1. Procedural Sedation Lutheran Medical Centerv

2. 1. Definitions along the Sedation Continuum
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1. Definitions along the Sedation Continuum
Minimal Sedation “Anxiolysis”
Procedural Sedation “Conscious Sedation”
Deep Sedation
General Anesthesia
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
To verbal or tactile stimulation
Following repeated or painful stimulation No
Maybe
Adequate
May be inadequate
Usually maintained
Usually maintained
Specific differences: Procedural and Deep
Response?
Airway intervention required?
Ventilation?
Cardiovascular function?
for both

3. 2. Verification of Provider Credentials (prior to EVERY procedure even if the physician performed the procedure yesterday)
Call Medical Staff Services or the Hospital Supervisor if you cannot obtain this information
Login to the Portal (my.exempla.org)
Open the Delivering Care tab
Choose the Privileges link
Choose appropriate hospital from the dropdown list
Enter search criteria
Click Submit
Click the provider’s name to see:
Privileges granted
Suspension status
Other information
For more details concerning requirements for specific privileges:
Click the Medical Staff tab
Choose Privileges Sheets link in the top right corner of the page
Open the appropriate list to see further definitions of the privileges granted

4. 3a. Prerequisites tasks for the licensed independent practitioner (LIP)
History
Baseline Physical Examination
Upper Airway Assessment
ASA Score
Plan of Care – rationale for procedure and sedation plan
Informed Consent
COR status
Re-assessment – immediately before the administration of sedation
Discharge criteria

5. 3b. NPO Status Recommendations - Elective and Emergent Procedures
Age
More than 8 years
years
6 months to 3 years
Less than 6 months
Solids &
Non-Clear Liquids* Clear Liquids**
8 hours 4 hours
6 hours 3 hours
6 hours 2 hours
4 hours 2 hours
* Non-clear liquid = breast milk, formula
** Clear liquids = water, clear juices, black coffee and tea (no milk)
NPO status for emergent and urgent procedures is determined by:
patient’s status
procedural risk and type
degree of sedation anticipated

6. 4a. RN Responsibilities:
Acts under the direction of a credentialed Medical Staff Member
Reviews/completes pre-procedure & post-procedure assessment
Administers medications for sedation/analgesia
Monitors patient
Completes required documentation
Ensures patient/family education

7. 4a. Respiratory Therapist Responsibilities:
Acts under the direction of a credentialed Medical Staff Member
Completes required documentation
Ensures patient/family education

8. 4b. RN Qualifications / Requirements
Acts within hospital approved Scope of Practice
Has successfully completed:
Current Basic Life Support (BCLS)
Procedural Sedation Clinical Competency
Nursing Adult and Pediatric  RNS
Departmental Competencies as required
If Applicable, has successfully completed:
Advanced Cardiac Life Support (ACLS)
Neonatal Resuscitation Program (NRP)
Pediatric Advanced Life Support (PALS)

9. 4b. Respiratory Therapist Qualifications / Requirements
Acts within hospital approved Scope of Practice
Has successfully completed:
Current Basic Life Support (BCLS)
Procedural Sedation Clinical Competency
Departmental Competencies as required
If Applicable, has successfully completed:
Advanced Cardiac Life Support (ACLS)

10. 5. Needed supplies and equipment
Oxygen
a positive pressure system that is capable of administering > 90% Oxygen at a 15 liter per minute flow rate for > than one hour (2 E cylinders)
Face mask and/or nasal prongs
Pulse oximeter
Intravenous equipment
Blood pressure equipment
Bag valve mask (ambu)
Oral/Nasal airway
Defibrillator & Cardiac monitor
Suction equipment
Emergency Medications
Atropine and reversal agents (i.e. Narcan and Flumazenil)
Advanced airway management equipment
laryngoscope handles and blades
endotracheal tubes and stylets
On COR Cart

11. 6. Monitoring requirements
Parameter
During the Procedure
After the Procedure
Vital Signs: BP
Respiratory rate
Oxygen saturation
Heart rate
Every 15 min
At least 20 minutes after last dose of IV medication
and until discharge criteria are met,       OR
For at least 1 hour after the
last dose of a reversal agent
and until discharge criteria are met
Responsiveness to commands:
Richmond Agitation Sedation Scale
Pain:
Adult  1-10
Neonatal Neonatal Infant Pain Scale (NIPS)
As needed
After the procedure
Cardiac Monitoring:
If needed, staff with rhythm recognition skills must be present
The decision to monitor the cardiac rhythm is based on:
Clinical indicators, history of significant cardiac disease, likelihood that procedure might result in rhythm changes, physician’s discretion.

12. Abnormal assessment findings and when to notify a LIP
When patient is:
Exhibiting signs of deep sedation, purposeful response only to repeated or painful stimuli
Rass score of –4 or –5
O2 Sat <92% during or > 30 min after last dose of medication
BP increase or decrease by 20% from baseline
Arrhythmias
Apnea
Any change in respiratory or circulatory parameter

13. General principles in administration of Sedatives & Analgesics
Combination of sedatives and analgesics increase the risk of respiratory depression and apnea
Medications should be administered:
one at a time
in incremental doses
with sufficient time to evaluate
(generally over 2 minutes and wait 2-5 minutes to evaluate)
Titrate narcotics to obtain pain relief and sedatives to decrease anxiety

14. 8a. Age Specific Considerations for medication
Pediatric patients
Geriatric patients
Medication dosage by weight
Preferred routes PO or IV
Knowledge of age specific vital sign normals/abnormals is essential
Oxygen desaturation occurs faster
Faster drug clearance due to increased renal/hepatic blood flow
Increased body fat therefore increased storage
Increased susceptibility to airway obstruction.
(S/S of respiratory distress includes cyanosis, grunting, retractions,
and nasal flaring.)
Available airway equipment must be appropriate size
Sniff position for infants
Increased sensitivity to medications, adjust dosage appropriately
Less oxygen reserve
Decreased drug metabolism from decreased renal and hepatic flow
Slower circulation time of medications
Decreased muscle tone (stiff neck)
Increased musculoskeletal disorders

15. 8b. Disease Considerations for medication
Renal/Liver patients
Obesity
Diminished drug clearance
Poor venous access
Inaccurate blood pressure
Hypertension
Difficult airway management
Respiratory insufficiency, diaphragm pushed up by abdomen
Positioning difficulties
Storage of medication in adipose tissue
Co-morbidity: diabetes resulting in circulatory disorders

16. 8c. Usual dosage for medication
Initial doses IV over 2 minutes unless indicated
MEDICATION
ADULT
PEDIATRIC
NEONATE
GERIATRIC
MIDAZOLAM (VersedTM)
Onset 2-5 min
Duration min
0.5-2 mg
mg/kg
0.5-1 mg
DIAZEPAM (ValiumTM)
Duration 6-8 hours
2-5 mg
0.04 mg/kg
over 5 min
2 mg
LORAZEPAM (AtivanTM)
Onset 5-10 min
Duration 4-6 hours
0.05mg/kg
mg/kg
0.01 mg/kg
0.05 mg/kg
FENTANYL (SublimazeTM)
Onset immediate
Duration min
mcg
0.5-1 mcg/kg
25-50 mcg
MORPHINE
Onset 5 min
Duration 4-5 hours
mg/kg
1-2 mg
KETAMINE (KetalarTM)
Onset 1-2 min
Duration 1-2 hours
1-2 mg/kg
over 2-3 min
Benzodiazepines
Narcotics
Other
Refer to policy for repeat doses and other vital information

17. 8d. Considerations & precautions for meds
Reduce dosage if used with narcotics
Reversal agent is flumazenil
Lorazepam may have longer onset of action up to 10 minutes
Major side effects and respiratory depression hypotension (averted if drug administered slowly)
Lorazepam injection must be diluted with = amount of diluent before IV use
Benzodiazepines
Will potentiate effects of benodiazepines
May need increased dose of naloxone to reverse CNS/resp. effects of fentanyl
Caution use in patients with asthma and/or COPD
Narcotics

18. 8d. Considerations & precautions for meds (continued)
Observe for sedation for a minimum of one to two hours
Monitor blood pressure, heart rate, respiratory rate.
Close cardiac monitoring for patients with history of hypotension or cardiac decompensation
Contraindicated in patients with elevated intracranial pressure, uncontrolled hypertension, aneurysms, thyrotoxicosis, CHF, angina
Caution in patients with coronary artery disease, tachycardia
Ketamine

19. 8c. Usually dosage for medications specific to the ED and ICU
ONLY for ED and ICU use
8c. Usually dosage for medications specific to the ED and ICU
Initial doses IV
MEDICATION
ADULT
PEDIATRIC
NEONATE
GERIATRIC
ETOMIDATE
Onset sec
Duration 3-5 min
mg/kg
over sec
Not recommended for Children under 10 years,
mg/kg over 60 sec
Refer to policy for repeat doses and other vital information
9. RN administration MUST be under direct supervision of credentialed physician and RT or 2nd physician not involved in the procedure. MUST be monitoring airway.

20. Considerations Precautions
ONLY for ED and ICU use
8d. Considerations & precautions for medications specific to the ED & ICU
Considerations Precautions
RN administration restricted to ED and ICU
Monitor blood pressure, heart rate, respiratory rate
Caution in patients with serious asthma, hypotension, myoclonus, and nausea/vomiting
Etomidate

21. 8c. Usually dosage for medications specific to the ED, ICU and GI Lab
Propofol is used in the GI Lab as well as the ED and ICU
8c. Usually dosage for medications specific to the ED, ICU and GI Lab
Initial doses IV
MEDICATION
ADULT
PEDIATRIC
NEONATE
GERIATRIC
PROPOFOL
Onset 30 sec
Duration 3-10 min
0.5-1 mg/kg slow
0.5 mg/kg slow
Refer to policy for repeat doses and other vital information
MUST be administered only by an anesthesiologist.

22. Benzodiazepine Antagonist
10. Identify appropriate interventions if pt. progresses to deep sedation Describe REVERSAL agents, their actions and criteria for use
Initial doses IV over 15 seconds
MEDICATION
ADULT
PEDIATRIC
NEONATE
GERIATRIC
FLUMAZENIL
(RomaziconTM)
Onset 30 sec
Duration 3-10 min
0.2 mg
0.01 mg/kg
(Max initial = 0.2 mg)
mg/kg
NALOXONE
(NarcanTM)
Onset 1-2 min
Duration 1-4 hours mg
0.1 mg/kg
0.1-2 mg
Benzodiazepine Antagonist
Narcotic Antagonist
Refer to policy for repeat doses and other vital information

23. Considerations Precautions Benzodiazepine Antagonist
10. Identify appropriate interventions if pt. progresses to deep sedation 11. Describe REVERSAL agents, their actions and criteria for use
Considerations Precautions
Observe for re-sedation for a minimum of one to two hours
Caution in patients addicted to benzodiazepines
Caution in patients with history of seizures
Caution in patients with history of panic attacks
FLUMZAENIL
Benzodiazepine Antagonist
Observe for re-narcotization for a minimum of one to two hours
Titrate to avoid excessive reduction in analgesia
Caution use in patients addicted to narcotics
May need higher doses with fentanyl
May not reverse cardiovascular effects of narcotics
Naloxone associated non-cardiogenic pulmonary edema has been reported throughout dose range
Narcotic Antagonist
NALOXONE

24. 12. Potential complications related to the procedure
Complication Treatment
Airway obstruction
Monitor pulse oximeter continuously
Stimulate patient to breathe
Position head appropriately
Chin lift and jaw thrust
Administer supplemental oxygen
Administer reversal agents
Oral or nasal airway
Suction airway if needed
Ventilate manually with bag valve mask device

25. 12. Potential complications related to the procedure
Complication Treatment
Bradycardia
(caused by hypoxemia, vagal stimulation)
Oxygen
Medications as ordered and indicated
If patient develops shortness of breath or chest pain, obtain EKG

26. 12. Potential complications related to the procedure
Complication Treatment
Tachycardia
(caused by pain, anxiety, hypoxemia, hypovolemia)
Notify MD of tachycardia
Administer pain medication as ordered by MD performing procedure
Administer O2 as needed
Administer IV fluids as ordered by MD

27. 12. Potential complications related to the procedure
Complication Treatment
Other dysrhythmias
Atrial dysrythmias, PVC’s
(caused by hypoxemia & hypovolemia )
Notify MD of dysrhythmias
Administer medication as ordered by MD
Look for underlying causes such as hypoxemia and hypovolemia and report to MD

28. 12. Potential complications related to the procedure
Complication Treatment
Hypotension
(caused by pre-existing condition, response to medications, hypovolemia )
As indicated and ordered:
Administer reversal medications
Administer fluids
Administer vasopressors

29. 12. Potential complications related to the procedure
Complication Treatment
Hypertension
(caused by pre-existing conditions, pain, stress)
As indicated and ordered:
Administer additional sedation
Administer analgesia
Administer patient medications for hypertension

30. 13. Criteria for discharging a patient
Stability of vital signs = BP and Pulse within 20 points for 3 consecutive observations (in the absence of significant hypertension or hypotension. )
SPO2 meets or exceeds oxygen saturation guidelines (greater than 90 % on room air or with supplemental oxygen or within baseline measurements)
Body temperature at or greater than 96.8 degrees
Patient orientation to name, place and day or to similar orientation present pre-procedure
Patient able to move all four extremities on command or in a manner similar to that present pre-procedure
Absence, control or MD awareness of: Pain, nausea and vomiting, wound drainage and bleeding
Airway patency and respiratory function must be adequate and appropriate for discharge

31. 13. Criteria for discharging a patient (continued)
Fluids balanced, taking into account previous NPO status and underlying conditions
Physician if needed and desired contacted prior to discharge
Vital signs remain stable after oxygen has been removed for 15 to 20 minutes
Patient will remain at least 20 minutes after IV analgesic, providing other discharge criteria have been met
Final nursing assessment and evaluation of patient condition will be performed and documented
Primary nurse will inform unit nurse, if applicable, in an organized report of patient condition and procedural experience
Patients not meeting pre-determined discharge criteria requires a specific physician order for discharge (Nurses notes will explain criteria not met and interventions)

32. 13. Criteria for discharging a patient (continued)
Discharge to Patient Care Unit
Vital signs monitored every 15 minutes after procedure until:
Patient has met specified criteria  or per physician order 
Transfer order written by physician  

33. 13. Criteria for discharging a patient
Discharge from Hospital
When criteria for discharging a patient has been met
Control of pain acceptable to the patient
Control of nausea
Ambulation in a manner consistent with the procedure and previous ability
Arrangements for safe transportation from the facility
Patient and responsible adult should verbalize an understanding of instructions
Patients should be evaluated for the need for provision of additional resources to contact if any problems arise
Patients are to be discharged per a physician’s order
A copy of the post procedure discharge instructions should accompany the patient home
It is recommended that the patient have a responsible adult with them for 24 hours post procedure

34. 14. Documentation
ELECTIVE PROCEDURE
H&P
An H&P must be in the patient chart prior to the procedure
An H&P Update must be completed if the original H&P was done prior to patient admission
Appropriate Informed Consent for the procedure must be in the patient chart
Emergent procedures must contain appropriate physician documentation

35. DURING TREATMENT & POST-PROCEDURE RECOVERY
14. Documentation
DURING TREATMENT & POST-PROCEDURE RECOVERY
Amount of medication used, including dosage, route, and times given
Notation if supplemental oxygen was given
Monitors employed
Oxygen saturation and vital signs at required intervals
Any complication and subsequent management
Level of consciousness and general appearance
Any restraints or protective devices used
Use of reversal agents
Response to the procedure
Condition of any dressings, procedure sites, or drainage
Orders for transfer/discharge
Discharge instructions given if discharged from facility

36. DURING TREATMENT & POST-PROCEDURE RECOVERY
14. Documentation
DURING TREATMENT & POST-PROCEDURE RECOVERY
Select appropriate areas for your department and complete Doc Flow Sheets

37. DURING TREATMENT & POST-PROCEDURE RECOVERY
14. Documentation
DURING TREATMENT & POST-PROCEDURE RECOVERY
For charting vitals, select specific Intra-Procedural Doc Flow sheet for your area

38. DURING TREATMENT & POST-PROCEDURE RECOVERY
14. Documentation
DURING TREATMENT & POST-PROCEDURE RECOVERY
Complete Vital Signs/Pain flow sheet, charting medications administered in the MAR

39. Conclusion
You have completed the training content for this lesson. You should now be able to:
Differentiate between procedural and deep sedation
Demonstrate correct timing and process of verification of provider credentials
Identify prerequisites tasks for the licensed independent practitioner (LIP)
Describe RN/RT prerequisite tasks
Describe needed supplies and equipment
Identify monitoring requirements
Recognize abnormal assessment findings and know when to notify a LIP
Describe usually dosage and age specific considerations for medication
Identify appropriate staff who must be in the room and who can supervise a RN administering medications
Identify appropriate interventions if patient progresses to deep sedation
Describe reversal agents, their actions and criteria for use
List potential complications
Describe criteria for discharging a patient
Describe essential elements to document in the patient’s medical record
Evaluate the procedure by completing the procedure review form
Interventions over a 7 month period reduced the rate of medication errors by 70% and ADE’s by 15%
Rozich JD, Resar RK. JCOM 2001; 8(10): 27-34
“Medications not reconciled at transition points may account for as many as 50% of all medication errors and up to 20% of acverse drug events seen both in the hospital and later in outpatient settings” – Institute for Healthcare Improvement (IHI).
Variances from home meds to admission orders range from 30% to 70%
Most common discrepancy in reconciliation found to be omissions of home medications
Many of the omissions had potential for serious harm

40. Click the EXIT button in the upper right hand corner to close this window
Interventions over a 7 month period reduced the rate of medication errors by 70% and ADE’s by 15%
Rozich JD, Resar RK. JCOM 2001; 8(10): 27-34
“Medications not reconciled at transition points may account for as many as 50% of all medication errors and up to 20% of acverse drug events seen both in the hospital and later in outpatient settings” – Institute for Healthcare Improvement (IHI).
Variances from home meds to admission orders range from 30% to 70%
Most common discrepancy in reconciliation found to be omissions of home medications
Many of the omissions had potential for serious harm