1. Implementing a Successful Sedation Program Elizabeth Wong, CRNA (nurse anes-the-tist) Elizabeth Wong, CRNA (nurse anes-the-tist)

2. Learning Objectives Define Anesthesia. Summarize what are the stages of anesthesia and how they differ from natural sleep. Compare and contrast the 4 types of anesthesia. Explain the components of the anesthesia continuum and who or what can safely deliver sedation.

3. Definition of Anesthesia  Anesthesia is the partial or complete loss of sensation, with or without loss of consciousness, that occurs on a temporary or permanent basis, as a result of disease, injury, or due to the administration of an anesthetic agent, usually by inhalation or injection.  Taber’s Cyclopedic Medical Dictionary, 18th edition, 1997. F. A Davis Co.

4. Four Types of Anesthesia  Local Anesthesia  Regional Anesthesia  Sedation  General Anesthesia

5. Local Anesthesia  Local anesthesia is used to provide loss of sensation to an area or locale of the body using local anesthetics such as lidocaine or bupivacaine.

6. Regional Anesthesia  Regional anesthesia is used to provide loss of sensation to a large section or region of the body using local anesthetics such as lidocaine or bupivacaine.

7. Types of Regional Anesthesia  Interscalene Block (shoulder & arm)  Axillary Block (elbow & lower arm)  Bier Block (lower arm)  Spinal Block (lower half of body)  Epidural Block (thoracic & lumbar)  Ankle Block  Field Block (hernia repair or breast biopsy)

8. Conscious Sedation  Sedation refers to the administration of sedatives, hypnotics, or narcotics in an effort to produce sedation (allay nervous excitement), amnesia, and/or analgesia.

9. Methods for Conscious Sedation  Medications for sedation can be administered via the intravenous, oral, or rectal routes.

10. Who is a Candidate for Sedation? Risk Classification (co-morbidities)Risk Classification (co-morbidities) NPO Status (fasting status)NPO Status (fasting status) Type of Surgery they will undergoType of Surgery they will undergo

11. Anesthesia Continuum Sedation occurs on aSedation occurs on a continuumcontinuum Awake Minimum Sedation Moderate Sedation Deep Sedation GeneralAnesthesia

12. End Point  The end point of the conscious sedation continuum is slurred speech and nystagmus (constant, involuntary, jerky movement of the eyeball). Courtesy: imagesmd.com

13. Indications for Sedation  Type of surgery or procedure  Patient cooperation  Anxious patient  Can be given in combination with local anesthesia or regional anesthesia

14. Contraindications for Sedation  Patient refusal  Uncooperative patient  Patient with communication difficulties (hard of hearing, deaf, language barriers)

15. Complications of Sedation  Allergic reaction to medication  Seizures  Bradycardia  Cardiovascular collapse  Need to progress to general anesthesia

16. General Anesthesia  General anesthesia is the act of complete loss of consciousness and loss of protective airway reflexes following the use of anesthetics that effect the brain. Awake Minimum Sedation Moderate Sedation Deep Sedation GeneralAnesthesia

17. Important Considerations in Sedation  Knowledge of the depth of anesthesia  Knowledge of the location of emergency drugs, suction, oxygen  Maintenance of NPO status  Assist in the conversion of sedation to general anesthesia

18. Natural Sleep  Natural sleep is a condition that is characterized by willful loss of consciousness that is accompanied by reduced cortical and physical activity.  Courtesy: auburn.edu

19. Natural Sleep versus General Anesthesia  Sleep  Amnesia  Unconscious  Spontaneous breath  Relaxed muscles  Self-maintained hemodynamics and airway reflexes  Easily aroused General Anesthesia General Anesthesia  Amnesia  Unsconscious  +/- Spon. Breathing  Relaxed muscles  +/- self-maintained hemodynamics  Loss of airway reflexes  Not arousable

20. Early versus Modern Anesthesia Balanced Anesthesia Amnesia Sedatives or General Anesthetics Narcotics Neuromuscular Blocking Agents

21. Anesthesia Care Plan Knowledge of the patient (preop eval) Knowledge of the surgeonKnowledge of the surgeon Knowledge of the surgeryKnowledge of the surgery Knowledge of nurse anesthesiaKnowledge of nurse anesthesia Knowledge of the anestheticsKnowledge of the anesthetics __________________________________________________ Anesthesia Care PlanAnesthesia Care Plan

22. Healthcare Professionals That Provide Sedation or General Anesthesia Registered Nurses (Conscious Sedation only) Certified Registered Nurse Anesthetists (CRNAs) Medical Doctors (MDs - Anesthesiologists) Doctors of Osteopathy (DOs - Anesthesiologists) Dental Anesthesiologists (dental offices only)

23. Propofol vs Midazolam Sedation Propofol for sedation during colonoscopy: A survey of a Cochrane review. Vilmann et al.Propofol for sedation during colonoscopy: A survey of a Cochrane review. Vilmann et al. Faster patient recovery, higher patient satisfaction, and unchanged complication rate compared to traditional sedativesFaster patient recovery, higher patient satisfaction, and unchanged complication rate compared to traditional sedatives Propofol vs. traditional sedative agents for GI endoscopy: a meta-analysis. Clinical Gastroenterology and Hepatology. Qadeer et al.Propofol vs. traditional sedative agents for GI endoscopy: a meta-analysis. Clinical Gastroenterology and Hepatology. Qadeer et al. Propofol has lower odds of cardiopulmonary complications compared to traditional agents.Propofol has lower odds of cardiopulmonary complications compared to traditional agents.

24. RN Administered Propofol Sedation  Physician pressure  Surgery center/Office-based practice wanting to save money of anesthesia costs  Some insurers will not reimburse MAC  Anesthesia provider shortage

25. NAPS...NAPS... The California BRN has not issued a declaratory or advisory statement on NAPS

26. Nurse Administered Propofol Sedation (NAPS)  Propofol is usually not part of conscious sedation policy of hospitals.  Administration of propofol is beyond most Board of Nursing’s RN scope of practice.  In most states Propofol is a drug administered by trained anesthesia providers only (recommended guideline by manufacturers).  There is no reversal agents for propofol.

27. NAPS Study Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized controlled trial. Heuss et al. American Journal of Gastroenterology.Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized controlled trial. Heuss et al. American Journal of Gastroenterology. 114 patients, 22-90 years old114 patients, 22-90 years old visual analog scales followed patient anxiety, tolerability, pain, and satisfactionvisual analog scales followed patient anxiety, tolerability, pain, and satisfaction Conclusion: Higher doses of propofol given with higher associated costs in PC. Greater patient and endoscopist satisfaction with NAPS.Conclusion: Higher doses of propofol given with higher associated costs in PC. Greater patient and endoscopist satisfaction with NAPS.

28. Computer Assisted Propofol Sedation (CAPS) Type #1 March, 2008 -Ethicon Endo-Surgery (a subsidiary of J & J) submitted an application to the FDA for approval of Sedasys™

29. Computer Assisted Propofol Sedation (CAPS) Type #2 June 2008 - “McSleepy” introduced by researchers at McGill University

30. StudiesStudies CAPS sedation for upper endoscopy and colonoscopy: a comparative multicenter randomized study. Gastrointestinal Endoscopist. Pambianco et al.CAPS sedation for upper endoscopy and colonoscopy: a comparative multicenter randomized study. Gastrointestinal Endoscopist. Pambianco et al. 1000 patients were evaluated for oxygen desaturation, patient/clinician satisfaction, level of sedation, and recovery time in endoscopist/nurse vs CAPS.1000 patients were evaluated for oxygen desaturation, patient/clinician satisfaction, level of sedation, and recovery time in endoscopist/nurse vs CAPS. Conclusion: Sedasys system could provide an effective alternative to endoscopist/nurseConclusion: Sedasys system could provide an effective alternative to endoscopist/nurse

31. There is only one standard of care for anesthesia delivery regardless of who (or what) delivers it!! T There is only one standard of care for anesthesia delivery regardless of who (or what) delivers it!!

32. AcknowledgementAcknowledgement Sam Martinez, Administrator for Channel Islands Surgery Center, for inviting me to present this lecture at the annual CASA meeting!!Sam Martinez, Administrator for Channel Islands Surgery Center, for inviting me to present this lecture at the annual CASA meeting!! Donna Funke, CRNADonna Funke, CRNA California Association of Nurse Anesthetists Board of Directors. California Association of Nurse Anesthetists Board of Directors.