Transcript Procedural Sedation

Procedural Sedation for Clinicians
Barnes-Jewish Hospital
Initial Appointment
Developed 5/2008
Learner Outcomes:
* State the definitions of sedation according to JCAHO
* Describe what patient response is expected for each degree of sedation
* List appropriate pre-procedural patient assessments.
* List the ongoing assessments, which should be monitored during the
procedure.
* List the common complications of Procedural Sedation
* Discuss the management of the common complications.
* Explain what is included in the post-procedural care.
* Explain the evaluation for patient discharge from the interventional
area/hospital.
* Describe components of an airway assessment.
* Identify appropriate medications for Procedural Sedation, considering
patient-specific characteristics.
* Outline the role for reversal agents used to reverse sedatives and describe
the required monitoring parameters.
What is Procedural Sedation?
• Procedure (n) A series of steps taken to accomplish an
end. Examples: EGD, bronchoscopy,
fracture/dislocation reduction, cardiac catheterization
• Sedation (n) Reduction of anxiety, stress, irritability,
or excitement by administration of a sedative agent or
drug.
• Procedural Sedation (n) Reducing anxiety or stress
with medications in order to perform a procedure.
These medications may include, but are not limited to
Opiates (e.g., morphine, fentanyl) and
Benzodiazepines (e.g., midazolam, lorazepam).
Definitions: Four Levels of Sedation and
Anesthesia (per JCAHO)
Minimal sedation (anxiolysis)
A drug-induced state during which patients respond
normally to verbal commands. Although cognitive
function and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected;
Patient is fully responsive.
Description per Richmond Agitation-Sedation Scale:
Briefly awakens with eye-contact to voice, >10 seconds
Moderate sedation
A drug-induced depression of consciousness during which
patients respond purposefully to verbal commands,
either alone or accompanied by light tactile stimulation.
No interventions are required to maintain a patent airway,
and spontaneous ventilation is adequate. Cardiovascular
function is usually maintained;
* Stable vital signs, intact airway.
* Patient responds to verbal stimulation - may utilize light touch to
support verbal stimulation.
* Patient follows simple commands
Description per Richmond Agitation-Sedation Scale: Movement or eye-opening
to voice, (but no eye contact) < 10 seconds
Deep sedation
A 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 maybe impaired.
Patients may require assistance in maintaining a patent airway
and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained;
* Patient only responds to repeated or painful stimulation.
* Patient does not follow commands, but may move spontaneously.
* Respiratory depression is possible: may include decreased
respiratory rate and/or difficulty maintaining an open airway.
* BP / pulse remain stable.
Description per Richmond Agitation-Sedation Scale: No response to voice, but
movement or eye opening to physical stimulation
Anesthesia
Consists of general anesthesia and spinal or major regional anesthesia.
It does not include local anesthesia. General anesthesia is a
drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation. The ability to independently
maintain ventilatory function is often impaired. Patients often require
assistance in maintaining a patent airway, and positive pressure
ventilation may be required because of depressed spontaneous
ventilation or drug-induced depression of neuromuscular function.
Cardiovascular function may be impaired.
* Depression of life sustaining functions (may include respiratory
depression and/or change in BP and pulse)
* No patient response to stimulation, even painful stimulation.
Description per Richmond Agitation-Sedation Scale: No response to voice or
physical stimulation
Sedation Continuum Moving from one state of conscious to another
is a dose-related continuum that depends on patient response NOT
type, dose or route of medication, or any other external factors..
MINIMAL
SEDATION
(ANXIOLYSIS)
MODERATE
SEDATION
DEEP
SEDATION
ANESTHESIA
Response
Normal
response to
verbal
stimulation
Purposeful
response to
verbal or
tactile
stimulation
Unarousable
even with
painful
stimulus
Airway
Unaffected
Spontaneous
Ventilation
Unaffected
No
intervention
required
Adequate
Purposeful
response
following
repeated or
painful
stimulation
Intervention
may be
required
May be
inadequate
Cardiovascular
Function
Unaffected
Usually
maintained
May be
impaired
Usually
maintained
Intervention
often required
Frequently
inadequate
The person monitoring the patient and/or the person
performing the procedure must be prepared and competent to
treat one level lower than the anticipated sedation level.
The most common indication patient may be beyond moderate
sedation into deep sedation is respiratory depression.
If the patient develops significant respiratory depression, the
clinician and assistant must be prepared to support the paitent’s
airway through oral/nasal airways and bag-mask ventilation.
In addition, the clinician must be prepared for insertion of a
definitive airway: for example, endotracheal intubation or
laryngeal mask airway.
Question 1
Which of the following notation by the Assistant would best
indicate your patient’s sedation is maintained at a moderate
sedation level?
A. Opens eyes to sternal rub
B. BP 128/68
C. Follows simple commands
D. RR remains 14-16
Answer: C
Question 2
Within 5 minutes of the end of the procedure, your patient is
snoring loudly and occasionally appears to have sleep apnea.
When you vigorously shake his shoulder and call his name
loudly, he arouses and takes a deep breath. This description
most accurately describes which of the following?
A. Anxiolysis
B. Moderate sedation
C. Deep sedation
D. General anesthesia
Answer: C
Question 3
You have given Ms Gray Midazolam 3 mg IVP and
Morphine 2mg IVP. She remains alert but states she
feels more relaxed. Select the level of sedation this
patient has received.
A. No sedation
B. Light sedation (Anxiolysis)
C. Moderate sedation
D. Deep sedation
Answer: B
Question 4
What is an indication your patient may be dropping
from moderate sedation to deep sedation?
A. BP drops from 128/62 to 118/56
B. SpO2 drops from 99% to 90%
C. Apnea develops
D. The patient squeezes your hand on command
Answer: B
Oral Intake Guidelines
• Age does not matter – what they took orally is the issue.
• Ingested Material
–
–
–
–
–
Clear Liquids
Breast Milk
Infant Formula
Non-clear Liquids
Light Meal
Minimum Fasting Period
2 hours
4 hours
6 hours
6 hours
6 hours
• Options for the patient not within these guidelines:
– Cancel the Procedure
• Postpone the Procedure
Emergent Procedures
• Emergent Procedures are life- or organ (i.e., CNS)
saving procedures (consult anesthesiology)
• Urgent procedure are those which need to be done
in 2-4 hrs
– Document why it is urgent;
– Assess the need for sedation and preferably
administer none;
– Consider postponing, or consult anesthesiology
– Monitor the patient's airway closely, and
– Look for active or silent regurgitation and aspiration.
Risk Assessment
• Risk Assessment: ASA PS (physical status)
classification
• ASA PS correlates with overall risk
• Needs to be used as a tool along with other
factors such as type of procedure, medications,
clinician comfort / skills
• “E” is added to the ASA PS number when the
procedure is done on an emergency basis This
indicates there is an increased risk due to the
emergence of the patient’s condition,
preparation or required procedure.
ASA PS (physical status) classification
Definition Details
ASA A
PS 1 normal
Healthy individual with no
systemic disease, undergoing
healthy elective surgery. Patient not at
patient extremes of age. (Note: Age
is often ignored as affecting
operative risk; however, in
practice, patients at either
extreme of age are thought to
represent increased risk.)
ASA A
Individual with one system,
PS 2 patient well-controlled disease.
Disease does not affect daily
with
activities. Other anesthetic
mild
systemic risk factors, including mild
disease obesity, alcoholism, and
smoking can be incorporated
at this level.
Examples
Fit patient with inguinal
hernia.
Fibroid uterus in an
otherwise healthy woman
Non-limiting or only
slightly limiting organic
heart disease.
Mild diabetes, essential
hypertension, or
anemia.
ASA PS (physical status) classification continued
ASA
PS 3
ASA
PS 4
Definition Details
Individual with multiple
A
patient system disease or well
controlled major system
with
disease. Disease status
severe
limits daily activity.
systemic
However, there is no
disease immediate danger of
death from any
individual disease.
A patient Individual with severe,
incapacitating disease.
with
Normally, disease state
severe
systemic is poorly controlled or
end-stage. Danger of
disease
that is a death due to organ
constant failure is always present
threat to
life
Examples
Severely limiting organic heart
disease. Severe diabetes with
vascular complications.
Moderate to severe degrees of
pulmonary insufficiency.
Angina pectoris or healed
myocardial infarction.
Organic heart disease showing
marked signs of cardiac
insufficiency, Persistent
anginal syndrome, or active
myocarditis. Advanced
degrees of pulmonary, hepatic,
renal, or endocrine
insufficiency.
ASA PS (physical status) classification continued
Definition
ASA PS 5 A
Details
Patient who is in
moribund imminent danger of death.
patient not Operation deemed to be a
expected to last resort attempt at
survive (24
preserving life. Patient not
hrs)
expected to live through
the next 24 hours. In some
cases, the patient may be
relatively healthy prior to
catastrophic event, which
led to the current medical
condition.
ASA PS 6 A declared
brain-dead
patient /
organ
donor
Examples
Burst abdominal
aneurysm with
profound
shock.
Major cerebral
trauma with rapidly
increasing
intracranial
pressure.
Massive pulmonary
embolus.
Informed Consent
*
The person performing the procedure (clinician) is to review objectives,
risks, benefits and alternatives of Procedural Sedation (informed consent)
*
This can be done at the same time as the procedure is explained
*
Informed consent for the sedation does not require a patient signature.
Rather there is a check box on the Pre-Procedure/Pre-Sedation Assessment
form. If paper forms are not available, it is the responsibility of the clinician
to document this in the pre- procedure note.
*
If the person who will monitor the patient (assistant) finds that the patient has
additional questions, the person performing the procedure (clinician) will be
contacted to answer these questions before sedation is given.
Responsible Individual for discharge planning
• The person who will provide the patient’s ride home and be available
to the patient after the procedure will be identified before the
procedure begins.
• This person may be an adult, or someone in their late teens that the
patient feels comfortable with.
• If the patient is an outpatient, this person frequently accompanies the
patient to the hospital
• If the responsible individual is not present, hospital staff need to verify
the individual by telephone.
• If the patient is an inpatient, it may not be necessary to identify this
individual pre-procedure.
• If the inpatient is discharged within 24 hours of the procedure, the
patient must be discharged to a responsible individual.
Responsible individual?
• For outpatients: If either the clinician (person performing
the procedure) or the assistant (person monitoring the
patient) feels the individual present would not be
appropriate in this role, or the patient has no one identified,
the clinician needs to determine:
– Can the procedure be cancelled (or postponed) until a
responsible individual is available?
– Should the procedure be completed and the patient kept
an additional 4 hours after discharge criteria are
reached, then released with appropriate transportation?
Discharge to Responsible Person
Guidelines:
Best Practice: Patient accompanied by Responsible Adult
If no responsible adult present at patient admission, staff
should
-Verify via phone the responsible adult who will be
present at discharge
-Or
-Identify a responsible individual to whom the patient can
be reasonably transported after the procedure
How do I know the
person is responsible?
Use your professional
judgment.
-Or
-Cancel the Procedure!
If no responsible adult present after the procedure is completed,
observe the patient for 4 hours after completion of the recovery period,
then discharge (patient must not drive for 24 hours after sedation).
Pre-Procedure/Pre-Sedation Assessment form (required for all
procedural sedation) includes documentation of the following:
Review of Systems:
*
Can be completed by nursing or medical staff. If completed by nursing, must
be reviewed by the clinician completing the pre-procedure assessment.
Focused Assessment:
*
Must be completed by a licensed independent practitioner according to
Medical Staff Bylaws. It includes procedure-specific parameters, and
addresses any new or pertinent data seen on the Review of Systems.
Airway Assessment:
*
Aim is to plan for airway management if that would be necessary.
*
Assessment parameters may include
* Assessing dentures, loose teeth, partials, etc.
* When the patient opens his/her mouth, how easily can the cords and
pharynx be visualized should intubation be necessary.
* Are there physical limitations, which would impede proper positioning
should intubation be necessary, such as kyphosis, short neck, etc.
•Pre-Procedure/Pre-Sedation Assessment form (required for all
procedural sedation) includes documentation of the following:
Risk Assessment (ASA PS Score)
* To be completed by clinician, even if you’re not Anesthesia personnel
Risks/Benefits/Alternatives for Sedation
*
Required discussion with patient should be documented either on outpatient
forms, or in procedure note
Risks/Benefits/Alternatives for Procedure
* As above, with the addition of signature on procedural consent
Sedation Plan:
*
The level of sedation that was presented to, and accepted by the patient. This
must be documented before initiation of the procedure.
Prevent wrong site / wrong patient / wrong limb /
wrong equipment
• Site Verification / Marking “YES” on the procedure site
– Must be completed before the procedure starts
– Is the responsibility of the person performing the procedure (clinician)
– Should be a process which includes patient input / verification /
understanding
• TIME OUT!
– To be completed immediately before the first dose of sedation / start of
the procedure.
– Is the responsibility of the clinician, although may be documented by
the assistant
– Should be a group interaction (clinician, assistant, others present in the
room)
– Includes four questions:
1. Is this the Correct Patient?
2. Is this the Correct Procedure?
3. Is this the Correct Site?
4. Is this the Correct Equipment?
Intra-procedure Monitoring requirements
*
BP, Pulse, Respiratory Rate, SpO2 required immediately before the
procedure / first dose of sedation, monitored frequently and documented
every 10 minutes throughout the procedure and recovery period.
*
Mechanical noninvasive blood pressure is preferred, however may
use manual (cuff) method.
*
Continuous Pulse Oximetry
*
Sedation
* Assessed and documented with vital signs
* RASS Sedation Scale
Richmond Agitation Sedation Scale (RASS)
Term (not included
on documentation
forms)
Description
+4
Combative
Overtly combative, violent, immediate danger to staff
+3
Very agitated
Pulls or removes tube(s) or catheter(s), aggressive
+2
Agitated
Frequent, non-purposeful movement. Fights ventilator
+1
Restless
Anxious, but movements not aggressive, vigorous
Score
0
Alert and Calm
-1
Drowsy
Not fully alert, but has sustained awakening
(Eye-opening/eye-contact) to voice, ≥ 10 seconds
-2
Light sedation
Briefly awakens with eye-contact to voice, <10 seconds
-3
Moderate sedation
Movement or eye-opening to voice, (but no eye
contact)
-4
Deep sedation
No response to voice, but movement or eye opening to
physical stimulation
-5
Unarousable
No response to voice or physical stimulation
Intra-procedure Monitoring requirements
• EKG monitor is applied
*
Assistants may not be able to perform rhythm interpretation
*
Is used by the assistant as a tool to identify when more in depth
patient assessment is required
1). For example: heart rate drops, assistant may stimulate
patient, check BP, or other
2). Another example: heart rate accelerates, assistant may ask patient
about comfort level.
*
Assistants should notify the clinician for any noticeable changes in
rhythm, rate, or other concerns noted on monitor for further medical
direction.
* Capnography?
*
Although not essential this indicates if patient is ventilating
adequately.
*
This will indicate hypoventilation before pulse oximetry.
*
Currently available to intubated patients only
Question 5
A 55-year-old woman has a history of adult onset diabetes
mellitus. She also has a history of hypertension. Both
diseases are controlled by diet alone. This patient is an
ASA PS classification of:
A. ASA I
B. ASA II
C. ASA III
D. ASA IV
E. ASA V
Answer: B
Question 6
A 71-year-old woman has a history of diabetes and CHF. She is on
multiple medications from her physician including nitropaste,
atenolol, lasix, and micronase. She lives a very sedentary life. She
presents for an EGD for a work-up of her “guiaiac positive stools.
On physical exam you hear rales ¼ of the way up on both lung
fields. This patient is an ASA PS classification of:
A. ASA I
B. ASA II
C. ASA III
D. ASA IV
E. ASA V
Answer: D
Question 7
A 55-year-old man is to have a closed reduction of a fractured wrist.
He has a history of ASCVD and had a MI a few years ago. He
underwent a carotid endarterectomy last year. He reports that he
does get a little tired after walking one block and has to rest after 1
flight of stairs. This patient is an ASA PS classification of:
A. ASA I E
B. ASA II
C. ASA III E
D. ASA IV
E. ASA V E
Answer: C
Question 8
Required monitoring parameters during the procedure include:
A. Heart rate, blood pressure, and oxygen saturation
B. Heart rate, rhythm interpretation, blood pressure,
respirations, oxygen saturation and level of sedation.
C. Heart rate, rhythm interpretation, blood pressure, oxygen
saturation, capnography and respirations
D. Heart rate, blood pressure, respirations, oxygen
saturation and level of sedation
Answer: D
Question 9
Informed consent needs to be obtained before
conscious sedation is administered. Which of the
following need not be included in Mr. Brown’s
informed consent?
A. Medications planned for Moderate Sedation
B. Benefits of Moderate Sedation
C. Alternatives to Moderate Sedation
D. Risks of Moderate Sedation
Answer: A
Question 10
The clinician is responsible for:
A. Sedation plan
B. Initiating the “Time Out”
C. Completing the history and physical
D. All of the above
Answer: D
Question 11
Which of the following is required for all outpatients
prior to the procedure?
A. Consent for sedation
B. Airway assessment
C. Presence of responsible adult
D. All of the above
Answer: D
Emergency equipment
* Oxygen with nasal cannula / mask
* Ambu Bag with mask
* Suction
* Crash Cart
* Airway box
* Reversal Agents
Complications
* Usually related to medications / patient response
* Respiratory Depression
- Patient stimulation may be all that’s needed
- Consider use of above emergency equipment
* Aspiration
- Suction
- May be silent. Watch skin color and SpO2
* Hemodynamic instability
- Consider fluid bolus
* For any complication, consider ACLS guidelines / calling a code (2-4700)
If respiratory depression and/or hemodynamic instability
occurs, consider use of reversal agents.
• Assistant Responsibilities
– Patient assessment and appropriate
documentation throughout the procedure
– Reassure patient and monitor patient
awareness.
– Provide comfort measures as needed
– Notify clinician of changes / concerns.
– Documentation of required parameters.
The Assistant is not to leave patient bedside for any reason
during the procedure (although may assist the clinician
with short, interruptible tasks) The assistant must be
able to drop those tasks if the patient needs attention)
Choosing appropriate medications
Agents should be chosen based on the desired
pharmacological response. Depending on the particular agent
one, two or all three of these below effects can be achieved:
* Anxiolysis
* Analgesia
*
Amnesia
Adverse effects - The potential side effects of any medication
in a particular patient must by considered. Many sedative
agents can produce cardiac or respiratory depression.
Pharmacokinetic Considerations
- When selecting a sedative, the following pharmacokinetic
parameters should be considered to optimize response in a
given situation.
* Onset and Duration
* Elimination Route
* Accumulation
* Drug interactions / potentiations
* Cross-Tolerance (e.g. patients with prior opiate use
may require higher doses of opiates; those with prior
ethanol exposure may require larger doses or
benzodiazepines, etc.)
Question 12
During the procedure Mr.... Green’s vital signs
should be documented at least:
A. Every 5 minutes
B. Every 10 minutes
C. Every 15 minutes
D. Beginning and end of the procedure
Answer: B
Question 13
The assistant’s responsibilities DO NOT include:
A. Documentation of vital signs
B. Patient comfort
C. Leaving the room to get supplies
D. Assisting with short interruptible tasks during
the procedure.
Answer: C
Question 14
Jane Smith is a 79-year-old female otherwise healthy female
who is to have a closed reduction of a right colles fracture
under moderate Sedation. Pre-procedure assessment includes
BP 142/74, P82, R18, T37.4, Sat 96% room air. Immediately
after administration of the medications, Mrs. Smith’s BP
drops to 108/56 and her heart rate rises to 98. What should be
the first intervention you provide?
A. Fluid Bolus
B. Romazicon 0.4 mg IVP
C. Page for Anesthesia
D. Cancel the procedure and reevaluate Mrs. Smith
Answer: A
Question 15
You have planned moderate sedation. You anticipate
the patient will achieve a RASS score of:
A. -1
B. -2
C. -3
D. -4
Answer: C
Question 16
During a painful procedure, you order morphine 4
mg IV. Within a few minutes of the morphine
administration the patient’s oxygen saturation is
92%. You should immediately:
A. Insert an oropharyngeal airway
B. Stimulate the patient
C. Apply non-rebreather mask at 12 L/min
D. Give a fluid bolus
Answer: B
Post-procedure Requirements
Procedural orders
*
*
*
*
Given orally throughout procedure
Written orders required
If assistant is utilizing handwritten documentation, sign, time and
date the bottom of monitoring form
If assistant is utilizing computer documentation, write orders for
medications etc. in patient chart when writing post-procedure
orders and notes.
Monitoring requirements
*
*
BP / P / RR / SpO2 documented every 10 minutes
Aldrete Score completed with each vital sign documentation
Baseline must be done before sedation initiated. This is
what post-procedure Aldretes are compared to.
ALDRETE POST PROCEDURE RECOVERY SCORE
Aldrete Post Procedure Recovery Score
Activity
Moves 4 Extremities voluntarily or on command
Moves 2 Extremities voluntarily or on command
Moves 0 Extremities voluntarily or on command
Circulation SBP ± 20 mmHg of Preprocedure Level
± 20-50 mmHg of Preprocedure Level
± 50 mmHg of Preprocedure Level
Preprocedure BP
/
.
Respirations
Able to deep breath or cough freely
Dyspnea, shallow, or limited breathing
Apneic or Mechanical Vent
Consciousness Awake (oriented, answers questions approp.)
Arousable on calling (responds to voice)
Non-responsive
Color
Normal
Pale, dusky, mottled, jaundiced, other
Cyanotic
Discharge score must be a minimum of pre-procedure score minus
one, with stable vital signs to meet discharge criteria.
TOTAL:
Base
Line
2
1
0
2
1
0
Post
Procedure
2
1
0
2
1
0
D/C
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
2
1
0
Post Procedure is done at the end of the procedure, then every 10 minutes until patient meets
recovery criteria. A minimum of 3 aldrete scores must be completed before the patient can be
identified as “recovered” When recovery criteria are met, the last (frequently the third) Aldrete
can be the D/C score.
Recovery criteria
*
A minimum of two consecutive Aldrete scores are baseline minus one with
stable vital signs
*
The patient’s room air oxygen saturation must be back to baseline
*
Sufficient time (i.e., a minimum of 1 hour) should have elapsed after the
last administration of reversal agents (naloxone, flumazenil) to ensure that
the patient does not become resedated after reversal effects have abated.
*
Patients who will be discharged to home and receive IV
medications for relief of pain, nausea, vomiting etc. must be
observed no less than two consecutive Aldrete / vital sign
assessments following administration of such medication
Discharge criteria
*
Vital signs stable (Vital signs include BP, HR, R,& O2 Sat. The VS are
determined to be stable if they are consistent with the patient’s age and with
the patient’s pre-operative VS)
*
Swallow, cough present (patient demonstrates ability to swallow
fluids and is able to cough
*
Able to ambulate (patient demonstrates ability to ambulate at preprocedure level)
*
Nausea, vomiting, dizziness is minimal
*
Absence of respiratory distress (patient’s respiratory effort
consistent with pre-procedure status)
*
State of consciousness (patient is alert, oriented to time, place and
person consistent with pre-procedure level of consciousness).
*
Level of comfort (Pain controlled as per BJH pain policy)
*
Post-procedure (oral and written) discharge instructions are
given to the patient and/or significant other regarding the following: purpose
and expected effects of sedation, patient’s care, emergency phone number,
medications, dietary or activity restrictions, and necessary precautions (e.g.,
no driving for 24 hours, avoid alcohol and use of power tools, etc.).
Question 17
After the procedure is completed, your patient’s
saturation drops , and Romazicon is given. She is
able to support her own airway and her saturations
return to normal. The minimal time she needs to be
monitored after the romazicon is given before
returning her to the nursing unit is:
A. 30 minutes
B. 1 hour
C. 2 hours
D. No more monitoring is necessary, the
benzodiazepine is reversed.
Answer: B
Question 18
After the procedure, your patient states she’s ready to
go home. Which of the following would indicate
that she would need to stay a little longer?
A. Dizziness when first sitting up.
B. Systolic BP 128-136 for the past hour
C. Wrist pain, reported 3/10
D. Aldrete score 2 below pre-procedure score.
.
Answer: D
Question 19
Mr. Brown’s mother has not arrived to driver her son
home yet. What should the nurse do?
A. Send Mr. Brown home in a cab
B. Wait another 30 minutes then allow Mr.
Brown to take a bus home.
C. Allow Mr. Brown to drive home
D. Release Mr. Brown only after a responsible
individual is present to drive
Answer: D
Question 20
Which of the following information should be
included in the discharge instructions when a patient
is discharged within 24 hours of receiving procedural
sedation?
A. Return to your normal activities
B. Avoid alcoholic beverages for the next 2 hours
C. Do not drive for 24 hours.
D. Clear liquid diet for 24 hours.
Answer: C
Procedural Sedation –
Pharmacologic Considerations
Case #1
A 76 year old male with a significant history of COPD,
hypertension, diabetes mellitus type 2, chronic renal insufficiency
and alcohol-induced liver failure presents for X procedure. The
decision is made to sedate the patient with midazolam. An initial
bolus dose of 5mg IV push is given and 10 minutes later, the
patient remains at his baseline level of consciousness.
Pharmacokinetics
Onset time (Single bolus dose)
Drug
Diazepam
Midazolam
Lorazepam
Fentanyl
Meperidine
Morphine
Onset Time (minutes)
1-2
3-5
10-20
1-2
3-5
5-10
Question 21
What is the usual Midazolam onset time and what is the
time interval that should elapse before a second
dose should be administered?
A. 30 seconds, 5 minutes
B. 1 minute, 1 minute
C. 3-5 minutes, 5 minutes
D. 10 minutes, 20 minutes
Answer: C
Case #2
A 44-year-old male with a significant history of HIV, Chronic renal
insufficiency, and diabetes mellitus type 2 presents for X
procedure. His current medicationRegimen that includes
ritonavir, lamuvidine, zidovudine, pravastatin, and metformin.
The patient is sedated with midazolam without apparent
complication. A 2 mg IV bolus x 1 is given with an observed
Ramsey score of 3 within 5 minutes. The level of sedation is
maintained throughout the procedure that is performed without
complication. 45 minutes into recovery (150 minutes from last
drug dose) the patient is observed to have difficulty walking
without assistance.
Pharmacokinetics
Duration of Effect (Single Bolus Dose)
Drug
Diazepam (Valium®)
Midazolam (Versed®)
Lorazepam (Ativan®)
Fentanyl
Meperidine (Demerol®)
Morphine
Duration (hours)
1-2
1-2
4-6
0.5-1
2-4
2-4
Pharmacokinetics
Route of Elimination
Hepatic
Renal
Diazepam (Valium®)
Midazolam (Versed®)
Lorazepam (Ativan®)
Fentanyl
Meperidine (Demerol®)
Morphine
Diazepam metabolites
Midazolam metabolites
Morphine metabolites
Meperidine metabolites
Propofol (Diprivan®)
Drug Interactions

CYP3A4 Inhibitors







azole antifungals
diltiazem
verapamil
protease inhibitors
macrolides
nefazadone
quinupristindalfopristin

Drug affected

midazolam
Question 22
What is the expected duration of effect of a
single bolus of midazolam?
A.
B.
C.
D.
20 minutes
1 to 2 hours
4 hours
6 hours
Answer: B
Question 23
What is the explanation for the prolonged
effect?
A.
B.
C.
D.
Drug-drug interaction
Chronic renal insufficiency
Too high of dose
None of the above
Answer: A
Case #3
A 28-year-old female with a significant medical history of
bilateral lung transplant secondary to cystic fibrosis presents
for X procedure. The patient is ordered to receive meperidine
75mg IV x 1, and midazolam 1 mg x 1. When obtaining the
pre-procedure history and physical the patient reports she is
allergic to meperidine. She received this drug during a
previous procedure and was observed to have visual
hallucinations.
Opioid Cross-Allergenicity
Morphine-like
 Morphine
 Hydromorphone
Meperidine-like
 Meperidine
 Fentanyl
Opioids
Equipotent Doses
Drug
Dose (mg)
Fentanyl
0.1
Hydromorphone (Dilaudid®)
1.5
Morphine
10
Meperidine (Demerol®)
75
Question 24
What alternative opioid agent should be
considered for moderate sedation?
A. Fentanyl
B. Morphine
C. Hydromorphone
D. B or C
Answer: D
Case #4
A 56-year-old female undergoing X procedure is complaining of
pain. 25 mcg of fentanyl is given in addition to the already
administered 2 mg of midazolam. 10 minutes after the dose of
fentanyl the patient is still complaining of pain. Another 25 mcg
of fentanyl is given, followed by another 25 mcg 5 minutes later
(total dose = 75 mcg in 25 minutes). Shortly after the third dose
of fentanyl, the patients breathing is observed to be extremely
labored and the pulse oximeter reveals an SaO2 of 89%. The
patient is placed on 4L/min O2 by nasal cannula with no
improvement in SaO2. The decision is made to administer
naloxone. 0.4 mg IV x 1. Within minutes the patient recovers
respiratory rate and function.
Naloxone (Narcan®)





Opioid antagonist
Dosing: 0.4–2 mg q 2-3 min, up to 10 mg
Onset time: 1-2 min
Duration of effect: 30-60 min
Adverse effects: precipitate withdrawal,
pulmonary edema
Flumazenil (Romazicon®)






benzodiazepine antagonist
Dosing: 0.2 mg q 1 min, up to 1 mg
Onset time: 1-2 min
Duration of effect: 30-90 min
Adverse effects: seizures
Reversing BZD-induced hypoventilation has
not been established
Question 25
What is the duration of effect of naloxone
and what is the minimum amount of time
after the dose that the patient should be
monitored?
A.
B.
C.
D.
30 min-1 hour, 30 minutes
30 min- 1 hour, 1 hour
1-2 hours, 1 hour
1-2 hours, 2 hours
Answer: B
Case #6
A 65 year old female presents to the emergency department
with a separated shoulder after a fall in her bathroom. She
rates her pain as 9/10. Meperidine 75 mg IV q 30 minutes is
ordered prior to the moderate sedation procedure to correct the
separation. What important history should be obtained prior to
meperidine administration?
Meperidine (Demerol®)
 Contraindicated in patients on MAOIs in
previous 14 days
 Phenelzine (Nardil®)
 Tranylcypromine (Parnate®)
 Effects of meperidine/MAOI combination
 Respiratory depression
 Hypotension
 Coma
 Other drugs w/ MAOI properties
BJH IV Medication Guidelines
Drugs with Level 1 MD Coverage
Level 1 Coverage: RN may initiate drug therapy
with a physician order, provided a physician is
available in person to the patient care area within
5 minutes of being contacted.
Fentanyl
Midazolam (Versed®)
Naloxone (Narcan®)
Flumazenil (Romazicon®)
Question 26
What important history should be obtained
prior to meperidine administration?
A.
B.
C.
D.
Allergy history
Seizure history
Medication history
All of the above
Answer: D
Question 27
What is the usual fentanyl onset time and what is the
time interval that should elapse before a second
dose should be administered?
A. 30 seconds, 1 minute
B. 1-2 minutes, 2 minutes
C. 8-10 minutes, 10 minutes
D. 15 minutes, 15 minutes
Answer: B
Please note:
• BJH residents must have an attending in the room
to provide procedural sedation.
• If unsure of drug dosage, please look them up.
• Please be familiar with the BJH IV Medication
Policy, and ask staff nurses if specific medications
are allowed to be given in that area.
• Thank you.
References
•
•
•
•
•
•
ASA (2002) Practice Guidelines for Sedation and Analgesia by NonAnesthesiologists. Anesthesiology. 96:1004-17.
Lin, DM & Wightman, MA. (2005). Sedation, Anesthesia, and the JCAHO (3rd ed.).
HCPro Inc. Marblehead, MA.
Sedation by Non-Anesthesia Personnel for Procedures. (2007) BJH
Policy/Procedure/Guideline
Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person
Surgery. (2007) BJH Policy/Procedure
Sessler CN, Gosnell M, Grap MJ, Brophy GT, O’Neal PV, Keane KA et al. The
Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care
patients. Am J Respir Crit Care Med 2002; 166:1338-1344.
Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S et al.
Monitoring sedation status over time in ICU patients: the reliability and validity of
the Richmond Agitation Sedation Scale (RASS). JAMA 2003; 289:2983-2991.