Conscious Sedation
ASA Class; Class 3
- A patient with severe systemic disease that is not incapacitating - (poorly controlled HTN, heart disease, IDDM)
Pasero Opioid-Induced Sedation Scale (POSS); Is S - Acceptable or Unacceptable - Interventions needed?
- Acceptable - No action necessary - May inc opioid if needed
Diazepam (Valium); Acts in CNS to produce what? Can cause....?
- Acts in CNS to produce sedation effects and depresses the Spacisty of muscles - Can cause resp depression
Etomidate is what type of drug?
- Amnesic - Hypnotic - Anesthetic
Ketamine (NDMA, hypnotic, hallucinogenic); Why should you be careful with this drug? And in what pts should you avoid use?
- Careful with this bc of hallucinations - Avoid using with pts with mental illness
Mallampati classification of airway
- Classification of intubation based on how airway looks and how easy intubation will be. - Class I, II, III, IV - Class I Easiest intubation - Class IV Difficult intubation
Diazepam (Valium); Nursing Considerations?
- Don't administer with other drugs - Push at IV push 5mg per minute - Can be hepatotoxic: monitor liver labs
Ramsay Sedation Scale (RSS); Patient may be discharged home with a responsible adult when...
- Gas exchange is adequate (capnography) - Ramsay Sedation Scale is at a 2 (cooperative, tranquil, oriented) - Patient may be sleepy but arousable for several hours after procedure Not allowed to drive for 24 hours
Propofol; is what type of drug?
- General anesthetic - Amnesic (don't remember after they wake up)
Ketamine (NDMA, hypnotic, hallucinogenic); Side effects?
- Hallucinations - Mental confusion - Nystagmus
Ketamine (NDMA, hypnotic, hallucinogenic); Nursing Interventions?
- Hallucinations are exaggerated by environmental noise, So nurse should: - Keep a quite environment - Don't stimulate pt to much.
Minimal sedation I anxiolysis; What effects would it have on the pt regarding sedation?
- Helps relax the pt - Sometimes they go to sleep - Other times people stay up and talk to you and don't remember talking to you.
Minimal sedation I anxiolysis; If pt is sensitive to the medication, what may you need to do regarding respiratory status?
- If pt is sensitive to versed they may need oxygen - or sometimes you can say take a deep breath for me and they will take a deep breath for you
Midazolam (Versed); Uses?
- Induction of anesthesia - Preoperative sedation - Moderate sedation
Etomidate; Uses?
- Induction of general anesthesia - Rapid sequence intubation
Midazolam (Versed); Side effects
- Light headedness - Drowsiness - Apnea - Laryngospasms - Sometimes resp depression if pushed to fast IV
Propofol; Nursing considerations?
- Maintain airway and sedation levels
Propofol; Color of medication? What is the time limit on medication use, and why?
- Milky white substance - Cannot use if over 6 hours bc of risk of bacterial infection in medication
Cyclobenzapine (Flexeril); Nursing considerations?
- Monitor liver labs if taken on reg basis - Can develop dependance
For conscious sedation how often should you monitor vitals throughout the procedure?
- Monitor vitals every 3-5 mins per facility protocols.
Etomidate; Nursing Interventions?
- Must maintain patent airway - Support pts airway and heart rate
What is the antidote for opioid overdose?
- Narcan is antidote for opioids
Candidates for moderate/deep sedation must be screened for what?
- Patients must be screened for risk factors
Ketamine (NDMA, hypnotic, hallucinogenic); Uses?
- People are using this for recreational use now - Moderate/conscious sedation
Ketamine (NDMA, hypnotic, hallucinogenic); Popular choice because of what?
- Popular choice bc it lacks cardiovascular depressive effects and resp depressive effects aren't as extreme as opioids
MAC (Monitored Anesthesia Care) uses what for sedation?
- Sedatives and Hypnotics - Used to keep pt sedated, but don't have to intubate - May have to support airway some - Not done by nurse
Modified Aldrete Scoring System; Used when? Scoring?
- Used immed after surgery or sedation procedures - Score 0-2 in 5 different areas
Minimal sedation I is called what? Would be like giving what medication?
- anxiolysis: (NOT moderate sedation) - versed
Diazepam (Valium); Duration? Used for what?
- long acting - Used for anesthesia induction
Cyclobenzapine (Flexeril); May be given for what type of procedure?
- may be given for mri to relax pt
What should you monitor for pts on opioids, and what should you have at the bedside?
-Monitor pt due to resp depression from opioids, make sure you have emergency equipment by bedside.
Intra-procedure; The nurse must document VS every 3-5 minutes (per facility protocol) to include...
1. Level of sedation 2. Cardiac monitoring 3. BP, Pulse, resp rate 4. O2 stats 5. Capnography 6. Tissue perfusion changes
How many people does it take to safely perform a conscious sedation procedure?
3 in total for the following • 1 for med admin • 1 for procedure • 1 to monitor pt status
ASA Class; Class 5
A moribund (at any point they can die) patient who is not expected to survive without the operation (intracranial hemorrhage in a comatose state)
ASA Class; Class 1
A normal healthy patient
ASA Class; Class 2
A patient with mild to moderate systemic disease (controlled HTN, DM)
ASA Class; Class 4
A patient with severe systemic disease that is a constant threat to life (cardiac failure, major organ insufficiency)
Rigors
After medication is given, sometimes people wake up shivering if warming methods don't work, then it's a CNS issue, so the meperidine is a cns depressant and will calm down the shivering
Moderate sedation I is called what?
Analgesia: (moderate sedation)
Alfentanyl (Opioid); Uses?
Anesthesia adjunct
Midazolam (Versed); Is what kind of drug?
Benzodiazepine Sedative Hypnotic
Diazepam (Valium); Is what type of drug?
Benzodiazepine Sedative Hypnotic Muscle relaxant
Propofol; Side Effects
Can cause apnea when used in high doses
Discharge Criteria for conscious sedation procedure Includes what?
Documentation of: (must meet all of the following): • Modified Aldrete score ≥ pre-procedure score • Level of consciousness ≥ pre-procedure score • Ability to ambulate at pre-procedure ability • Ability to void • Ability to tolerate food/liquids • Discharge instructions to patient and responsible adult
Minimal sedation I anxiolysis; How should you maintain safety of this pt?
Don't let them get up to use the BR, give them a bedpan
Cyclobenzapine (Flexeril) antidote for OD?
Flumazenil (romazicon)
Diazepam (Valium); Antidote for OD?
Flumazenil (romazicon)
Midazolam (Versed); Antidote
Flumazenil (romazicon)
ASA Class; E is added in what circumstances?
If the procedure is performed as an emergency
Propofol; Peak/Duration?
It takes about 40 secs to work -Very short half life -Titrated easily
Conscious sedation is different from what?
MAC (Monitored Anesthesia Care)
Fentanyl (Opioid); Monitor what?
Monitor v/s and resp stats
Propofol; Antidote for OD?
NO ANTIDOTE Good for procedures bc of short half life you can cut it off and pt starts waking up
Midazolam (Versed); Onset/Duration?
Onset is about 1.5-5 minutes Duration is appox. 2-6 hours
Etomidate; Peak/Duration?
Peaks in 3-5 mins Lasts about 2.5 hours
Modified Aldrete Scoring System; What is required if pt scores less than an 8?
Provider has to come and see pt to approve discharge
Midazolam (Versed); C/I in which pts?
Pts with glaucoma
Pasero Opioid-Induced Sedation Scale (POSS); Scoring/Scale?
S = Sleep, easy to arouse 1 = Awake and alert 2 = Slightly drowsy, easily aroused 3 = Freq drowsy, arousable, drifts off to sleep during conversation 4 = Somnolent, minimal or no response to verbal or physical stimulation
Cyclobenzapine (Flexeril) is what type of drug?
Skeletal muscle relaxant
Fentanyl (Opioid); Uses?
Supplemental to general anesthesia
Fentanyl (Opioid); Peak/Duration?
Very short acting, peaks in about 3-5 mins and last from 30 mins - 1 hr
Can a nurse administer conscious sedation?
Yes, however they need further training for administering sedation, including the following: • ACLS for adults getting sedated • PALS for ped sedation
Propofol; Uses?
conscious sedation
General anesthesia; What functions are impaired?
• Ability to independently maintain ventilatory function is often impaired. • Cardiovascular function may be impaired.
Deep Sedation I analgesia: What may be impaired?
• Ability to independently maintain ventilatory function may be impaired
Patient reaction to sedation is dependent upon what?
• Age • Size (weight) • Medical conditions/Meds you take at home • Combination of drugs used (In hospital/procedure) • Route and rate of admin • Overall drug dosage being used
Conscious sedation; Amnesia action is... and what is the timeline that the pt can return to ADLs?
• Amnesia action is short • Pts have a rapid return to ADLs.
Morphine Sulfate (Opioid); Uses?
• Anesthesia adjunct • Severe pain
Moderate sedation I Analgesia; Also has what effect on the pt?
• Antianxiety effects
Deep Sedation I analgesia; What system is maintained?
• Cardiovascular function is usually maintained. - BP, HR
Minimal sedation I anxiolysis; What may be impaired with this sedation?
• Cognitive function and coordination may be impaired
What basic equipment must be available in a room where conscious sedation is being performed?
• Defibrillator • IV supplies • 100% O2 source and supplies • EKG monitor and display • Crash cart • Ambu bag • Suction equipment • IV supplies • Airway and vent equipment • BP monitor, pulse ox • EKG monitor and display • Thermometer • Stethoscope
Meperidine (Opioid); Nursing interventions?
• Dilute when giving it as IV push • Monitor loc, v/s, ect
Post-procedure; Nurse Documentation of VS includes what?
• Every 15 mins • Until pt has recovered
Post-procedure; Nurse must Document what?
• IVF administered and time • Medications used • PO fluids and nourishment • Side Effects that may occur (n/v, ect.) • Unusual events • Record of VS • Adequacy of ventilation • LOC • Pain assessment
Documentation - Pre-procedure; Credentialed Sedation Provider must document...
• Informed consent • Any relevant hx • Overall phys assess of pt • Mallampati classification of airway • Pain assessment • Review any pertinant diagnostics • NPO • ASA class
Deep Sedation I analgesia: Possible interventions that may be needed?
• May require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate
Alfentanyl (Opioid); Side Effects?
• Muscle rigidity • Nausea • Produces hypnosis • Pts wake up itching • Bradycardia • Resp depression
Nursing Pre-procedure; Assess, verify and document what?
• NPO Status • Presence of: - current History and Physical (look for it in chart/can't have procedure w/o this bc you have to have a baseline) - signed/completed informed consent • Baseline: - vital signs [HR, cardiac rhythm, BP, RR, O2 sat and ETCO2 (recommended if available)] • Pain assessment • Level of sedation/ responsiveness (Ramsay or RASS sedation scale may be used). • Secure IV access approp for procedure being done...20G or greater • Monitoring equipment placement, apply BP cuff, pulse ox and ekg leads • O2 administration - O2 admin, even if sating okay...just to boost them up prior to anesthesia • Universal Protocol - Pre-operative verification of the correct person, procedure and site - Marking of the operative site and laterality, where applicable (Provider marks, Nurse validates and documents) pt verbally says this is correct/no mind altering meds prior to this being done - "Time Out" immediately before starting the procedure - Remain with the patient from the time sedation is initiated.
Post-procedure; Nurse Documentation of meds includes what?
• Name and dose of meds • Including O2
Moderate sedation I Analgesia; Respiratory and cardiovascular interventions/function on this medication?
• No interventions are required to maintain a patent airway and spontaneous ventilation is adequate • Cardiovascular function is usually maintained.
Who can perform conscious sedation?
• Nurse with ACLS or PALS • Cert Nurse anesthetist • Anesthesiologist • Qualified provider
General anesthesia; Interventions needed?
• Often requires assistance in maintaining a patent airway, and positive pressure ventilation may be required - because of depressed spontaneous ventilation or drug-induced depressions of numerous functions (tubed or ventilated with bag valve mask, may need BP med depending on response)
Deep Sedation I analgesia: Pt arousal/responds to what?
• Patient cannot be easily aroused but responds purposefully following repeated or painful stimulation
General anesthesia: (NOT moderate sedation) ; Pt arousal?
• Patient is not aroused, even by painful stimuli, due to loss of consciousness
Minimal sedation I anxiolysis; Pt response to verbal commands after taking this medication?
• Patient responds normally to verbal commands
Moderate sedation I Analgesia; Pt response to commands after this medication is given?
• Patient responds purposefully to verbal commands • either alone or accompanied by light tactile stimulation due to depressed consciousness.
Meperidine (Opioid); Uses?
• Pre-op sedation • Anesthesia adjunct • Rigors
What are the S/E of opioids?
• Resp depression • Some have hypotensive effects as well
Post-procedure; Nurse Documentation of Adequacy of ventilation includes what?
• Resp rate • Resp effort • Skin color • Airway patency • O2 saturation
What procedures can conscious sedation be used?
• Short less invasive procedure • For procedures where pts just need to relax, and maintain their airway for the procedure • Ex's: Cardioversion, endoscopy, Lasix, Closed fracture reductions
Conscious sedation
• The IV delivery of sedative, hypnotic and or opioid drugs to reduce sensory perception but allow the pt to maintain a patent airway.
Intra-procedure; Nurse - Documentation of the following must be evident...
• The patient should be on all monitors with alarms functioning. • Start and stop times of the procedure • List of name of all present in the procedure including their roles • Name, dosage, route, and time of administration of all medications (including O2) • Type, rate and amount of IVF used (including blood products) • Unusual events • Nurses may administer medications under the direction of provider • Must have appropriate credentials (ACLS, PALS, NRP)
High Risk Patients Include...
• Those >70 years • Pediatric patients • Morbidly obese patients • Patients at increased risk of aspiration • (full stomach, trauma, hiatal hernia) • Patient with cardiovascular and pulmonary diseases • Pregnancy • Patients with difficult airway • ASA classification of 4 or >
Who are Candidates for moderate/deep sedation?
• Those who must undergo painful or difficult procedures • Where cooperation and/or comfort will be difficult or impossible without pharmacological support through the titration of opioids and sedatives.
Post-procedure; Nurse documentation of IVF admin includes what?
• Time administered • Any IV discontinued or restarted. • If something infiltrates during the procedure
What must be documented in a conscious sedation procedure?
• V/S every 5 mins • EKG status • Airway • respiratory status • cardiac rhythm • LOC • O2 stats • capnography • Glasgow coma score - continuously assessed
Minimal sedation I anxiolysis; What functions are unaffected with this?
• Ventilatory and cardiovascular functions are unaffected
Meperidine (Opioid); Side effects
• Wake up Itching • Seizures from CNS irritability
