Moderate Sedation Certification

ASA 6

*Declared brain-dead whose organs are being removed for donor purposes

ASA 5

*Moribund patient not expected to survive longer than 24 hours without surgical intervention

ASA 3

*Severe systemic disease that is not incapacitating: -Poorly controlled HTN -Multiple medications for cardiac, respiratory, and/or metabolic disorders -Metastatic dz with some interference with function -PNA *Divided into Stable and Unstable

ASA 4

*Severe systemic dz that is a constant threat to life -COPD on multiple inhalers and difficulty breathing supine -Metastatic dz with severe organ dysfunction -Recent MI with continuing symptoms -Severe HTN with angina -Sepsis -Organ insufficiency

Mallampati Airway Assessment

- Accurate predictor of subtle anatomic causes of difficult intubation - Classification is made per visualization of the soft palate, uvula, anterior and posterior tonsillar pillars

Midazolam (Versed) Contraindications

- Acute narrow-angle glaucoma -Shock

Romazicon Overdose

- Excessive doses result in anxiety, agitation, increased muscle tone, possible convulsions

Romazicon Potential Adverse Reactions

- N/V; sweating; hot flashes; agitation; HA; injection site pain -DO NOT use in patient's who chronically take benzodiazepines -May cause tremors, profuse sweating, hypotension, seizure activity *Caution in patients with seizure disorders as it may reverse the effects of anti-seizure medications

Midazolam (Versed) Adverse Reactions

- Respiratory depression - Apnea - Cardiac Arrest - Coughing - Bronchospasm - Laryngospasm - Hypotension - PVC - Tachycardia or bradycardia - Hiccups - N/V - Urticaria - Pain at infusion site

Midazolam (Versed) Dosage Recommendations: Pediatric

-0.025-0.05 mg/kg IV over 2 minutes -Max dose 0.1mg/kg

Supplemental O2 via Face Mask with Reservoir

-A flow of 6L/min will allow for O2 concentrations of 60% -A flow of 10L/min will allow for close to 100%

Diazepam (Valium) Adult Dose

-Administer in 1-2 mg increments every 2 minutes IV until desired effect--slurred speech--achieved -Generally 10-20mg in 60 minutes

Opioids Effects

-Analgesia and sedation -NO amnestic effects

Anesthesia and Surgical History Considerations

-Any complications with past anesthesia -Any patient with h/o airway difficulties should be referred to Anesthesia for their recommendations

Physical Examination: GI System

-Assess for current N/V, diarrhea, constipation, GI bleeding, GERD -Any GI surgery -Histamine blocker or non-particulate antacid considered for those with GERD

Physical Examination: Integumentary System

-Assess skin, color, temperature, turgor, integrity

Airway Assessment Considerations

-Cervical Range of Motion -Any restrictions with hyperextension of the head and neck

Considerations during Induction Phase

-Continuous cardiac monitoring and VS -Pre and post sedation rhythm strip *LOC most important*

Airway Adjuncts for Anesthesia

-ETT (absolute control of airway) -Laryngeal mask airway

Pre-op Assessment Neurologic System

-H/O TIA, CVA, seizure disorder, head trauma, convulsive disorder or epilepsy -Assess general affect and behavior; speech pattern alterations; LOC; orientation; gait -If local anesthesia is to be used, assess pre-existing numbness or weakness

Physical Examination: Musculoskeletal System

-H/O arthritis or recent fractures -Assess level of mobility; ROM; muscle strength, neurovascular status in any affected area

Capnography Numeric Values: Less than 35mmHg

-Hyperventilation/Hypocapnia -pH increases -Patient is being ventilated too fast

Capnography Numeric Values: Greater than 45mmHg

-Hypoventilation/Hypercapnia -pH decreases -Patient is being ventilated too slowly

Midazolam (Versed) Dosage Recommendations: Geriatric or patients with impaired pulmonary/hepatic function

-Initial dose 0.25mg-0.5mg IV over 2 minutes -Max dose 2.0mg

Romazicon Administration Technique IV Bolus

-Initial dose of 0.2mg -Phase One: 0.2mg IV over 15 seconds to 1 min -Phase Two: If patient does not reach desired level of consciousness after 45 seconds, repeat dose at one minute intervals until a cumulative dose of 1 mg has been given -80% of the max response is seen in 3 minutes *Anesthesia should be consulted if no desired clinical response with the administration of the initial 1 mg dose*

Midazolam (Versed) Dosage Recommendations: Adult

-Initial dose of 1-2mgs IV over 2 minutes just before beginning procedure -Titrate to effect--slurred speech--by giving additional IV doses over 2 minutes -Do not exceed a total dose of 3.0mg unless needed to obtain effect -Wait at least 2 minutes after each administration of medication to determine effect *Reduce dosage for alcohol intoxication or h/o COPD

Pulse Oximetry

-Measures oxygenation (concentration of oxygen in body) -Can lag behind breathing changes -Inaccurate at low oxygen saturation, low perfusion states, motion, ambient direct light -Affected by ambient light, shivering, abnormal hemoglobin, Pulse rate and rhythm, vasoconstriction, cardiac function

Physical Examination: Hepatic System

-Medical h/o hepatitis or cirrhosis -Impaired liver function can result in either resistance to sedation medications or increased sensitivity to the medications

Oral Airway

-Must be measured properly -Keeps the posterior pharynx open and prevents airway obstruction -Only used with unresponsive patients as it can otherwise induce vomiting, laryngospasm, or bronchospasm -Airway is inserted backwards and rotated into position

Airway Adjuncts for Sedation

-Nasal Airway -Oral Airway

ASA 1

-Normal, healthy adult -No chronic illness -No regular medications -Excludes very young and very old -Good exercise tolerance

Diazepam (Valium) Considerations

-Not compatible with other agents as it easily precipitates -Painful upon injection -Long half life due to metabolites

Undesirable Effects of Conscious Sedation

-Nystagmus as this indicates a deeper level of sedation -Agitation as this is a possible paradoxical effect -Respiratory depression -Autonomic responses such as increased HR and BP

Physical characteristics that can indicate potential for difficult airway management

-Obesity -Short, thick neck -Limited neck ROM -Deviated trachea -Hypognathic (recessed) jaw -Hypergnathic (Protruding) jaw -Small mouth opening (<3cm) -High arched palate -Macroglossia (Large tongue) -Protruding teeth -Loose teeth or dentures -Non visible uvula -Tonsillar hypertrophy

Romazicon IV Onset, Peak, Duration

-Onset 1 to 2 minutes - Peak effect 6 to 10 minutes - Lasts 45-90 minutes

Romazicon via IV bolus or infusion

-Onset 1 to 2 minutes -Peaks 6-10 minutes with 80% of the max response seen within 3 minutes -Lasts 45 to 90 minutes

Diazepam (Valium) IV

-Onset 1 to 5 minutes -Peaks in 3 to 5 minutes -Lasts 2 to 4 hours

Midazolam (Versed) PO

-Onset 10-20 minutes (usually less than 10 minutes) -Peak 30 minutes -Lasts 2-6h

Diazepam (Valium) PO

-Onset 15 to 60 min. -Peaks in 60 minutes -Lasts 3 to 6 hours

Midazolam (Versed) IM

-Onset 5-15 minutes -Peak 15-60 minutes -Lasts 2-6 hours

Midazolam (Versed) IV

-Onset of action is 1 minute -Peak effect seen in 3-4 minutes -Durations of Action 15-80 minutes

Required Equipment for Sedation

-Oxygen Source -Suction -Bag valve mask -Airway adjuncts -IV access -Emergency medications -NIBP -Pulse Oximeter -Capnography -Electrocardiograph -Crash Cart

Medication Interaction with Benzodiazepines

-Patients who chronically take Cimetidine (Tagamet) or Ranitidine (Zantac) are especially susceptible to Benzo overdose -These drugs block H-2 receptors and may dramatically increase the sedative effect of even smaller doses of benzodiazepines

Considerations for hyperthyroidism or hypothyroidism

-Pharmacologic effects of sedative and analgesics may be altered in these conditions -Airway management may be more difficult in either situation and the thyroid gland may be enlarged in hyperthyroidism and the tongue may be enlarged in hypothyroidism

Diazepam (Valium) Potential Adverse Reactions

-Phlebitis at injection site -Bradycardia -Hypotension -Respiratory depression and apnea -Agitation -Confusion -Hiccups -Diplopia -Rash -Urticaria -Vesicant

Supplemental O2 via Simple Face Mask

-Recommended for 8-10 Liters/min (40-60%) -Flow rate must be at least 5L/min to prevent CO2 rebreathing

Desirable Effects of Conscious Sedation

-Relaxation -Cooperation -Diminished verbal communication -Easy arousal from sleep -Slurred speech is a good indicator of sedation (may or may not be seen)

Physical Examination: Renal System

-Renal dz impairs excretion of sedation medications and their metabolites -Renal dx requires close regulation of fluid status -Those with renal insufficiency or renal failure may not be a candidate for nurse-monitored sedation -Assess fluid status: Length of NPO status, urine output, skin turgor, mucous membrane appearances, BP, and HR

Opioid Adverse Reactions

-Respiratory depression -N/V -Pruritus, urticarial -Urinary retention in young males -Constipation

Romazicon Adverse Effects

-Return of respiratory depression which has exceeded the therapeutic effects of flumazenil -Cutaneous vasodilation -Sweating -Flushing -Dysrhythmias -Bradycardia or tachycardia -HTN

Flumazenil (Romazicon)

-Reversal for Benzodiazepines as it is the specific benzo antagonist -Reverses sedation, respiratory depression, amnesia -Peak effect in 6-10 min.

Capnography

-The combination of a waveform and numerical value of ETCO2 -Measures the amount of carbon dioxide in respiratory gases -Monitors ventilation, defined as the adequacy of respiration (how adequately the patient is inhaling O2 and eliminating CO2) -Provides breath-to-breath feedback so that changes in breathing are reflected immediately -Provides information about end-tidal carbon dioxide values, defined as maximal concentration of carbon dioxide (CO2) at the end of an exhaled breath...The normal values are 5% to 6% CO2, which is equivalent to 35-45 mmHg.

Mallampati Class IV

-The soft palate is not visible at all; only hard palate visible -Need anesthesia consultation

Midazolam (Versed) Administration

-Very potent, short-acting drug that must be given by slop IVP over 2 minutes -May dilute with D5W or NS -Recommended concentration of 0.25mg/ml -Titrate to effect in 0.5mg increments -Give no faster than 0.5mg over 2 minutes

Mallampati Class III

-Visualize soft palate and base of uvula -Need anesthesia consultation

Supplemental O2 via NC

-Volume of 1-6L/minute = 24-44% concentration of O2 -FiO2 (% of oxygen) is increased by 4% for each L/Minute (Natural air FiO2 is 20%) -Mouth breathing does not ablate effectiveness as O2 is entrained from the nose via inspiratory flow through the posterior pharynx

Nasal Airway

-Well tolerated by semi-conscious patient

Diazepam (Valium) Pediatric Dose

0.1 to 0.3 mg/kg

Benzodiazepines cause what effects

1. Anxiolysis 2. Amnesiac...antero-grade amnesia 3. Anti-convulsive 4. Skeletal muscle relaxation 5. Sedative-hypnotic in large doses 6. When used alone, will cause little respiratory or cardiovascular depression, but synergistic effects seen when combined with other CNS depressants **NO analgesic properties**

Primary Agents Used for Sedation (Classes)

1. Benzodiazepines 2. Opioids 3. Anesthetics 4. Alpha-2 Receptors Agonists 5. Reversal Agents 6. Emergency Medication

Pre-Operative Nursing Assessment Steps

1. Chart Review 2. Patient Interview 3. Physical Exam and Review of Systems

Instructions for well-controlled insulin dependent DM and for those procedures that may last longer than 1 hour

1. Consult anesthesia for medication recommendations 2. Usually take normal dose of NPH evening prior and half prescribed AM dose the morning of 3. Finger stick glucose every 30min. during the procedure and every hour during recovery

Joint Commission standards for limiting risk associated with prescribing and ordering medication...7 specific areas relevant to anesthesia and conscious sedation that hospitals are required to address

1. Distribution, administration, and/or disposal of controlled medications including adequate documentation and record keeping as required by state and federal law 2. Proper storage, distribution, and control of investigational medications and those in clinical trial 3. Situations in which all or some of patient's medication orders must be permanently or temporarily concealed and mechanisms for reinstating them 4. PRN prescriptions or orders and times of dose administration 5. Control of sample drugs 6. Distribution of medications to patients at d/c 7. Procurement, storage, control, and distribution of prepackaged medications obtained from outside sources

Instructions for patients well controlled on oral hypoglycemic receiving sedation for short-term period (<1 hour)

1. Do not take normally scheduled AM dose of medication secondary to long-term effects of possible greater than 36h 2. Finger stick glucose prior to procedure and after the procedure

Instructions for conscious sedation given for a short term procedure (<1h) administered to patients with DM that are well controlled on oral hypoglycemics

1. Do not take scheduled AM dose of oral hypoglycemic 2. Fasting blood glucose morning of procedure 3. Post-op finger stick *Insulin dependent patients require anesthesia consultation*

Pulmonary System Physical Assessment

1. Does the patient have a current cough, sputum production, rhinitis, sore throat, dyspnea, hemoptysis, wheezing? 2. Use oxygen at home? 4. Physical characteristics that may indicate potential difficult airway management

JCAHO Care Standard: Qualified Individuals conducting sedation must possess education, training, and experience in?

1. Evaluating patients prior to moderate or deep sedation 2. Rescuing patients who slip into a "deeper than desired" level of sedation or anesthesia 3. Managing a compromised airway during a procedure 4. Handling a compromised CV system during a procedure.

Physical Examination: Neurological Considerations

1. H/O TIA, CVA, Seizure disorder, head trauma, convulsive disorders, epilepsy 2. Assess general affect, behavior, speech pattern alterations, LOC, orientation, gait 3. Determine pre-existing numbness or weakness prior to local anesthesia

Physical Examination: Cardiac Considerations

1. H/O myocardial infarction -Assess for angina -Assess for SOB: at rest; w/ exercise/activity; paroxysmal nocturnal dyspnea -Signs of CHF -Elective procedures postponed at least 6 months post-MI 2. Will the patient be able to lie flat for procedure? -Paroxysmal nocturnal dyspnea 3. Subacute Bacterial Endocarditis Prophylaxis before and after procedure necessary -Valvular heart disease 4. HTN-Controlled? Compliance? 5. Recent Cardiac Sx 6. Dysrhythmias 7. Pacemaker or Automatic Internal Defibrillator?

Goals of Safe Sedation

1. Maintain adequate ventilation, homeostasis, and circulation 2. Maintenance of appropriate level of consciousness 3. Promote comfort by elevating pain threshold 4. Patient Safety-be knowledgeable about possible consequences of respiratory depression, airway obstruction, apnea, hypoxia, hypercapnia, bradycardia, asystole, brain injury/death 5. Using the essential components required to conduct safe sedation 6. Understand the importance of a systematic approach to sedation that promotes safety and efficacy.

Levels of Sedation Analgesia

1. Minimal Sedation 2. Moderate Sedation/Analgesia 3. Deep Sedation/Analgesia 4. General Anesthesia

Pre-sedation Assessment Overview: Parts of the Assessment

1. NPO Status 2. Chief complaint 3. Current medications 4. Drug allergies 5. H/O substance abuse 6. Concurrent medical problems 7. Communication Ability

What conditions place patient's at enhanced risks for aspiration with sedation?

1. Obesity 2. DM 3. Pregnancy 4. Bowel Dysfunction

Pre-Sedation Assessment: Chart Review

1. Past medical illnesses 2. Prior Surgical Procedures 3. Allergies 4. Drug reactions and intra-anesthetic complications 5. Lab Studies 6. Current medications 7. Compliance of medication regimen

General Anesthesia

1. Patient cannot be aroused, even with painful stimuli 2. Intervention required to maintain patent airway 3. Spontaneous ventilation is frequently inadequate 4. Cardiovascular function may be impaired

Elements of Pre-operative Preparation

1. Patient counseling 2. Rapport 3. Verbal reassurance 4. Patient expectations 5. IV Access 6. EKG/BP 7. Pulse Ox 8. Informed Consent

Minimal Sedation

1. Patient is able to respond normally to verbal stimulation. 2. Airway and Spontaneous Ventilation is not affected and thus "normal" 3. Cardiovascular function is not affected

Deep Sedation/Analgesia

1. Patient responds to repeated or painful stimulation 2. May require intervention to maintain patent airway 3. Spontaneous ventilation may be inadequate 4. Cardiovascular function is usually maintained

Moderate Sedation/Analgesia

1. Patient responds to verbal or tactile stimulation 2. No intervention to maintain patent airway 3. Spontaneous ventilation is adequate 4. Cardiovascular function is usually maintained

Role of the Sedation Nurse

1. Pre-op Nursing Assessment 2. Intra-op Nursing Actions: medication administration; patient monitoring; patient safety; procedure specific 3. Post-op monitoring during recovery 4. Follow post-op d/c criteria 5. Explain post-d/c written instructions 6. Follow-up

Extra precautions necessary with asthmatic patients

1. Pre-op bronchodilator 2. Steroid-dependent asthmatics are NOT candidates for nursing administration of sedatives 3. Presence of wheezing despite bronchodilators and steroid therapy should be consulted by anesthesia

How is Aspiration Risk Reduced

1. Pre-procedure fasting--Defined as no food for 6 hours prior to procedure. May have clear fluids until 2h prior to procedure. 2. Medication is titrated to maintain reflexes

Airway Assessment: Patient History

1. Problems with anesthesia 2. Stridor, snoring, sleep apnea? 3. Advanced rheumatoid mouth and jaw

Pre-Sedation Assessment: Ancillary Studies

1. Recent EKG (<1year) 2. Patients at risk for myocardial injury (anti-hypertensive) 3. Pregnant, must have OB consult 4. <5 years old require a consult with anesthesia

Monitoring Parameters

1. Respiratory rate and function 2. SaO2 3. BP 4. LOC 5. Skin condition 6. Continuously placed IV

Cardiovascular Physical Assessment should include

1. Skin color 2. Peripheral pulses 3. Presence of edema or jugular vein distention 4. Baseline heart rate 5. BP 6. Auscultation of heart soudns

Patient history to consider during pre-op preparation

1. Smoking- PPD and years 2. Drug allergies and reaction 3. Alcohol Abuse 4. Menstrual Hx and Urine HCG for fertile women 5. Height and Weight to dose medications 6. Drug Abuse 7. Daily Medications 8. Post Facial/Neck Trauma or Surgery 9. Dentures or any removable items in mouth

Romazicon Administration Technique IV infusion

30-60 mcg/minute (0.5-1 mcg/kg/min) Total dose not to exceed 3mg/h

Minimal Oxygen Saturation

95% on RA or supplemental O2

Moderate "Conscious" Sedation

A minimally depressed level of consciousness induced by the administration of pharmacologic agents in which the patient retains continuous and independent ability to maintain protective reflexes and a patent airway and to be aroused by physical or verbal stimulation.

ASA Physical Status

American Society of Anesthesiologists Physical Status System helps qualify the relative risk to patients sedative medications pose

O2 delivery system recommended in acute and emergent situations

Bag-valve device

ASA 2

Mild systemic disease: -Controlled HTN -Type II DM -H/O tobacco use -Obesity -Non-metastatic carcinoma -Well controlled asthma -Child with underlying cerebral palsy -Child with well-controlled seizure disorder

Extra precaution for chronic bronchitis patients

Pre-op inhaler bronchodilator

Capnometer

Provides a numerical measurement of carbon dioxide

Airway Assessment

Results will indicate the potential ease or difficulty of positive pressure ventilation. If assessed as having a difficult airway, it is critical that the patient maintain protective airway reflexes

Danger for DM under deep sedation

Signs of hypoglycemia are masked and blood sugar can fall dangerously low

Capnogram

The waveform of carbon dioxide over a period of time

Mallampati Class II

Visualize soft palate, fauces, uvula

Mallampati Class I

Visualize the soft palate, uvula, anterior and posterior tonsillar pillars