1. Moderate Sedation & Analgesia
Lesson 1: Introduction
Lesson 2: The Sedation Continuum
Lesson 3: Guidelines & Regulations
Erlinda C. Oracion, M.D., D.P.B.A
Department of Anesthesiology

2. Introduction
Welcome to the introductory lesson on moderate sedation/analgesia . This lesson gives the course rationale, goals, and outline.

3. We watch while you sleep…
And because our patients are our partners…..
We watch while you sleep…

4. Course Rationale
Sedation and anesthesia are important risk factors for morbidity and mortality during procedures.
Giving sedation safely is critical to:
Help prevent negative outcomes
Comply with regulations

5. Course Rationale This course will teach you:
How moderate sedation relates to other types of anesthetic services, and how this relates to patient safety
How The Joint Commission expects accredited facilities to manage moderate sedation

6. Course Goals After completing this course, you should be able to:
List the levels of the continuum of sedation
Identify key features of each level
Recognize the significance of the continuum for sedation safety
List the Joint Commission standards for moderate sedation
Identify key requirements of each standard

7. Over the last 15 years…
Administration of sedatives and analgesics for performance of procedures is a significant independent risk factor for morbidity and mortality both inside and outside the OR.

8. Although sedation is often offered as “safer than general anesthesia”,
this may not be altogether correct.
1984- Natof studied 40 ambulatory centers (87,492 patients)
Complications 1: 106 (LA with sedation) vs 1:120 (GA)

9. Gastroenterology literature Walker JA.Am J Gastroent 2003;98:1744-50
NAPS (Nurse Administered Propofol Sedation)
2000 patients- GI endoscopies (ASA 1 and 2)
3- laryngospam
11 desaturated <90% spO2 despite 4L/min O2
4 desaturated <85% spO2, were assumed apneic

10. Course Outline Lesson 1 provided the course rationale and goals
will describe the sedation continuum
Lesson 3
will list and explain the Joint Commission standards for moderate sedation

11. LESSON 2: THE SEDATION CONTINUUM

12. After completing this lesson, you should be able to:
List the levels of the sedation continuum
Identify key features of each level
Recognize the significance of the sedation continuum

13. The Sedation Continuum
Moderate sedation is on a continuum with other levels of sedation.
The levels on this continuum are:
Minimal sedation (anxiolysis )
Moderate sedation/analgesia (formerly “conscious sedation”)
Deep sedation/analgesia
General Anesthesia
Let’s take a closer look at each level on the following screens

14. Minimal Sedation: Anxiolysis
Minimal sedation is also called anxiolysis.
In this drug-induced state:
The patient feels relaxed .
The patient responds normally to speech.
Thinking and coordination may be affected.
Breathing and heart function are not affected

15. Moderate Sedation & Analgesia
In this drug-induced state:
The patient has depression of consciousness
The patient will respond purposefully to spoken words, or spoken words with a light touch.
The airway remains patent without help.
The patient’s breathing is adequate.
Heart function is usually maintained.
“Moderate sedation/analgesia” was called “conscious sedation.”
For this definition, “purposeful” movement does not include reflex movement away from pain.

16. Deep Sedation/Analgesia
Deep Sedation/Analgesia is the next level on the continuum.
In this drug-induced state:
The patient has depression of consciousness and is difficult to awaken.
The patient will respond purposefully to repeated or painful stimulation. Reflex movement away from pain is not “purposeful”.
The patient may need help to keep the airway open.
The patient’s own breathing may not be adequate.
Heart function is usually maintained.

17. General Anesthesia General Anesthesia is the deepest form of sedation.
In this drug-induced state:
The patient loses consciousness.
The patient cannot be awakened, even by painful stimuli.
The patient often needs assistance maintaining the airway and ventilation. This often requires positive pressure ventilation.
Heart function may be impaired.

18. Levels of Sedation GENERAL ANESTHESIA MINIMAL DEEP SEDATION MODERATE
-anxiolysis
MODERATE
SEDATION
-conscious sedation

19. The Sedation Continuum: Summary
This table summarizes the sedation continuum.
Continuum of Depth of Sedation
Minimal
Sedation
(anxiolysis)
Moderate
Sedation/
Analgesia
Deep Sedation/
General
Anesthesia
Responsiveness
Normal response to speech
Purposeful response to speech or touch
Purposeful response to repeated or painful stimulation
No response, even to pain
Airway
Unaffected
Remains open
May need help to maintain airway
Often needs help to maintain airway
Breathing
Adequate
May not be adequate
Often require ventilatory support
Heart Function
Usually maintained
May be impaired

20. Levels of Anesthesia and Sedation- Minimal Sedation (Anxiolysis)
A drug induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

21. Levels of Anesthesia and Sedation- Moderate Sedation/Analgesia
(conscious sedation): a drug-induced depression of consciousness during which the patients 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.

22. Levels of Anesthesia and Sedation- Deep Sedation/ Analgesia
is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.
The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.

23. Levels of Anesthesia and Sedation- General Anesthesia
A drug-induced loss of consciousness- patients not arousable, even by painful stimulation.
Ability to maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of a depressed spontaneous ventilation or drug-induced depression of neuromuscular function.
Cardiovascular function may be impaired.

24. Levels of Sedation GENERAL ANESTHESIA MINIMAL DEEP SEDATION MODERATE
-anxiolysis
MODERATE
SEDATION
-conscious sedation

25. Monitored Anesthesia Care (MAC)
MAC does not describe the continuum of depth of sedation;
“a specific anesthesia service in which an anesthesia provider has been requested to participate in the care of the patient undergoing a diagnostic/ therapeutic procedure.”

26. Sedation is a continuum- not always possible to predict how an individual patient will respond.
Skill required  ability to rescue from deep sedation levels
Because sedation is a continuum, it is not always possible to predict how an individual patient will respond.
Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended.

27. The Sedation Continuum: Summary
This table summarizes the sedation continuum.
Continuum of Depth of Sedation
Minimal
Sedation
(anxiolysis)
Moderate
Sedation/
Analgesia
Deep Sedation/
General
Anesthesia
Responsiveness
Normal response to speech
Purposeful response to speech or touch
Purposeful response to repeated or painful stimulation
No response, even to pain
Airway
Unaffected
Remains open
May need help to maintain airway
Often needs help to maintain airway
Breathing
Adequate
May not be adequate
Often require ventilatory support
Heart Function
Usually maintained
May be impaired

28. Significance of the Continuum
Why is it important to understand the continuum of sedation? Because sedation is a continuum, the response of any one patient may be unpredictable.
For example, a patient may be moderately sedated for a procedure. However, the patient may respond to the drug in an unexpected way, and enter a state of deep sedation instead.

29. Significance of the Continuum
Why is it important to understand the continuum of sedation? A moderately sedated patient may progress to deep sedation. Therefore, moderate sedation must be monitored just as carefully as deep sedation and anesthesia.
This is the rationale for many of the regulations related to moderate sedation. Moderate sedation does not usually put a patient’s breathing or heart function at risk. But a moderately sedated patient may progress to deep sedation.

30. Review The best description of “moderate sedation” is:
A risk-free treatment
A point on the continuum of sedation
A lesser form of sedation than “minimal sedation”
A treatment entirely different from general anesthesia
MULTIPLE CHOICE INTERACTION
Correct: B
A: Incorrect. Moderate sedation is not risk-free. The correct answer is B.
B: Correct
C: Incorrect. Moderate sedation is deeper than minimal sedation. The correct answer is B.
D: Incorrect. Moderate sedation and general anesthesia are both points on the continuum of sedation. The correct answer is B.

31. Summary You have completed the lesson on the sedation continuum.
Remember:
Moderate sedation is a point on a continuum. It falls between minimal sedation and deep sedation.
Because sedation is a continuum, the response of any patient is individual and may be unpredictable.

32. Moderate sedation/ analgesia
Minimal sedation
(anxiolysis)
Moderate sedation/ analgesia
(conscious sedation)
Deep sedation/
analgesia
General Anesthesia
Administering clinicians
RN, Physicians
Sedation trained RN, Credentialed physicians
Anesthesiologist only
Responsiveness
Normal response to verbal stimulation
Purposeful** response to verbal or tactile stimulation
Purposeful** response following repeated or painful stimulation
Unarousable even with painful stimulus
Airway
Unaffected
No intervention required
Intervention may be required
Intervention often required
Spontaneous ventilation
Adequate
May be inadequate
Frequently inadequate
Cardiovascular function
Usually maintained
May be impaired

33. Objectives of Moderate Sedation
Blunting of anxiety and fear
Elicit cooperation from the patient
Afford amnesia for the patient
Increase the pain threshold

34. Individuals administering Moderate Sedation/Analgesia (“Conscious Sedation”)
should be able to -rescue a patient who enters a state of deep sedation -manage a compromised airway -provide adequate oxygenation and ventilation

35. Lesson 3: Guidelines & Regulations

36. Introduction & Objectives
Welcome to the lesson on guidelines and regulations.
After completing this lesson, you should be able to:
List the The Joint Commission standards related to moderate sedation
Identify key requirements of each standard

37. JCAHO COMPARABLE CARE MANDATE
"conscious sedation" for non-operating room procedures represents a dynamic continuum significantly overlapping monitored anesthesia care (MAC), this implies that such areas must have processes
presedation assessment,
intraprocedure monitoring,
discharge criteria,
facilities, equipment, and personnel similar to those utilized for MAC delivered by qualified anesthesia providers.

38. JCAHO COMPARABLE CARE MANDATE
mandates that sedation practices throughout the hospital be "monitored and evaluated by the Department of Anesthesiology"

39. Question: Does the person administering sedation have to be qualified to monitor the patient if other staff who are present are qualified?
Standard PC states, “Sufficient numbers of qualified staff (in addition to the individual performing the procedure) are present…” to evaluate, monitor, administer medication, assist with the procedure if needed and recover the patient.

40. The Joint Commission Standards
The Joint Commission has several standards for anesthesia services, including moderate sedation.
For Moderate sedation, these standards are:
Moderate sedation must be given by a qualified provider.
Patients who will receive moderate sedation must be assessed ahead of time.
Sedation options and risks must be discussed with the patient and family prior to the sedation/procedure.

41. The Joint Commission Standards
For Moderate sedation, these standards are:
The patient must be re-assessed immediately before the sedation is given.
The patient’s oxygenation, ventilation and circulation must be monitored during sedation.
The patient must be assessed in the post-sedation recovery area before discharge.
A qualified provider must discharge the patient from the post-sedation recovery area, or discharge must be based on established criteria .

42. Pre-sedation Assessment (1)
All patients must be assessed before sedation. Hospitals with obstetric or emergency services should be able to perform an assessment quickly. These hospitals should be able to gather enough information to give moderate sedation safely within 30 minutes after deciding to sedate the patient. The patient must give informed consent before moderate sedation can be administered.

43. Pre-Sedation Assessment (2)
The pre-sedation assessment should include information about the procedure and the patient.
The Assessment should include:
Indication for the procedure
Determination that the patient is an appropriate candidate for sedation and the procedure

44. Pre-Sedation Assessment (2)
The Pre-sedation assessment should also include:
Patient history—should include:
Allergies or adverse drug events
Prior sedative or anesthesia experiences
Potential for pregnancy

45. Pre-Sedation Assessment (2)
Pre-sedation assessment should also include:
Physical History—should include:
Baseline vital signs and oxygen saturation
Weight
Airway status
Appropriate fasting interval
Aspiration risk factors
Status of cardiac, pulmonary, and neurologic systems
Mental status and level of consciousness
Appropriate lab tests
ASA status

46. Pre-Sedation Assessment (3)
The patient’s ASA status should be determined.
The ASA describe five physical status classes:
ASA Class I – A normal healthy patient.
ASA Class II – A patient with mild systemic disease.
ASA Class III – A patient with severe systemic disease.
ASA Class IV - A patient with severe systemic disease that is a constant threat to life.
ASA Class V – A moribund patient who is not expected to survive without the operation.
ASA Class VI – A declared brain-dead patient whose organs are being removed for donor purposes.
An “E: is added to status number to designate an emergency operation
An organ donor is usually designated as Class 6

47. Pre-Sedation Assessment (3)
Patients in ASA classes I and II can be given moderate sedation. Medical consultation is suggested for class III patients. Patients in ASA classes IV and V should not be given moderate sedation by a non anesthesia provider.

48. Pre-sedation Assessment (4)
Conditions that will affect the use of moderate sedation:
Indication for the procedure
Altered mental status
Atypical airway anatomy
Obesity
Pregnancy
Sleep apnea
Current medications
Substance abuse
Cardiovascular disease
Respiratory disease
Liver disease
Kidney disease
Central nervous system dysfunction

49. Discussion of Options & Risks
Sedation options and risks may be discussed with the patient and family before giving moderate sedation. Patients must give informed consent for any treatment. This includes moderate sedation. Part of informed consent is a full understanding of the options and risks of treatment. Discussing the sedation procedure ahead of time can also help calm patient fears.

50. Discussion of Options & Risks
Patient education also should include information on:
Resuming activity
Consciousness checks
Dietary restrictions
When medications can be resumed
Potential post-procedural complications
Whom to contact for questions for help

51. Sedation Care Plan
The moderate sedation of each patient must be carefully planned.
The Plan of Care should:
Take into account the physical status of the patient (ASA class)
Meet any other patient needs identified during the pre-sedation assessment

52. Sedation Care Plan All providers should be informed of:
The patient’s care needs
The sedation plan of care
The patient should be assessed again
immediately before moderate sedation
is given.

53. Question: Are specific privileges to administer moderate sedation required?
Standard PC EP 4 states that “Individuals monitoring moderate or deep sedation are qualified and have the appropriate credentials to manage patients whatever level of sedation or anesthesia is achieved…”

54. Qualified Provider (1)
The qualified provider requirement covers the training and credentials of the provider who gives moderate sedation.
A provider “qualified” to give moderate sedation must be trained in:
How to evaluate patients before sedation
How to give drugs for moderate sedation
How to monitor patients to keep them moderately sedated
How to “rescue” patients from deep sedation

55. Qualified Provider (1)
The ability to “rescue” patients from deep sedation includes training in:
How to manage an airway
How to give oxygen and ventilation
How to deliver appropriate reversal agents

56. Qualified Provider (2)
“Rescue” of patients from sedation may also include the use of “reversal drugs.” Patients given reversal drugs must be monitored. Seizures or other heart and nervous system problems may occur. Note: The effect of the reversal drug may wear off before the effect of the sedating drug. Extended monitoring will be needed.

57. Qualified Provider (3)
Moderate sedation procedures are performed by a licensed independent practitioner (LIP) The qualified provider requirement also covers the number of personnel during a procedure.

58. Qualified Provider (3)
In addition to the LIP, there must be enough other qualified personnel to:
Evaluate the patient before the sedation
Give the sedation
Perform the procedure
Monitor the patient
Recover and discharge the patient

59. Monitoring
Patients must be monitored during moderate sedation. The person monitoring the patient can not have additional assignments. Physiological monitoring is the only way to ensure that patients get the supportive treatment they need.

60. Mandatory equipment Cardiac monitor Pulse oximeter
Medications for sedation and reversal of effect
Blood pressure determination unit
Oxygen source and administration equipment
Bag-valve-mask
Standard emergency equipment and drugs for resuscitation
Defibrillator
Suction machine
Stethoscope

61. Monitoring The following need to be monitored in some or all patients:
Heart rate and oxygenation—should be continuously monitored by pulse oximetry.
Respiratory rate--& pulmonary ventilation should be continuously monitored
Blood pressure—should be measured at regular intervals.
EKG—should be monitored:
If the patient has significant cardiovascular disease
If cardiac arrhythmias are expected or detected.

62. Post-Sedation Assessment & Discharge
Data from monitoring must be recorded in the patient’s medical record.
After moderate sedation, patients must be:
Assessed in the post-sedation recovery area
Discharged by a qualified LIP or according to established criteria
Discharged home with a responsible adult
Meeting discharge criteria should be documented
in the medical record.

63. Review MULTIPLE CHOICE INTERACTION
A provider qualified to give moderate sedation is trained in:
How to evaluate patients before sedation
How to rescue patients from deep sedation
How to give drugs to achieve moderate sedation
How to monitor patients to keep them moderately sedated
All the above
Correct: E
A: Not quite. The best answer is E. A qualified provider is trained in all these areas
B: Not quite. The best answer is E. A qualified provider is trained in all these areas
C: Not quite. The best answer is E. A qualified provider is trained in all these areas
D: Not quite. The best answer is E. A qualified provider is trained in all these areas
E: Correct.

64. Review MULTIPLE CHOICE INTERACTION
The physical status of a patient with well-controlled hypertension would be:
ASA class I
ASA class II
ASA class III
ASA class IV
ASA class V
Correct: B
A: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.
B: Correct. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.
C: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.
D: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.
E: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.

65. Summary
Remember:
Patients must be assessed before moderate sedation. ASA class should be determined
Sedation options and risks must be discussed with each patient.
A sedation care plan must be developed for each patient.
You have completed the lesson on guidelines and regulations.

66. Summary
Remember:
Moderate sedation must be given by a qualified provider.
Patients must be monitored during sedation.
Patients must be assessed after sedation.
Note: They may be discharged from the post-sedation recovery area only by a qualified LIP or according to established criteria.
You have completed the lesson on guidelines and regulations.

67. [Moderate Sedation] Course Glossary # Term Definition 1. Analgesia
Pain relief 2.
Anxiolysis
The use of drugs to lessen anxiety without lessening awareness 3.
Apnea
Not breathing 4.
ASA
American Association of Anesthesiologists 5.
Continuum
On a scale progressing from the smallest to the greatest amount 6.
Criteria
Standards or measures used to make a judgment or decision 7.
The Joint Commission
Joint Commission of the Accreditation of Healthcare Organizations 8.
Positive pressure ventilation
Artificial breathing using positive pressure to maintain inflation of the lungs 9.
Reversal drugs
Drugs that neutralize the effects of the drugs used to sedate the patient
10.
Sedation
Sleepiness, or the act of cause sleepiness

68. Objectives completed List the levels of the continuum of sedation
Identify key features of each level
Recognize the significance of the continuum for sedation safety
List the Joint Commission standards for moderate sedation
Identify key requirements of each standard

69. THANK YOU FOR YOUR ATTENTION!