Transcript Sedation in Endoscopy

Sedation in Endoscopy
Trina VanGuilder, RN, BSN, CGRN
Franklin, Tennessee
October 16th, 2010
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4/9/2015
Today’s topics
 Why we administer sedation agents for
Endoscopic procedures?
 How do we know we are administering
Sedation properly?
 How do we prevent poor outcomes?
 How should we respond when sedation
does not go as planned?
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Sedation Facts (SF)
 www.sedationfacts.org
 Comprehensive resource for evidenced based
information
 Joint efforts by SGNA,ASGE,AGA, ACG
 Funded by a grant from Ethicon Endo-Surgery, Inc
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4/9/2015
What does SedationFacts have to
offer you?
 24/7 Fingertip access FREE to…
 Emerging Agents and Technologies
 Upcoming conferences and Training
 Reference websites and articles
 Ask a question to the experts
 State by state BON Position statement
 Newsletter and Sedation updates
 Airway management
 SGNA Position statements related to Sedation (staffing guidelines, pt classification, etc.)
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WHY?
Reduce patient anxiety
• Brings them in
• Fear of pain
• Patient satisfaction
Ability to perform procedure
successfully
• Enhanced outcome
• Reduces potential injury to patient
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Why Not…those who prefer no sedation
 Fear, curiosity, convenience
 Loss of control
 Effects of drugs (short and long term)
 What may go on in the room
 Desire to watch the procedure
 Cost
 Drive/return to work
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SF
4/9/2015
How do we know we
are administering
sedation correctly?
What is correctly?
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If you are following National standards
And
You have guidelines to meet these standards
And
You have current policies in place and follow them
CONGRATULATIONS!!!!!
YOUR DOING IT RIGHT
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Liability and Standards
Liability
Policy
Policy
Guidelines
Standards
Example: Colon Cancer Screening
 Standard
 Screening Colonoscopy (National Gold Standard)
 Guideline
 50 years old (family history, symptoms, high risk
 Other: time in/out, to cecum, polyp removal, etc.
 Policy
 Facility policy (policy on screening, preps, sedation)
 Liability
 If policy, guideline, standard is not
followed and bad outcome occurs
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Sedation
 Standard (Examples)
 BOD Position Statement
 Regulatory process (JC, AAAHC, State, FDA)
 Administered by properly trained personnel
 Nationally recognized practices (SGNA, ASGE, etc)
 Dept training and competency policy
 Guidelines (Examples)
 Documented training/competency
 Quality Monitoring of each sedation case
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 Assessment process
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Continued
 Policy (Examples)
 Number of staff in each procedure room
 How often VS are taken
 Discharge instructions
 Liability (when the unexpected happens)
 Did you perform your trained
responsibilites in a customary
way that others in your same role would perform under the
same or similar circumstances?
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SF
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Why Do We Need Policies and
Competency?
 To care for our patients safely and effectively.
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To prevent disaster
To protect us legally
To build confidence
To standardize practices
To validate that staff are properly trained
 To care for our patients safely and effectively.
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Competency
 “An ability to do something, especially measured against a
standard.”
SEDATION COMPETENCY
 Knowing and following national standards (based on EBP)
 Knowing and following the drug label
 Knowing how to intervene effectively if a crisis arises
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Competency is not…
 Taking a class
 Passing a test (written or clinical)
 Getting CE’s
 Doing something the way you have always done it (unless
it is the standard of care)
 Doing it because this is the way you were shown to do it
(unless it is the standard of care)
 Administering sedation without an event
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Always remember this question
 Did you performs your
learned responsibility
in an ordinary
fashion that anyone
else in your position
would perform it in a same
or similar situation?
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Who Can Administer Sedation
for Procedures?
 Physician
 Dentist
 Registered nurse
 Radiology technologist ( in the presence of the
direct supervision of an individual permitted to perform
procedures under sedation)
 CRNA
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Key Points to Successful
Sedation Administration
 Staff must possess skills in airway management.
 A secure IV access ,emergency equipment and reversal
agents must be available.
 Know and respond to warning signs (restlessness and
agitation must ALWAYS first be evaluated as potential
hypoxia.)
 O2 saturation does not equate to ventilation.
 Room environment
 Know patient previous response to sedation
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Key Points to Successful
Sedation Administration
 Staff must possess skills in airway management.
 A secure IV access ,emergency equipment and reversal
agents must be available.
 Know and respond to warning signs (restlessness and
agitation must ALWAYS first be evaluated as potential
hypoxia.)
 O2 saturation does not equate to ventilation.
 Room environment
 Know patient previous response to sedation
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Tips for Successful Sedation of the
Difficult to sedate patient?
Know your patient BEFORE you schedule the exam.
Know to what degree your patient may be affected by AOD.
Review the case with your physician
Schedule patient with anesthesia when necessary or possible
Use Droperidol using proper criteria
Use Phenergan prior to the procedure
Be prepared for administration of larger doses of routine sedation
agents.
 Be prepared to treat the patient who may become deeply sedated
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Regulatory Standards (JC, AAAHC, CMS)
 Sufficient number of qualified staff are present
 Individual administering moderate or deep sedation much be
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qualified to do so
RN must at least supervise nursing care provided to patient
Appropriate equipment must be immediately available
Resuscitation equipment must be available with a person
trained in proper use of the equipment
Patient must be assessed ( H&P)
Patient must be assessed immediately before sedation
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Regulatory standards Continued
 Time out must be performed
 Education must be provided to the patient before and after the
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procedure
Monitoring must occur throughout the procedure
Sedation medication must be monitored and documented
Patient assessment must be performed upon arrival to RR
DC must occur through DC criteria or by a qualified practionier
Verbal/Written DC instructions must be given/signed
Med Reconciliation must be completed and given to pt
PI monitoring of sedation cases must take place
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ASA Revised NPO Guidelines for
Sedation
 2 hours prior to sedation:
nothing by mouth
 Up to 2 hours prior to
sedation: clear liquids
 Up to 4 hours prior to
sedation: infants may have
breast milk
 Up to 6 hours prior to
sedation: may have nonhuman
milk and infant formula
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 Up to 8 hours prior to
procedure: may have solid
food
 Medications: gastric
stimulants, drugs that block
gastric acid secretion, and
antacids may be ordered preprocedure in patients with risk
of aspiration.
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Airway Assessment
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Airway assessment
Why do we EVALUATE?
1 in 10,000 patients will have airway
problems
1% have a failed airway (pt. cannot be
intubated after 3 tries)
Be prepared for emergent intubation
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Assessment
How do we assess airway?
 History of airway compromise
 Physical assessment
 Morbidly obese
 Facial Hair
 Narrow Face
 Overbite
 Trauma
 Obstructions
 Neck Mobility
BE PREPARED
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IT IS TOO LATE TO ACCESS AN AIRWAY
WHEN YOUR IN A CRISIS
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Mallampati Grades
Class I
Soft palate, fauces,
Uvula, tonsular
pillars
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Class II
Soft palate, fauces,
Uvula
 Difficulty
Class III
Soft palate, base of
uvula
Class IV
Hard palate only
Mallampati Score
 Patient sitting up with neck extended
 Open mouth wide
 Protrude tongue
 No phonation
 View posterior pharynx
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Assessment / Documentation
 Pre-procedure is done before giving sedation. The
assessment and documentation should include:
 Intra-procedure begins when patient enters procedure
room before sedation is administered
 Post-procedure begins when sedation administration and
procedure has ended
 Assignment of ASA (American Society for Anesthesiologist)
classification per the physician.
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ASA Revised NPO Guidelines for
Sedation
 2 hours prior to sedation:
nothing by mouth
 Up to 2 hours prior to
sedation: clear liquids
 Up to 4 hours prior to
sedation: infants may have
breast milk
 Up to 6 hours prior to
sedation: may have nonhuman
milk and infant formula
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 Up to 8 hours prior to
procedure: may have solid
food
 Medications: gastric
stimulants, drugs that block
gastric acid secretion, and
antacids may be ordered preprocedure in patients with risk
of aspiration.
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Tips for Successful and Safe
Sedation Administration
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Staff must have knowledge of:
Dosage limits
Onset
Duration
Interaction
Precautions
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Tips for Successful Sedation of the
Difficult to sedate patient?
Know your patient BEFORE you schedule the exam.
Know to what degree your patient may be affected by AOD.
Review the case with your physician
Schedule patient with anesthesia when necessary or possible
Use Droperidol using proper criteria
Use Phenergan prior to the procedure
Be prepared for administration of larger doses of routine sedation
agents.
 Be prepared to treat the patient who may become deeply sedated
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Tips for Successful and Safe
Sedation Administration
START LOW AND ADMINISTER SLOW
 Initiate sedation at the lowest dosage
 Titrate slow
 CAUTION when administering 2 drugs.
THE NURSE IS THE MOST
IMPORTANT MONITORING TOOL.
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Equipment and
Supplies
 Cardiac monitor
 Intravenous supplies
 Pulse oximeter
 Emergency cart/AED
 Oxygen and
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administration
equipment
Bag valve mask device
Oral and nasal airways
Intubation tray
LMA
 Defibrillation equipment
 Reversal agents
 Suction equipment
 Blood pressure monitor
 Thermometer
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Pediatric/Geriatric Reminders
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Geriatrics
 Altered metabolism/excretion
 Liver or kidney or heart disease effects
 Weakened muscles
 Respiratory muscles
 Cough reflux
 Gastric sphincter
 Heart contractions
 May require lower dose
 May require same doses at less frequent intervals
 Watch for increase fall risk
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 Post procedure care after leaving facility
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Pediatrics
 Airway
 Small airway
 Larger tongue
 Less pulmonary reserve
 Easier to become hypoxic, harder to restore ventilation
 Dosing
 Dose by weight not by age
 When unsure have another HCP double check doses
 Rescue intervention
 Have appropriate size rescue equipment in room BEFORE
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starting procedure
 REVERSE WITH CAUTION
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DRUG
NAME
CLASS
D O SA G E
ONSET
DURATION
PEAK
ELIMINATION
R E V E R SA L
AGEN T
A D V E R SE
EFFEC TS
C O N T R A IN D IC A T IO N
PR E C A U T IO N S
MIDAZOLAM
Versed
Class: Benzodiazepine
Dose: IV: 0.25-2mg Q2-5
minutes
Onset: 30-60 secs.
Peak: 10-15 mins.
Duration: 1-2 hrs
Elim ination: Excreted in the
urine half life1.2-12.3 hrs
ROMAZICON 0.2 mg over 15
secs. May repeat over 60
seconds for total dose of 1 mg
FENTANYL
Sublimaze
Class: Opioid
Dose: IV 1.0mcg/kg, q 510mins.
Onset: 1-3 mins
Peak: 5-15mins.
Duration: 30-60 mins
Elim ination: Metabolized in the
liver Excreted by kidneys
Seizures, Respiratory depression
NARCAN 0.1 mg - 0.2 mg Q 2-3
Euphoria, laryngospasms, skeletal
minutes
muscle rigidity, bradycardia
MEPERIDINE
Demerol
Class: Opioid
Dose: IV:12.5 - 25mg Q2-15
minutes
Onset: 1-5 mins.
NARCAN 0.1 mg - 0.2 mg Q 2-3
Peak: 10-20 mins.
minutes
Duration: 1-2 hrs
Elim ination: Metabolized in the
liver Excreted by kidneys
MORPHINE
Duramorph: MS Contin,
Roxanol
Class:Opioid
Dose: IV: 1-4mg Q 2-15 mins.
Onset: 1-3 mins.
Peak: 10-20 mins.
Duration: 1-2 hrs
Elim ination: Excreted in the
urine and bile
NALOXONE
Narcan
Class: Narcotic
Antagonist
Dose: IV: 0.1- 0.2mg Q 2-3
mins.
Onset: 1-2 mins.
Peak: 5-15 mins.
Duration: 45 mins.
Elim ination: Excreted in the
urine
Excessive amount may cause
excitation reaction and cardiac
arrest.
Contraindication in patients w ith know n
hypersensitivity to naloxone. If administered to opioid
dependent patient severe w ithdraw al symptoms may
result. Administer w ith caution to patients w ith
supraventricular arrythmias, head injuries or
convulsive diso
FLUMAZENIL
Romazicon
Class: Narcotic
Antagonist
Dose: IV: 0.2mg over 15
secs.may repeat at 60 second
intervals up to max dose of 1
mg.
Onset:
30-60 seconds
Peak: 6-10 mins.
Duration: Influenced by the
dose administered and the dose
Agitation, dizziness, N/V fatigue,
blurred vision.
Contraindication in patients w ith know n
hypersensitivity to flumazenil or benzodiazepines for
anti-seizure treatment,cyclic antidepressant overdose,
caution in renal and kidney failure
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Pain at injection site, H/A,
Respiratory depression, Euphoria,
agitation, insomnia,N/V
Respiratory depression,
drow siness, dizziness, confusion,
H/A, convulsions at high dosed,
Tachycardia or bradycardia,
asystole, flussiong, tinnitus
Sedation, dizziness, delirium,
NARCAN 0.1 mg - 0.2 mg Q 2-3
seizure, nausea, hypominutes
hypertension, flushing, rash
Patients w ho receive narcotics may need smaller
doses.
Know n hypersensitivity to Fentanyl. Use w ith caution
in patients w ho have asthma, COPD, seizures, head
injury
Know n hypersensitivity to Demerol Use w ith caution
in patients w ho have asthma, COPD, seizures, head
injury, supraventricular arrhythmias
Use caution
in the elderly. M ay cause hypertension, anxiety,
tachycardia.
Know n hypersensitivity to Morphine, codeine,
hydrocodone, oxycodone. Use w ith caution to
patients w ith supraventricular arrhythmias, head
injury, increased intracranial pressure, asthma, COPD
seizure disorder.
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RESCUE
INTERVENTIONS
DURING SEDATION
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INDICATORS OF HYPOXEMIA /
INADEQUATE VENTILATION
MILD
 Slight pallor
 Increase heart rate
 Slight decrease in
respiratory rate
 Slight decrease in
baseline oxygen
saturation
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MODERATE / SEVERE
 Pallor
 Increase in heart rate
 Shallow respirations
 Decrease in respiratory rate
 Decrease in oxygen saturation
 Delayed capillary refill (in
Pediatric Patient)
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Airway Management
AIRWAY MANAGEMENT
 Attempt to awaken patient first
 Reposition head- sniffing position
 Insert airway: nasal or oral
 Mask ventilation
TIPS
 Best way to deal with trouble is to avoid trouble, learn the signs of bad
airway.
 Most patients who have respiratory compromise can be managed with
simple maneuvers
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What is a rescue intervention?
 Chin lift > than 30 seconds
 Oxygen delivery necessary to increase O2
 Airway (oral or nasal)
 Ambu
 Reversals
 Intubation
 Code
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Sedation Bloopers
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Stepping on O2 tubing
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Syringes
Unlabeled syringes
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Wrong size airway
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Wrong size ambu bag
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Unattended narcotics
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Others Bloopers…
 Pulling out the ambu bag and losing the mask on the floor
 Improper intubations
 Oblivious to staff narcotic misuse
 Malfunctioning Intubation blade
 Drug administration to please physician
 Drug administration to please patient
 Using O2 NC > 6 liters
 Inability to perform (quickly) in crisis due to anxiety or lack of
training
 Treating patient without confirming monitoring issues
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Difficult to Sedate?? Now What?
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The Difficult to
Sedate Patient
Indicators
Chronic narcotic usage
Use of street drugs
Alcohol usage (31%)
Anxiety
Difficult or prolonged procedures
Past experiences with sedation and procedures
IBS/IBD
Antidepressants
History of substance abuse
 Assessment of lifestyle habits
 Old records
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How can you determine if a patient
may be difficult to sedate?
 Assessment of lifestyle habits
 Lab work
 Patient history
 Patient behavior/appearance
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Tips for sedation of the difficult to
sedate patient?
 Know your patient BEFORE you schedule the exam.
 Know to what degree your patient may be affected by AOD.
 Review the case with your physician
 Schedule patient with anesthesia when necessary or possible
 Use Droperidol using proper criteria
 Use Phenergan prior to the procedure
 Be prepared for administration of larger doses of routine sedation agents.
 Be prepared to treat the patient who may become deeply sedated
 EtCO2 monitoring
 SCHEDULE AHEAD FOR DEEP SEDATION WHEN NECESSARY
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Drug requirements for difficult to
sedate patients
 Patients with alcohol and
drug dependencies (AOD)
often require 2.5 times
more sedation agents than
patients without AOD
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 When Propofol is used for
sedation the patient does
not routinely require
additions amounts to
achieve the same level of
sedation
Never assume all difficult to
sedate patients are drug abusers
4/9/2015
Adjunct Drugs to administer to
promote a positive outcome in the
difficult to sedate patient.
• Phenergan- 25 mg IV 15 to 30 minutes
prior to procedure
• Benadryl- 25 to 50 mg IV
• Droperidol- ONLY if patient not high
risk for QT problems and if cannot use
propofol
• Propofol
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Hot topics and updates in Sedation
 Airway
 CMS requirements
 Staffing
 Time out
 Medical Reconciliation
 New and upcoming technologies/drugs
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:Latest CMS
updates in
Sedation 2009
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Summary of 2009 CMS Guidelines
“Because we cannot always predict individual pt response
to drugs, procedures must be in place to ensure pt
rescue from a deeper level of sedation than intended.”
“Health Care Facilities must have policies and procedures
consistent with the State scope of
practice law that assure all anesthesia services
are provided in a safe, well organized
manner by qualified personnel.
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