Conscious Sedation 台中榮民總醫院 台中榮民總醫院 內科部 加護中心 內科部 加護中心 李博仁醫師 李博仁醫師

Case Presentation Case Presentation 吳 xx, 74 year-old age man. C.C: PET whole body scan:The 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 S-SCOPE + BX: 91/06/27 unpleasant

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; 49: Early DS:Patient attitudes toward undergoing colonoscopy without sedation. Am J Gastroenterol 1999; 94:

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; 49: Rex DK: Patients willing to try endoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc 1999; 49:

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 AspirationOversedationHypoventilation Vasovagal episodes Airway obstruction Rankin GB. Indications, contraindications and complications of colonoscopy. In Gastroenterologic Endoscopy 1989

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

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

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.

Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia

Non-Anest Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists hesiologists Anesthesiology 2002; 96:1004–17

Who Can Administer Conscious Sedation? Qualified providers Certified Registered Nurse Anesthetists (CRNAs) AnesthesiologistsPhysiciansDentists Oral surgeons are qualified providers of conscious sedation

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 )

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.

Preprocedure evaluation Patient Evaluation strongly agree:history, 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

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

Problems with sedation (sedation and procedure-related complications ) DesaturationArrhythmias 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; 45:1-9 Alcain G, Guillen P. Predictive factors of oxygen desaturation during upper gastrointestinal endoscopy in nonsedated patients. Gastrointest Endosc 1998; 48:

Airway Assessment Procedures for Sedation and Analgesia

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 OxygenationHemodynamics

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

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

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 “beep”alarms Supplemental Oxygen

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

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

Emergency Equipment for Sedation and Analgesia (1)

Emergency Equipment for Sedation and Analgesia (2)

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

Training of Personnel Strongly agree :education and training (1) potentiation of sedative-induced respiratory depression by concomitantly administered opioids 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

Combinations of Sedative– Analgesic Agents Equivocal regarding :moderate sedation Deep sedation, satisfactory: Intravenous combinations of sedative–analgesic 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

Drugs used in conscious sedation for endoscopy

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% mg given slowly intravenously repeating doses every 2 to 3 minutes total dose is 2.5 to 5 mg

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

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) 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, 1983;Wille et al., 2000) Many endoscopists prefer midazolam for conscious sedation because it has short duration of action and efficient amnesic effect (Whitwam, Al-Khudhairi, & McCloy, 1983;Wille 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

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

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

Reversal Agents Naloxone and flumazenil available whenever opioids or benzodiazepines administered

Special Considerations * Age >60 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

Recovery Criteria after Sedation and 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

Recovery Criteria after Sedation and 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

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.

Discharge criteria after sedation

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. (A), Prospective controlled trials. (B), Observational studies. (B), Observational studies. (C), Expert opinion (C), Expert opinion

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