1. . Moderate Sedation Annual Review 2009

2. . Objectives At the end of this review, the learner will be able to: 1. State the definition of Moderate Sedation (MS) 2. List the patient parameters that must be maintained that distinguish MS from deep sedation or general anesthesia 3. List the responsibilities of the Registered Nurse in the administration and monitoring of MS

3. . Note: The following information is based on Kaleida Health policy #CL.4: Moderate Sedation for Operative and Invasive Procedures (revised 5/05).

4. . Use of Moderate Sedation Some of the procedures that are commonly performed under moderate sedation include the following: Angiography Bronchoscopy Synchronized cardioversion Endoscopy ED procedures EP Studies Lab procedures

5. . IMPORTANT!! Per policy CL.46. All female patients age 9 (nine) and older must have a negative pregnancy test unless menopausal surgically menopausal, or currently pregnant. Before proceeding with moderate sedation....Is your patient pregnant?

6. . IMPORTANT The medications used to cause moderate sedation have been shown to have adverse affects on the fetus!! BEFORE THE PROCEDURE IS STARTED. All female patients 9-years-old or older, that are not menopausal, MUST HAVE HCG TESTING DONE AND NEGATIVE RESULTS RECEIVED BEFORE THE PROCEDURE IS STARTED.

7. . Moderate Sedation Moderate Sedation is a drug induced depression of consciousness during which: A. patients respond purposefully to verbal commands B. patients respond to light tactile stimulation C. cardiovascular function is maintained D. no interventions are required to maintain a patent airway E. spontaneous ventilation is adequate F. continual clinical observation of patient’s physiologic variables is maintained: pulse, O 2 saturation, level of consciousness, blood pressure, and respirations.

8. . Caution!! While the ultimate goal of Moderate Sedation is minimal depression of consciousness during which the patient maintains his/her own airway, it is easy to produce unconsciousness due to: Increased potency and quicker onset times of newer agents used Inconsistencies in patient response to sedatives and analgesics Use of multiple sedative and analgesic agents in combination, which increases the level of sedation and complication rate.

9. . During procedure assess patient for signs of Deep Sedation, and be ready to handle possible complications. Deep sedation manifests as: Severely slurred speech Unresponsiveness Unconsciousness Deep sedation is related to complications of : Cardiopulmonary depression Hypercarbia Delayed recovery

10. . Moderate Sedation Review Part 1: The Procedure

11. . The Procedure 1. Monitoring: The Healthcare provider monitoring the patient and documenting during the procedure may not:  perform the procedure  participate in the performance of the procedure  have other responsibilities besides monitoring and documenting the patient during the procedure.

12. . The Procedure--monitoring During procedure, parameters must be monitored every 5 minutes:  respiratory rate  oxygen saturation (must have audible tone and alarm on oximeter during procedure)  blood pressure  pulse rate AND…

13. . The Procedure—monitoring  level of sedation, based on sedation scale (See next column) Sedation Scale Scale Patient Condition 1 Awake, verbalizes, cooperative 2 Drowsy, but awake; may have eyes open or temporarily closed; can communicate verbally. 3 Eyes closed; mimics sleep behaviorally and physiologically; arousable with minimal or moderate stimuli 4 Sleep; arousable, with moderate to intense stimuli 5 Sleep/non-arousable; loss of protective reflexes temporarily

14. . Procedural Equipment: minimal Must be available in room where procedure is being performed:  blood pressure monitor and stethoscope  pulse oximeter  oxygen source and delivery system (e.g. nasal cannula)  suction source and suction equipment  bag/mask/valve device (Ambu bag) with reservoir and tubing  IV supplies  Airways, in sizes appropriate to patient age and size  Appropriate reversal agent for medication being administered (e.g., Romazicon®, Narcan®)

15. . Procedural Equipment: emergency  Emergency cart with defibrillator  Emergency intubation equipment

16. . Medication Administration Medications should be given: 1. in an amount necessary to render the patient calm, cooperative, able to follow commands 2. according to Corporate medication policies

17. . Medication administration IMPORTANT: When additional medication is ordered for sedation after the initial dose has been administered The cumulative TOTAL dose will be communicated AUDIBLY to the ordering practitioner (Example: “I have just given 1mg Versed which makes a total dose of 2 mg given.”)

18. . Documentation During the procedure all of the following must be documented on the flowsheet EVERY 5 minutes : Pulse rate O 2 saturation Blood pressure Respiratory rate, quality, and effort* Level of sedation* Assessment of patient status after administration of medications Interventions, and patient response to interventions. *Appropriate documentation keys should be used

19. . Example of documentation grid on MS flowsheet

20. . Example of documentation keys

21. . Post-Procedural Observation To be done every 15 minutes for a minimum of 30 minutes and will include: 1. Pulse rate 2. O 2 saturation 3. Blood pressure 4. Respiratory rate 5. Level of sedation 6. Effectiveness of pain control NOTE: Baseline oxygen saturation must be maintained for at least 15 minutes before discharge.

22. . Remember! The Physician or dentist must be present in the procedure area until the patient has returned to:  a sedation level of 2 OR  pre-sedation baseline, if that level was greater than 2

23. . If a reversal agent is used: * post-procedure observation will be maintained for a minimum of 90 minutes from the time of administration of reversal agent.

24. . Documentation—post- procedural

25. . Reportable conditions Document and bring to the attention of the physician/dentist: a. Use of reversal agent b. Persistent oxygen saturation less than: 92% in patients over 12 years of age, or as specified by responsible physician/dentist 94% in patients under 12 years of age or as specified by responsible physician/dentist c. Any signs/symptoms of respiratory distress or manual manipulation of airway. d. Persistent change* in heart rate of + 20% from admission baseline e. Persistent change* in blood pressure of + 20% from admission baseline f. Agitation or combativeness *NOTE: Persistent changes in vital signs or O 2 saturation will be reported after two consecutive abnormal readings.

26. . Discharge Criteria a. Discharge of an outpatient from the procedure area will not occur until:  the patient is awake and has normal vital signs, and has returned to pre-sedation baseline  the patient or responsible person is provided with verbal and written instructions

27. . Discharge Criteria-continued Discharge of an inpatient will not occur until:  a responsible person is given written/verbal report  post-procedure report is given to the unit receiving the patient with documentation of the name of the person receiving the report.

28. . Documentation—discharge criteria