SEDATION ISSUES

IN ENDOSCOPY

ALAN BREWSTER CRNANorthland Anesthesia

North Kansas City Hospital

No Declarationsor

Conflicts of Interest

Did You Know?

March 21

80th day of the Year

285 days till 2016

14 Days till the next full moon

Objectives

You will have a better understanding of pharmacy products that you may encounter

The environment you work in will be ready to handle most type of sedation cases

Special considerations when conducting moderate sedation

Take away one item you may have learned today and use or at least remember in practice

se·da·tionsəˈdāSH(ə)n/nounnoun: sedationthe administering of a sedative drug to produce a state of calm or sleep.

Definitions

Minimal Sedation

Moderate Sedation

Deep Sedation

Anesthesia

Minimal Sedation

Create Anxiolysis

A drug induced state during which patients respond normally to verbal commands

Moderate Sedation

Conscious Sedation

A drug induced depression of consciousness during which the patient responds purposefully to verbal commands

Deep Sedation

AKA ‘Room air general’

A drug induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated or painful stimulation

Anesthesia

A drug induced loss of consciousness during which patients are not arousable, even with painful stimulation

-CV changes-Loss of airway reflexes

Moderate Sedation

What is it?

Why is it needed?

Where can it be carried out at?

Moderate Sedation

A technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function

Why is it needed?

Exhibit A

Exhibit B

Exhibit C

Which would patients prefer?

OR

Which would you prefer?

As a health care provider?

Being the patient?

OR

What we see

Vs

What they think

In reality

In the Patient’s mind

Conscious SedationWhere can it be carried out at?

GI lab

ICU

Radiology

ER

Cath Lab

Patient’s room

Behind the scenes

Goals-

Policies Standing orders

Safety

Goals

Patient Satisfaction

GI Physician Happiness

Safety of Patient/ Staff

Completing the Mission

Policies

Policies

Per Hospital

NKC Hospital Policy

Policy

Appendages

Monitor Tools

Summary Tools

Policies

Per Unit

Per Physician

Safety

Patient Safety– *Number 1 priority* Positioning Corneal Abrasions Delirium

Staff Safety

Distractions

How easy is to be distracted?

-Procedure Screens-Monitors-Music-Social Interaction-’Your’ Day

Risk vs Benefits

Benefits? Risk? Airway Obstruction

Apnea

Hypotension

Adverse incident

Did You Know?

March 21 Birthdays

Johann Sebastian Back

Ronaldinho

Timothy Dalton (007)

What do you want to know?

NPO status Allergies, Allergens Medications Health issues of the patient Environment Procedure Type Staffing Issues

NPO Status

Allergies

Medications Home

Beta Block, antihypertensive, blood thinners Did they take?

Floor meds Herbal meds

Procedure Type

Health Issues

Acute Chronic

Single organ involvement Multi organ dysfuction

Unexpected Unexplained

Health issues

Hypertension Heart Defects Renal History of stroke or transient ischemic

attack (TIA) (certain oral sedation methods may trigger a TIA)

Neuromuscular disorders (such as muscular dystrophy)

Did You Know?

Today in History

2006 Twitter founded

1970 First Earth Day

1963 Alcatraz Closed

Patient Factors

Age

Size

Pathophysiology Single organ issues

Multi organ issues

What if they looked like

How would you handle each of these or others physically challenging

patients?

Boy Scout Motto

Be Prepared!

Environment

Pyxis Oxygen Source Suction Monitor Airway equipment

Ambu bag Code Cart

Take One of those Items Away

RECIPE FOR

DISASTER!

Don’t Forget!

Murphy’s Law

1. If anything can go wrong, it will.

2. If there is a possibility of several things going wrong, the one that will cause the most damage will be the first one to go wrong.

3. If anything just cannot go wrong, it will anyway.

4. If you perceive that there are four possible ways in which something can go wrong, and circumvent these, then a fifth way, unprepared for, will promptly develop.

Murphy’s Law continued

4.5 An IV will work fine in the holding area, but when you get to your procedure room, it will not work fine and will stop working when you need it the most.

5. Left to themselves, things tend to go from bad to worse.

6. If everything seems to be going well, you have obviously overlooked something.

7. Nature always sides with the hidden flaw.

8. Mother nature is a bitch.

Procedure Type

EGD

Colonoscopy

ERCP

Issues That May Occur

EGD Aspiration Larygospasm Bradycardia Hypotension Apnea

Sudden Stimulus phenomenom

Colonoscopy Vagal reflex Hypotension Aspiration Hypotension Apnea

ERCP Issues

Positioning

Airway Control

Length of Procedure

In a nutshell- The worst candidate for the most aggressive procedure.

Aspiration Larygospasm Bradycardia Hypotension Apnea

Sudden Stimulus phenomenom

Allergic reaction to contrast dye

ERCP

Staffing Issues

Experience

Trying to more with less personnel

Call crew

Safety in Transfering

Did You Know?

Today in History

U2 released ‘With or Without You’

Madonna released ‘Like a Prayer’

Music

Soothes the Savage Soul

Decreases Stress in Patient

Decreases Stress in Staff

What you should know and understand

What you are giving How much am I giving Why are you giving What happens if ……… Plan B?

Sedation

Who do we have to thank for what we use today?

Babylonians

Egyptians

Indians

?????

Romans

Greeks Chinese

Mayans?

The Beginning of Modern Day Sedation Medications

Herbal

Opium

Alcohol

Combination

Opium

Fentanyl Morphine

DemerolOpium Synthesis

Pharmacy 101

Sedation agents Midazolam (Versed)

Synthesized in 1975 Diazepam (Valium) Lorazepam (Ativan)

Medications

Benzodiazepenes Narcotics Local Anesthetics Others

Benzodiapenes

Interferes with formation and consolidation of memories of new material and may induce complete anterograde amnesia

Binds to GABA-A receptor (CNS)

Desired Effects

Sedation Hypnotic Anxiolytic Anticonvulsant Amnesiac Muscle Relaxant

Side effects

Drowsiness Dizziness Decreases alertness

and concentration Hypotension Trembling

Nausea/Vomiting Confusion Blurred Vision Hypoventilation

Special Consideration

Myasthenia Gravis COPD OSA Personality Disorders Elderly ETOH, controlled substance abuse Pregnancy

Narcotics

Greek -- ‘to make numb’ --causing loss of feeling or paralysis

Predates recorded history

Narcotics

Fentanyl (Sublimaze) Meperadine (Demerol) Morphine Dilaudid

Desired Effect

↓ Perception of Pain ↓ Reaction to Pain ↑ Pain Tolerance

Relieve Pain Dulls senses Induces sleep

Drug Potency of Narcotics

Morphine 1

Meperidine 0.1

Hydromorphone 10

Fentanyl 75-125

Sufentanil 500-1000

Side effects

Nausea, Vomiting Itching Urinary Retention Constipation Drowsiness Dizziness

Euphoria Decreased

respiratory effort Cough Suppression

good? bad? Allergy?

Local Anesthetics

Lidocaine Spray Viscous

Benzocaine Spray

Other pharmacy agents

BenadrylReglanOndansetronCompazinePhenergan

Interactions

Synergistic effects 1 + 1 does not always = 2

Unexpected reactions

You can always give more, but…

TitrateVigilancePatienceAnticipate the stimulus

Every Patient is different

Things you want to Know!

Are other medications on board?

Narcotics

Sedatives

Recreational drug usage

Rescue Medications

Where are they at?

Which one do I administer?

How much do I give?

Antagonist agents

Benzodiazepines Flumazanil

Narcotics Narcan Stadol Nubaine

Antagonist potential problems

Chronic benzo users

Acute pain patients

Chronic pain patients

ABC’STake care of A and B

you will avoid C

Airway

Airway issues OSA (obstructive sleep apnea

Did they bring their CPAP machine How often do they use it

Jaba the Hut Previous trach

How are you going to manage it?

Breathing

Breathing

O2 delivery system

Are they currently on O2?

Do they have limited reserves?

Do they use CPAP, BiPAP?

Do they use it at home?

Circulation

Circulation

Monitors are our best friend The Up, downs and every direction

Pulse Blood pressure O2 Saturation

Home Medications What do they take Did they take morning meds?

What are we going to do about it?

Fluid Volume

Bowel prep

Circulation

Fluid deficit

Bowel prep

Chronic dehydration

Disease process

Is Their Tank Empty?

Sedation Needs

Young vs Old

Healthy vs Sick

Male vs Female

The needs of our population

Are they the same?

Who needs more?

Who needs less?

Same age Same size Same health Same mom

Do they need the same amount of medication?

The Young

The Elderly

The Elderly with Multiple Health Problems

The Overweight

Everyone is different

Sedation needs to be tailored to the individual

Don’t be fooled by your previous patient Simple guidelines

Titrate Patience Vigilance Anticipate

The most complex cases are the anticipated simple cases

Evaluating your depth of Sedation

What signs are you looking for?

Ramsay Sedation Scale

Recovery

Airway Oxygenation Vitals stable? Orientation

Discharge

Are they ready to go forward

To the floor

To home

Aldrete Scoring system

No doubts in your mind!

Did You Know?

The Month ofMarch is

Caffeine Awareness Month

Frozen Food Month

Peanut Month

Anesthesia

More and more have became involved

Benefits Risk Cost Patient Satisfaction Staff Satisfaction

Anesthesia

My environment How is it different? Should it be different?

Health History Family History

Malignant Hyperthermia Trigger agents- Inhalation agents,

Succinylcholine

Benefits

Rapid room to scope time Less stress on Room

GI Physican Procedure RN

Quicker discharge times Patient satisfaction

Risk

Anesthetic agents

Propofol Etomidate Ketamine Other mediacations

Propofol

Diprivan

MJ (Michael Jackson White Stuff Milk of Amnesia

Propofol

DIPRIVAN Injectable Emulsion is an intravenous sedative-hypnotic agent for use in the induction and maintenance of anesthesia or sedation. Intravenous injection of a therapeutic dose of Propofol induces hypnosis, with minimal excitation

Key things about Propofol

It is a cardiac depressent

Will cause apnea

Irritating to vessels when injected

Apnea and Hypotension

Etomidate

Etomidate is a short-acting hypnotic, which appears to have gamma-aminobutyric acid (GABA)–like effects. Unlike the barbiturates, etomidate reduces subcortical inhibition at the onset of hypnosis while inducing neocortical sleep

Etomidate

In a retrospective review of almost 32,000 people, etomidate, when used for the induction of anaesthesia, was associated 2.5-fold increase in the risk of dying than those given propofol

Why? Are we using Etomidate in sicker patients?

Key items about Etomidate

Less cardiac depressent

Adrenocortical suppression lasting 4-6 hours

May cause myoclonus

Irritable to vessels when injected

Ketamine

Ketamine is a rapid-acting general anesthetic producing an anesthetic state characterized by profound analgesia, normal pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression.

The anesthetic state produced by Ketamine has been termed “dissociative anesthesia” in that it appears to selectively interrupt association pathways of the brain before producing somesthetic sensory blockade.

Dissociative Anesthesia

Loss of some types of sensation with persistence of others. A loss of sensation for pain and temperature occurs without loss of tactile sense

Ketmamine Side effects]

Cardiovascular: Arrythmias, bradycardia or tachycardia, hyper- or hypotension

Central nervous system: Ketamine is traditionally avoided in people with or at risk of intrcranial pressure (ICP) due to concerns about ketamine causing increased intracranial pressure. It does not increase ICP more than opioids.

Gastrointestinal: Anorexia, nausea, increased salivation, vomiting

Local: Pain or exanthema of the injection site Neuromuscular and skeletal: Increased skeletal muscle tone

(tonic-clonic movements) Ocular: Diplopia, increased intraocular pressure, nystagmus Respiratory: Airway obstruction, apnea, increased bronchial

secretions, respiratory depression, laryngospasm Other: Anaphylaxis, dependence, emergence reaction

With Versed pre Ketamine

Without Versed

Sodium Pentothal

Rapid-onset short-acting barbiturate general anesthetic that is an analogue of Thiobarbital

Sodium Pentothal Uses

Anesthesia

Medical induced Coma

Status Epilepticus

Why is it gone?

Euthanasia

Others

Benadryl Lidocaine Compazine Phenergan Droperidol

Did You Know

March was named for the Roman God "Mars

Stages of Anesthesia

Stage I--Analgesia. This stage lasts from the beginning of the administration of anesthesia to the beginning of the loss of consciousness.

Stage II--Excitement. This stage lasts from the loss of consciousness to the loss of the eyelid reflex (which marks the beginning of surgical anesthesia).

Stage III--Surgical Anesthesia. Most operations are performed at this stage of anesthesia, which begins following the excitement stage.

Stage IV--Medullary Paralysis. This stage begins when the anesthetic depresses the medulla.

Stages of Anesthesia

Your shoes, my shoes

Be prepared Have a mental backup plan Know your rescue plan of action Don’t be afraid to ask for help If needed, say ‘Uncle’ **Stay Calm**

Humor?

No Humor?

Anesthesia is compared to

Moderate Sedation

Be prepared for an alternate way to land

Take Home Message

Be Prepared Be Vigilant Expect the unexpected at anytime

Patient Safety is #1 Goal Patient satisfaction

In Summary

Each and Every Patient is Different in their own way

Know your patient Know what you are administering Be Prepared Be Vigilant Plan B? ALWAYS remember– You can give more,

but you can’t take away what you have given

Did You Know?

March 21

National French Bread Day

QUESTIONS

ANSWERS?

IF you are still awake

Birth of Anesthesia

March 30,1842- First time ether was used