name and medical record on arm band. C. Verification of the site, both physically and verbally, and if required, marking of the site. D. A review of the expected course of the procedure and recovery. E. All of the above

Procedural Sedation Post Test 10. Development of chest wall rigidity (“wooden chest”) may result in serious respiratory compromise and is most often seen with the rapid administration of: A. Fentanyl (Sublimaze) B. Morphine C. Ketamine (Ketalar) D. Flumazenil (Romazicon) 11. The reversal agent and initial dose preferred for a 300-pound 18 year-old who has had Diazepam, Midazolam, and Lorazepam during a procedure is: A. Flumazenil (Romazicon) 0.2 mg, repeat every 1-2 minutes as needed B. Naloxone (Narcan) 0.4 mg, repeat every 2-3 minutes as needed C. Both a and b

Procedural Sedation Post Test 12. During conscious sedation, vital signs and oxygenation status are recorded at least every ______ minutes. A. 1 B. 5 C. 15 13. To verify a physician’s privileges to perform procedural sedation: A. Call the house supervisor B. Go to the Kaiser Permanente Credentialing web site C. Call the MD to see if they are privileged 14. Complications of procedural sedation can include: A. Abnormal cardiac function and deterioration B. Hypoventilation and allergic or reverse reaction C. Hypoventilation, allergic or adverse reaction, abnormal cardiac function, and deterioration in mental status

Procedural Sedation Post Test 15. A 60 year-old male patient with coronary artery disease undergoes a pacemaker implant under IV sedation. During the procedure, the patient’s oxygen saturation decreases to 84%. The patient is snoring and responds to vigorous stimulation. You should: A. Lift the chin and jaw, attempt to provide a better airway, notify the physician immediately after the change in the patient's condition, increase oxygen delivery, call for assistance and consider reversal agents. B. Continue to monitor for further changes; reduce the next dose of sedation medication by half. C. Document the patient's status on the assessment form; notify the MD at the conclusion of the procedure.

Procedural Sedation Post Test 16. After receiving Morphine and Valium for sedation and analgesia, your patient loses consciousness and becomes dusky in appearance, and the oxygen saturation decreases rapidly from 95% to 75%. What is the appropriate nursing action? A. Ambu bag delivery of oxygen B. Nasal cannula delivery of oxygen C. Be ready to give IV Narcan and Romazicon D. A and C 17. During a procedure in which you are administering procedural sedation, respirations suddenly become stridorous and you notice a red rash occurs on the patient’s hands. The appropriate nursing action is to: A. Intubate B. Do nothing C. Stop the medication and treat per the physician’s order D. Call a code blue

Procedural Sedation Post Test 18. Emergency equipment which must be immediately accessible during IV sedation includes: A. Emergency cart with defibrillator, cardiac monitor, airways, bag-valve mask, and intubation equipment, including ET CO2 monitor B. Emergency drugs including reversal agents C. Oxygen and suction with tubing D. All of the above 19. The reversal agent and initial dose preferred for a 44-pound (20-kg) child who has had Morphine during a procedure is: A. Flumazenil (Romazicon) 0.1 mg – 0.2 mg B. Naloxone (Narcan) 0.01 mg/kg C. None of the above

Procedural Sedation Post Test 20. A patient whose PASS score is “1” for consciousness is: A. Presumed to be moderately sedated B. Presumed to be minimally sedated C. Presumed to be deeply sedated