Procedural Sedation

ObjectivesWho needs this course

Review pre sedation requirements

Talk about high risk specialties

Reportable conditions

Discuss airway support options

Drugs available

Conscious Sedation for MD’sJoint Commission requirementProof of completion of module at another hospital or training program within the last 2 years is adequateOngoing certification – must a minimum of 6 cases every 2 years

May watch this presentation and take a written/multiple choice test.MH: Anesthesia, EM, GI, Cards, Trauma, and critical care residency training adequate with appropriate number of cases.

Sedation continuumMinimal Sedation (anxiolysis)A drug induced state during which patients respond normally to verbal commandsCognitive function and coordination may be impairedVentilatory and cardiovascular functions are unaffected.

Moderate sedation (“conscious sedation”)A drug-induced depression of consciousness during which patients respond purposefully to verbal commandsNo interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.Cardiovascular function is usually maintained.

Sedation continuumDeep sedationAn intentional drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.The ability to independently maintain ventilatory function may be impaired. Must have dedicated sedation physician AND second provider to perform the procedure

Limited to anesthesia or emergency medicine physicians

General anesthesiaA drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.The ability to independently maintain ventilatory function is impaired. Cardiovascular function may be impaired.Limited to anesthesiologists

General StuffConscious sedation does not apply to

Intubated patientsTherapeutic use of medications

NPO status for elective cases2 hours clear liquids & Meds4 hours for breast milk6 hours solids (based on poor science)

NPO may be adjusted for emergenciesConsider anesthesiology for

Critically illElderly with multiple medical problemsDeep sedation for very difficult proceduresLong procedures

What KillsWhy do most sedation related deaths occur?

Lack of qualified helpInadequate monitoringOversedationLack of basic resuscitation equipmentNo reversal agentsUsually code after the procedure is completedMajority occur outside the hospital

What leads to over sedation?Difficult / painful proceduresFailure to reduce the dose in the elderlyImpatient physiciansImpaired metabolism (Liver > Renal)Incorrect dosing

The Dosing Continuum

Toxicity

Dose

Efficacy

What about aspiration?First case reported 1870Aspiration risks

Rare with conscious sedationStomach acidity correlates with severityMost occur in OR

Inhalational anesthesia emetogenic2/3 occur during airway manipulation

What specialties are highest risk?

Cosmetic SurgeryDentistryPodiatryGIPain specialists

85% of Lawsuits are from outpatient cases

Pre sedation requirementsPhysician documentation

H&P completed within 30 days of the procedure.If patient condition or planned procedure has changed from initial H&P, physician must write an interval note within 24 hours prior to procedure.The plan for sedation with complicationsThe planned procedure with risks, benefits, alternatives, and complications for the procedure. Verify NPO status

Pre sedation requirementsPulse OximeterEnd tidal CO2 monitorBlood pressure monitorOxygen Delivery SystemSuction EquipmentIV Equipment & suppliesCardiac MonitorCrash Cart

Number of Qualified IndividualsQualified Registered Nurse who is dedicated to monitoring the patientPhysician performing procedureAdditional staff required to assist the physician with the procedure

NOT the nurse monitoring the patient!

Reportable conditionsAny untoward drug reactions

Respiratory rate less than 12/minLoss of protective reflexesApnea or Code BlueUse of reversal agentIntubation requiredDeathRelease from Observation not met within60 min from completion of the procedure(i.e. Over sedation)

Interventions for hypoxia or hypoventilation

If O2 saturation <90%Administer O2 -100% via maskEncourage or stimulate patient to breathe deeply Reposition the Airway – Chin liftNasal or Oral airwayAssist Ventilations with Bag Valve MaskAdminister reversal agents

MedsNarcoticsBenzodiazepinesBarbituratesKetaminePropofol & Etomidate

Limited to Emergency Medicine and Anesthesia

NarcoticsLow dose

Analgesia > sedationApnea before loss of consciousness

ExamplesFentanyl (Sublimaze) Morphine Hydromorphone (Dilaudid) Meperidine (Demerol)

NarcoticsDrug Onset (IV) Duration Elimination

Fentanyl 2 minutes 20 minutes Liver

Dilaudid 2 minutes 3-5 hours Liver

Morphine 10 minutes 3-5 hours Liver

Meperidine 5 minutes 1 hour Liver / Renal

FentanylRapid onset, short durationHalf life ~ 10 minutesLow dose (1-3 mcg/kg) pure analgesia

No chest wall rigidity with doses < 5 mcg/kg

MeperidineAbsolute contraindications

MAO inhibitorsKnown hypersensitivity

Relative contraindicationsSeizure disorderRenal failureSSRI use

BenzodiazepinesLoss of consciousness before apneaSedative only, no analgesia

ExamplesMidazolam (Versed)Lorazepam (Ativan) Diazepam (Valium)

Midazolam (Versed)Preferred agentMost amnesticWater soluble and least irritatingRapid onset, short duration of actionWait 2 minutes to reassess sedation levelMay see paradoxical agitation in children and those with ADD

BenzodiazepinesDrug Onset (IV) Duration Prolonged

Elimination

Midazolam 2 minutes 30 min Liver, elderly, CHF

Lorazepam 5 minutes 1 hour Renal

Diazepam 5 minutes 30 min Liver, elderly, CHF

KetamineDissociative agentAnalgesic and sedative propertiesEmergence reactionsHypersalivationMinimize stimulation during recoveryDose – 1 mg/kg IV with 2 mg Versed

Reversal agentsNaloxone (Narcan)

Reverses effects of narcotics0.4 mg PO, IN, SQ, IM, IV – Partial Reversal2 mg – Full reversalUse carefully in chronic narcotic patients

Flumazenil (Romazicon)Reverses effects of benzodiazepines0.01 mg/kg up to 0.5 mg IV q minute up to 2 mgUse carefully in chronic benzodiazepine patients

Minimum monitoring time after administration of a reversal agent is one hour

SummaryMost complication from sedation happen when the procedure is completeProcedural sedation does not apply to intubated patientsHave an anesthesiologist preform sedation for long or difficult procedures, patients with complex medical problems, and unstable patients.

What’s Next?Now that you have completed the presentation:

Take the multiple choice self test; &Turn into the Medical Staff office.