Adult Moderate Sedation Policy
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Transcript of Adult Moderate Sedation Policy
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The policy is designed to provide specific
recommendations for the safe care of patients
(15 years of age or older) during the delivery ofmedications(s) for sedation and analgesia,
known as moderate sedation, by non-
anesthesiologists during diagnostic, therapeutic,
or surgical procedures.
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` Endoscopic examinations
` Vascular and cardiac catheterizations
` Radiological procedures
` Other procedures performed in clinics, patient
care units, or in the emergency department
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Moderate sedation can be described as a state,
which allows patients to tolerate procedureswhile maintaining adequate cardiopulmonary
function and the ability to respond purposely toverbal commands or physical stimuli.
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` Preoperative medications` Patient controlled analgesia` Post operative or labor analgesia
` Pain Management (dressings, burns or angina)` Sedation in the intensive care unit` Sedation for treatment of insomnia` Anxiolysis` Pulmonary edema
` Drug or alcohol withdrawal or prophylaxis` Treatment of seizure disorders` Multiple trauma patients in the ER` Premedication with a standard dose
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Minimal
Sedation
(Anxiolysis)
Moderate
Sedation/Analge
sia (Conscious
Sedation)
Deep Sedation
/Analgesia
General
Anesthesia
Responsiveness Normal
Response to
verbalstimulation
Purposeful
response to
verbal or tactilestimulation
Purposeful
response
followingrepeated or
painful
stimulation
Unarousable
even with painful
stimulus
Airway Unaffected No intervention
required
Intervention may
be required
Intervention
often required
Spontaneous
Ventilation
Unaffected Adequate May be
inadequate
Frequently
inadequate
Cardiovascular
Function
Unaffected Usually
maintained
Usually
maintained
May be impaired
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`Age
`
Weight
` Preexisting medical condition
` Deep sedation or general anesthesia requiresskilled anesthesia personal
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` Request to Credentials Committee
` Completion of training
` Complete a written post test
` Proof of certification in ACLS
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`ACLS certification
`
Recredentialing follows procedures described inthe Medical Dental Staff Bylaws and is the
responsibility of the individual physician
` Successful completion of the sedation andanalgesia test is required
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` Airway management
`
Use of medication and dosages
` Pulse oximetry
`
Cardiac monitoring equipment
` Arrhythmia recognition
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`All personnel shall demonstrate understandingof the pharmacology and side effects ofmedications
` Training in basic monitoring techniques andbasic airway management
` The means for notifying additional support staffservices such as Respiratory Therapy and"Code Blue" pages should be posted inprocedure/sedation area
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` Bag valve device (Ambu) and other O2 deliverysystems such as nasal cannula and masks
` Suction catheter or cannula` Oral and nasal airways`Automatic BPmonitor` Pulse Oximeter` EKGmonitor` Emergency Code Cart
` Reversal agents`Atropine
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The American Society of Anesthesiologist (ASA)
risk classification is used in the selection ofpatients to receive moderate sedation.
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` Class I: A normally healthy patient
` Class II: A patient with mild systemic disease
` Class III:A patient with severe systemic disease
that limits but is not incapacitating` Class IV:A patient with severe systemic disease
that is a constant threat to life
` Class V: A morbid patient who is not expected
to survive with or without theoperation/procedure
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` Patients with an ASA classification greater than 3
` Patient has limited range of head/neck motion
` Abnormal craniofacial anatomy
` Morbid obesity
` History of sleep apnea
` During pregnancy
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Ambulatory patientsM
UST HAVE
a responsible,designated adult to escort them home.
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` The patient must be informed about the risks andalternatives of sedation as a component of the plannedprocedure
` The informed consent for any short term therapeutic,
diagnostic, or surgical procedure in which moderatesedation is to be employed will include the risks ofsedation and the alternatives to sedation
` Documentation of the consent for both the procedure
and the administration of moderate sedation must beincluded in the patient's chart
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` Patients undergoing moderate sedation forelective procedures should not drink fluids or eatsolid foods for a sufficient period of time to allowgastric emptying before their procedure
` Solids and Non-clear Liquids: NPO for 6 hoursClear Liquids: NPO for 2 hours
` Medications may be administered with a sip ofwater
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` Anxiety
` Abdominal Pain
` Autonomic Dysfunction
` Pregnancy
` Mechanical Obstruction
` NPO guidelines do not guarantee complete gastricemptying
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` When patient requires emergency procedure
and is not NPO, conscious sedation might be
dangerous
Delayed
Executed judiciously to avoid unconsciousness and
the suppression of airway reflexes
Not Administered
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` The patient's state of consciousness and medicalcondition appropriate for using moderate sedation
` Individual sedation plan indicating medication
` A sedation order is signed or cosigned by thePhysician
` No allergies or sensitivities to prescribed
medications
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` The Appropriate history and physical exam are documented in thepatient's chart prior to the procedure:
-Actual or estimated weight in lbs. or kg.-Allergies and previous allergic reaction-A list of concurrent medications
-Time of last oral intake-Pertinent medical history including history of tobacco,alcohol, or substance abuse
-History of sedation/anesthesia problems-Baseline vital signs including blood pressure, heart rate,respiratory rate, and O2 saturation
-P
hysicalE
xam- General neurological status- Examination of airway- Pulmonary and Cardiac status
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` Functioning IV line or saline lock
` Oxygen requirements evaluated: it should beconsidered when hemoglobin oxygen saturation
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OtherPre-Procedure Items (cont)
Report any problems associated with theprocedure
Confirm that the patient has reviewed andreceived written instructions
A time out is conducted before starting theprocedure
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` Monitor and document vital signs every
5-10 minutes: Heart Rate
EKGRhythm
Blood Pressure
Respiratory Rate
O2 Sat. (continuous)
Patients Responsiveness
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` Document IV fluids, including blood products, andmedications(s) administered, route, site, time, dosage,and initials of individual administering medication
` Record oxygen therapy in liters/minutes orFi02 andmeans of oxygen therapy
` The individual who monitors the patient shall inform theMD of any changes in the patient's physiological status
from his/her baseline assessment and record itsoccurrence, interventions and outcome
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` Patient's vital signs every 5-10 minutes for a minimum of 30 minutesfollowing the last dose of medication administered
` After 30 minutes vital signs recorded every 15 minutes, untildischarge criteria are met to end the recovery period. The patientmust be observed for a minimum of 30 minutes post procedure
` Recovery Score documented at end of procedure and every 15minutes until the target score met
` Patient's requiring reversal will require a recovery period of 2 hoursfollowing administration of the reversal agent
` Discharge orders and follow-up care must be written by thephysician
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Respiration Able to breath deeply and cough freely
Dyspnea or limited breathing
Apneic
2
1
0
Circulation BP 20% of pre-anesthetic level
BP 21-49% of pre-anesthetic level
BP 50% of pre-anesthetic
2
1
0
Level of
Consciousness
Fully awake
Arousable on calling/responds to stimuli
Not responding
2
1
0
Activity Moves all extremities
Moves 2 extremities
Unable to move extremities
2
1
0
O2 SAT Adult Only
O2 SAT>92% on room air
O2 supplement to maintain O2 SAT>90%
O2 SAT
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` Recovery Score greater or equal to 8. If the score isless than 10, a note will indicate reason
` Vital signs and O2 Sat stable
` Swallow, cough, and gag reflexes are present
` Nausea and dizziness are minimal
` Dressing and/or procedure site checked
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Recovery / Discharge (cont)
Minimal pain managed by appropriate analgesics
Patient alert
Patient can sit unaided if appropriate to baseline andprocedure
Discharge order written, if applicable
If patients are to be transferred for further recoverywithin the institution, they will be accompanied by aMD, PA, or RN to the designated recovery area
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` Recovery Score of 10 (or pre-procedure state)
` Hydration adequate/able to drink fluids
` Voided or unable to void but comfortable
` Patient and/or family given written dischargeinstructions which will include an explanation ofanticipated limitation on activities
` 24 hour emergency contact (person/service)
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For patients discharged from the recovery areaand the hospital, a discharge order is written bya qualified licensed independent practitioner
Ambulatory patients may not leave the hospitalunless accompanied by a responsible,designated adult
A follow-up phone call is recommended, within24 hours post procedure
Outpatient Discharge (cont)
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` Medications will not be administered without the directpresence of the credentialed physician
` Written and signed physician medication order
` A list of medications and dosages is provided in thewritten policy document to serve as a guide for a saferange of drug administration for moderate sedation
` Dosages should always be titrated for desired
therapeutic effect. Any drugs outside these guidelinesmust be approved by the Chief of AnesthesiaDepartment or designee
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Each department/division involved in moderate
sedation should participate in Performance
Improvement activities for its practice. TheDepartment of Anesthesia will assist
departments in developing mechanisms to
monitor their quality of moderate sedation
services. The Joint Commission recommendedsample size for quarterly review is detailed in
the written policy document.
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