Transcript Moderate Sedation National Training

Moderate Sedation In-Service Training Web Course Credits
Developed by The Employee Education System in conjunction with the VHA National
Anesthesia Service
(Patient Care Services), Michael J Bishop, MD, Director
LEAD AUTHOR:
Vadim Vornik, MD, Department of Anesthesiology, North Texas VA
MODERATE SEDATION WORKGROUP MEMBERS:
•Beverly O’Connor-Griffin, CRNA, Bay Pines VA
•Susan T Brooks, RN, Baltimore VA
•Grace Chien, MD, Portland VAMC
•Kent Yucel, MD, Boston VA Health Care System
•Sean Kennedy, MD, (Anesthesiology Field Advisory Committee), Philadelphia VA
•Susan Valley, MD, (Anesthesiology Field Advisory Committee), Northern California VA HCS
•Jonathan Mark, MD, (Anesthesiology Field Advisory Committee)Durham VA
•Douglas Rotte, (Central Office Anesthesiology Health Systems Specialist)
EES PROJECT TEAM:
Richard Lussier, DR. P. H. - Program Manager, Employee Education System
Beau Chandler - Program Specialist, Employee Education System
Darea Chappelle - Program Specialist, Employee Education System
Russell Bennett, MBA - Media Producer, Employee Education System
General Information
•Privileges may be granted to a licensed
independent practitioner to perform procedures
under moderate sedation. Such privileges are not
required when monitored anesthesia care is
provided by an anesthesia provider.
•Moderate sedation training or evidence of ongoing
competency is required at the time of re-privileging.
•Evidence of mastery of the content of this course
or equivalent training is required for nursing
personnel who assist with administration of
sedation and monitoring.
Course Summary
•This course consists of eight parts:
–Definitions, Objectives, Standards, Guidelines
–Pre-sedation Assessment
–Sedation Pharmacology
–Monitoring and Documentation
–Airway Management
–Complications of Sedation
–Post-sedation Patient care
–Sedation of the Geriatric Patient
•Each part will require about 10-15 min to complete
•At the end of the course the final exam will be conducted.
You are required to have at least 75% correct answers in
order to get full credit.
Good Luck!!
Part 1: Definitions, Objectives,
Standards, Guidelines
JCAHO Standards Overview
•New JCAHO Sedation/Analgesia Standards
became effective in January 2004.
•The JCAHO Standards for sedation and
anesthesia apply when patients receive, in any
setting for any purpose, by any route, moderate or
deep sedation as well as general, spinal, or other
major regional anesthesia.
•These standards DO NOT apply to patients
receiving minimal sedation (anxiolysis).
The VA Moderate Sedation
Directive
•Strict adherence to the JCAHO sedation
standards
•Adequate training of all individuals administering,
monitoring, and or supervising moderate sedation
with mandatory supervisory CPR competence
The Goals of Moderate
Sedation/Analgesia
•Providing a comfortable and cooperative
patient
•Elevation of pain threshold
•Rapid recovery
Objectives of Moderate
Sedation
•Maintain adequate sedation with minimal risk
–The patient’s ability to communicate should be
preserved. Monitoring must be employed. Emergency
resuscitation must always be on hand.
•Relieve anxiety and produce amnesia when
desired
–These objectives are accomplished by means of good
preoperative communication and instructions as well as
administration of anxiolitic drugs.
•Provide relief from pain and other noxious stimuli
–Opioids are given to supplement local or topical
anesthetics as needed.
Levels of Sedation & Analgesia
Sedation and analgesia is a continuum and consist of the following states:
Minimal
Sedation
(anxiolysis)
Moderate
sedation/
analgesia
(conscious
sedation)
Deep
Sedation/
Analgesia
General
Anesthesia
Responsivene
ss
Normal
Purposeful*
response to
verbal/tactile
stimulation
Purposeful*
response to
tactile or
painful
stimulation
Unarousable
even with
painful
stimulation
Airway
Unaffected
No
intervention
required
Intervention
may be
required
Intervention
often required
Spontaneous
ventilation
Unaffected
Adequate
May be
inadequate
Frequently
inadequate
Cardiovascula
r function
Unaffected
Usually
maintained
Usually
maintained
May be
impaired
* Reflex withdrawal from a painful stimulus is NOT considered a purposeful response
Definitions
•Because it is not always possible to predict how
each patient will respond to sedative and/or
analgesic medications, practitioners intending to
produce a given level of sedation should be able to
rescue patients whose level of sedation becomes
deeper than initially intended!
e.g.: The practitioner who provides moderate
sedation must be able to manage a compromised
airway or hypoventilation in a patient who cannot be
easily aroused, but responds purposefully following
repeated or painful stimulation (deep sedation/
analgesia).
Part 2: Pre-sedation
Assessment
The Goals of Pre-Sedation
Patient Assessment
•Identify pre-sedation risk factors
•Determine if any pre-sedation investigations or
specialty consultations are required
•Optimize the patient’s condition prior to the
procedure
•Review available documentation related to
previous sedation/analgesia
•Formulate a sedation plan
•Obtain informed consent
•Reduce patient’s anxiety through education and
communication
Conducting the Pre-Procedure
Assessment
•The assessment is best conducted by the provider who will
participate in the administration of sedation. If it is not possible, a
different qualified staff member can perform the pre-procedure
evaluation. In any case, an LIP must either complete or sign off on
the assessment prior to the start of the case and/or administration of
sedation.
•When possible, pre-sedation assessment should be conducted
several days prior to the proposed procedure to allow sufficient time
for the collection of consults and laboratory results.
•The pre-sedation assessment must be completed before the
administration of any sedative agent. A set of vital signs must be
documented prior to giving any sedatives. On the basis of the
collected information a sedation plan should be developed and
clearly documented in the chart.
•The patient must be reassessed again immediately prior to the
procedure. Any interval changes must be documented in the chart
and addressed if necessary.
Components of the PreSedation Evaluation
•Documentation of relevant past medical
history
•Focused physical examination
•Collecting relevant specialists’
consultations and tests
Collecting the Past Medical
History (PMH)
•At least the following information should be
collected:
–Height and weight (obesity, malnourishment)
–Major organ systems abnormalities and evaluation of
the airway
–History of any previous adverse experiences with
sedation/analgesia as well as regional and general
anesthesia
–Drug allergies and current medications
–Tobacco, alcohol or substance use or abuse
–Time and nature of last oral intake
–An assessment of risk such as the American Society of
Anesthesiologists Physical Status
Obesity and Moderate Sedation
•Morbidly obese patients undergoing sedation are under
significantly higher risk of complications than non-obese
patients with otherwise similar medical problems
•The negative effect on organs and systems is directly
related to the degree of obesity with minimal changes in
overweight patients (BMI=25-29kg/m2) and maximal impact
on morbidly obese patients (BMI above 35kg/m2)*
•Obese patients have a high prevalence of obstructive apnea
and desaturate quickly. In general no sedative drugs should
be administered before all the monitors have been applied
and airway equipment is readily available
•Obese patients are prone to pulmonary aspiration
secondary to decreased gastric motility, increased gastric
volume and intra-gastric pressure. Pre-medication with
antacids, gastric stimulants and H2-blockers may be needed
prior to administering sedation
*Body Mass Index (BMI) = Weight (kg) / Height2 (M)
Pharmacokinetics and
Pharmacodynamics in Obesity
•In obese patients lipophilic drugs (benzodiaiepines,
opioids) may demonstrate longer elimination half-life. In
addition the sensitivity to the sedative drugs is
unpredictable in this population
•To minimize the development of deep sedation states,
dosage requirements for sedative medications should be
based on ideal body weight and NOT the patient’s actual
weight
•If obstructive sleep apnea is suspected further decrease in
dosage of sedative medications (as much as 50% to 70%)
may be needed
In general when dealing with obese patients titration to
clinical effect is the safest approach to avoid
oversedation
Sleep Apnea and Moderate
Sedation
•Sleep apnea is cessation of air flow for longer than 10 sec during sleep
leading to arterial hypoxemia and hypercarbia.
•If sleep apnea is suspected, pre-sedation assessment should include
questioning about associated signs and symptoms such as morning
headaches, overwhelming somnolence during normal waking hours,
loss of initiative, memory problems, etc.
•Institution of CPAP immediately after the procedure results in
significantly fewer desaturation episodes. Ask those patients who use
CPAP at home to bring their personal CPAP machines when coming
for the procedures. This approach helps to avoid delays with the
delivery of CPAP machines to numerous sleep apnea patients coming
to the hospital.
•Since sleep apnea patients are at increased risk for developing
hypoxemia after the procedure, they should receive written discharge
instructions to avoid taking any CNS depressants or consuming alcohol
in the immediate post-procedure period. In some cases 24-hrs in-house
observation may be considered.
PMH: Malnourished Patients
•Patients with nutritional disorders, carcinoma,
recent weight loss, advanced renal and liver
diseases may experience an exaggerated effect
from sedatives and analgesics as a result of the
CNS hypersensitivity to drugs and decreased
plasma protein binding ability.
•Titration of pharmacologic agents is advised in
such situations by administration of small
incremental doses slowly over several minutes
while continuously assessing the patient’s
condition.
PMH: Major Organ System
Diseases
Evaluation should focus on the following:
•Assessment for disease severity, stability and any
recent changes in the patient’s condition
•Assessment for prior and ongoing treatment and
determining the time of the last dose of medication
•Determining the variables that may affect the
patient’s sensitivity to sedative drugs, predispose
to airway compromise or/and cardio-pulmonary
instability
PMH: Previous Complications with
Anesthesia
Review any old anesthesia or sedation flow sheets
focusing on:
•airway management
•reaction to the medication
•family history of complications related to anesthesia
PMH: Current medications
Review the patient’s list of current medications
focusing on the drugs that might:
•affect pharmacokinetics or/and
pharmacodynamics of the sedatives (e.g.: MAO
inhibitors + meperidine  hypertension,
hyperpyrexia, coma)
•cause hemodynamic or respiratory compromise in
combination with sedatives (e.g.: ACE inhibitors +
sedatives  exaggerated hypotension)
PMH: Alcohol Abuse
•In addition to multisystem disease state, chronic
alcohol consumption leads to cross-tolerance to
sedatives/analgesics.
•Patients who seem to be acutely intoxicated are
generally not good candidates for sedation
because it suggests they are not NPO and also
may not be able to follow post-procedure
directives. In such patients, the urgency of the
procedure should be weighed against the
potentially increased risk.
PMH: Stimulant Abuse
•Cocaine – is a potent vasoconstrictor and has direct negative
effects on the heart as well as causing coronary vasospasm,
dysrhythmia and seizures. Any elective procedures should be
delayed if the patient appears acutely intoxicated.
•Marijuana – produces mild to moderate sympathetic
stimulation, increases heart rate and myocardial oxygen
consumption, sometimes produces orthostatic hypotension.
Severe tachycardia warrants cancellation of the case.
•Amphetamines - Chronic abuse of amphetamines leads to
tolerance and psychosis. Catecholamine stores may be
depleted. Any elective procedure should be delayed if the
patient appears acutely intoxicated.
•Ecstasy – chemically resembles a combination of
amphetamine and mescaline. Most common complications
include hyperthermia, mental status changes, tachycardia,
tachypnea, profuse sweating. No procedure should be
performed till at least 6 hrs since last consumption.
Focused physical examination
•At a minimum, focused physical examination
should include the following:
–Baseline vital signs (BP, HR, RR, room air SpO2)
–Mental status, level of awareness
–Body habitus
–Auscultation of heart & lungs
–Airway assessment
–Any pre-existing neurologic or motor deficits
•If the collected information suggests presence of
a new serious medical problem, further detailed
evaluation will be necessary and elective
procedure should be delayed.
Perioperative Mortality
Class
Definition
Approximate
Mortality Rate
1
A normal healthy patient
0.06-0.08%
2
A patient with mild systemic disease and no
functional limitations
0.27-0.4%
3
A patient with moderate to severe systemic disease
that results in some function limitation
1.8-4.3%
4
A patient with severe systemic disease that is a
constant threat to life and functional incapacity
7.8-23%
5
A moribund patient who is not expected to survive 24 9.4-51%
hours with or without surgery
6
A brain-dead patient whose organs are being
harvested
E
The procedure is an emergency (for example, “2E”)
The ASA classification system was not intended to be used in patients undergoing minor procedures under
sedation/analgesia. Still, it remains useful in identifying high risk patients.
Guidelines to identify "high risk"
patients
1. Difficult airway
2. Age >70 years
3. Sleep apnea or airway obstruction
4. Morbid obesity
5. Severe major organ system disease resulting in ASA
score greater than 3
6. Drug or alcohol abuse
Although the majority of “high risk” patients are safely
managed by an experienced practitioner, consideration
should be given to consult an anesthesiologist if significant
difficulties are expected or invasive monitoring is required.
Laboratory testing
•Pre-procedure laboratory testing should be
guided by the patient’s underlying medical
condition and the likelihood that the results
may affect the management.
•A “routine” comprehensive laboratory
testing for asymptomatic patients is
discouraged since it increases cost but does
not improve safety.
Specialist Consults
•Whenever possible, appropriate medical
specialists should be consulted before the
administration of sedation to patients with
significant underlying conditions.
•Consideration should be given to consult an
anesthesiologist if:
–the patient is severely compromised or medically
unstable
–the patient has difficult airways
–the patient has a know history of complicated or
unsuccessful moderate sedation/analgesia
NPO Status
•NPO Guidelines for healthy patients:
•Clear liquids administered up to 2 hours before a scheduled
procedure do not alter residual gastric volume when compared with
the standard NPO overnight fasting
•Solid food consumption warrants 6-8 hr delay of a procedure
•The following factors slow down gastric emptying and
increase the risk of pulmonary aspiration (strict 6-8 hrs
NPO status is required for patients with these conditions no solid or liquid food is allowed):
–pregnancy
–diabetes with neuropathy
–esophageal dysmotility
–extreme anxiety or fear
–Obesity
- recent opioid administration
- severe pain
- trauma
- known GERD
- hiatal hernia
Documentation of the Preoperative
Evaluation
•A standardized pre-sedation evaluation
form should be completed prior to all
sedation procedures.
•The pre-sedation evaluation must be signed
by the attending physician in all cases.
Pre-procedure Patient Education
•By the end of the pre-sedation assessment the patient should
be given detailed instructions pertinent to the planned
procedure. At least the following issues should be addressed:
–NPO
–Time of arrival
–Estimated procedure time
–Medication instructions
–Procedure-specific guidelines (e.g.: bowel preparation, dye
preparations, etc)
•Patients must be instructed to arrange for a competent adult
to accompany them home. It is not acceptable to discharge a
sedated patient from the hospital without an accompanying
responsible adult. This designated person will assume postsedation care and will follow the post-procedure instructions. If
such person is not available, the procedure should be rescheduled or the patient needs to be lodged or admitted
overnight.
Last Preparations for the
Procedure
•The site, procedure and patient are accurately
identified and documented according to the JCHAO
requirements. Informed consent is re-checked.
•Presence of a responsible adult for post-procedure
home transportation or arrangements for lodging or
overnight admission are confirmed.
•The patient’s health status is re-evaluated
immediately before the sedation procedure, and any
changes from the last visit are documented and
addressed.
•Pre-procedure vital signs are checked and
documented.
Part 3: Sedation
Pharmacology
Titration to Clinical Effect
•Titration to clinical effect is considered to be the
safest approach to administering
sedation/analgesia
•Titration provides for slow, controlled rise in
plasma level
•Titration allows to combine different groups of
medications safely
General Recommendations
•The drugs should be titrated using minimal nesessary
doses with sufficient interval in between to allow enough
time for the drug to demonstrate its full effect.
•Dosage requirements for sedation generally decrease in
elderly patients, in debilitated patients and in patients with a
significant cardiac, pulmonary or CNS disease.
•Total doses and/or frequency of administration may also
need to be reduced in patients with renal and/or hepatic
dysfunction.
•Drugs that are anesthetic agents (e.g. propofol, thiopental,
methohexital, ketamine, etomidate, etc.) must be
administered by an anesthesiologist, nurse anesthetist or
by a licensed independent practitioner with sufficient
training and ability to rescue a patient from general
anesthesia.
Benzodiazepines (BDZ)
The following effects on major systems are
typically observed with the administration of
BDZs:
•Cardiovascular System: Systemic blood pressure is
slightly decreased.
•Respiratory System: This effect is usually insignificant
unless the drugs are administered quickly or combined
with other CNS depressants.
•Central Nervous System: These drugs provide antiseizures effect, produce anterograde amnesia,
anxiolysis and centrally-mediated muscle relaxation.
Opioids
• The following effects on major systems are
typically observed with the administration of
opioids:
•Cardiovascular System: Bradycardia (fentanyl, morphine) or
tachycardia (meperedine). Hypovolemic patients may develop
hypotension.
•Respiratory System: Respiratory depression or apnea. Extreme
caution must be exercised when administering to patients with COPD
or decreased respiratory reserve especially when combined with BDZ.
•Central Nervous System : Euphoria, sedation. Addition of other
CNS depressant drugs produces a synergistic effect.
•A sudden increase in muscle tone ("stiff-chest" syndrome) causing
difficulties with ventilation may occur if fentanyl is administered
rapidly. The treatment consists of assisted ventilation and naloxone
(IV). If hypertonus does not resolve within a minute, immediate
consultation with an anesthesiologist should be requested.
Administration and Doses of
Sedative Drugs
Drug
Single
Dose
Titration
Onset
Peak
Duration
Antagonist
Other
Midazolam
(Versed)
0.5-2
mg IV
Small
increments
every 3-5
min
1-2.5
min
3-5
min
20-40 min
Flumazenil
No active metabolites
Fentanyl
(Sublimaze)
25-50
mcg IV
Small
increments
every 3-5
min
1-5
min
3-5
min
30-60 min
Naloxone
May cause the
“stiff-chest” syndrome
Meperidine
(Demerol)
12.550 mg
Small
increments
every 1015 min
1-5
min
5-7
min
60-120
min
Naloxone
Causes less spasm of
smooth muscles. Avoid
in renal impairment, in
patients on MAO
inhibitors, in patients
with severe CAD (risk of
tachycardia)
Morphine
1-3 mg
IV
Small
increments
every 5-15
min
1-5
min
20-30
min
20-180
min
Naloxone
Lower the dose for
renal impairment
Reversal Agents: General
Consideration
•Reversal agents should be available whenever
opioids/BDZ are administered.
•Before or concomitantly with pharmacological reversal,
patients who become hypoxic or apneic should:
–Continue to receive supplemental oxygen (should always (!) be
available and administered to the sedated patient)
–Be stimulated and encouraged to breath deeply
–Receive mask ventilation if spontaneous ventilation becomes
inadequate
•After pharmacological reversal, patients should be
observed long enough to ensure that cardio-pulmonary
depression does not recur once the effect of the
antagonist dissipates.
•Routine administration of the reversal agents at the end
of the case is not recommended.
Administration and Doses of
Reversal Agents
Drug
Bolus Administration
Dose
Onset Duration Other
Flumazenil
(Romazicon)
0.2 mg
IV
Administer the dose
over 15 sec; may
repeat every 1min up to
max dose of 1 mg.
No more than 3 mg is
recommended in any 1hour period
0.5-1
min
60 min
May precipitate seizures
in patients chronically
treated with BDZ.
May cause cutaneous
vasodilatation,
sweating, flushing,
arrhythmias, HTN.
Naloxone
(Narcan)
0.1-0.2
mg IV
Administer 0.02-0.04
mg IV every minute till
the desired degree of
reversal is achieved.
The large bolus (0.2-0.4
mg IV) should be
reserved for emergency
reversal of profound
respiratory depression.
1 min
15-30 min
Caution must be utilized
when administering to
patients with preexisting
cardiac disease or
patients with known or
suspected physical
dependence to opioids.
Part 4: Monitoring and
Documentation
Monitoring: The Basics
•The administration of moderate sedation/analgesia for each patient is
documented in the medical records regardless of the duration of the
case.
•At a minimum, the procedure flow sheet should include vital signs:
1. Before giving the first dose of the drug
2. After the administration of the sedatives/analgesics
3. At regular intervals during the procedure (max interval is 5 min)
4. During the initial recovery
5. Just before discharge
•A designated individual ("monitoring person"), other than
practitioner performing the procedure, must be present to provide
monitoring:
–Throughout the procedure a monitoring person should have no other
responsibilities apart from the continuous monitoring of the patient.
–Under certain circumstances institutional sedation policy may allow
the monitoring person to assist with minor tasks while maintaining
adequate monitoring once the patient's level of sedation / vital signs
have stabilized.
Monitors
•Minimal monitoring for moderate sedation
procedures include:
•Non-invasive blood pressure
•Pulse oximetry
•Respiration rate
•Level of consciousness
•Level of pain
•ECG for patients with significant cardiac disease
Level of Consciousness
•Evaluate the patient's behavior and response to stimuli on any
available standardized sedation scale:
•Observer's Assessment of Alertness / Sedation (OAA/S)
•Sedation Visual Analogue Scale
•Modified Ramsey Sedation Scale (RSS), e.g.:
Responsiveness
Score
Patient paralyzed, unable to assess level of sedation
0
Patient anxious, agitated, or restless
1
Patient cooperative, oriented, and tranquil
2
Patient sedated but responds to commands
3
Patient asleep but responds to glabellar tap
4
Patient asleep but responds to nail bed pressure
(no response to glabellar tap)
5
Patient asleep, no response to nail bed pressure
6
Monitor Alarms
•All monitors have alarms activated when the
patient's vital signs deviate from the preset
thresholds. These alarms become activated by
default whenever the monitors are turned on.
•The alarms must not be disabled during the
procedure, and the volume of the alarm should be
set high enough to be heard despite ambient noises
of the procedure room.
•Alarm limits should not be set broadly since it may
obscure a dangerous situation. Initial alarm limits
should be set approximately 20% above/below the
patient's pre-sedation baseline vital signs.
Moderate Sedation Flow Sheet
•During any sedation/analgesia procedures vital
signs, given medications, performed measures
and other intra-procedure events must be
documented. Most facilities will use a flow sheet
for this documentation.
•Vital signs are recorded every 5 min, and any
monitored artifacts should be documented to avoid
confusion and misinterpretations during a later
review of the record.
•The flow sheet should be signed by the attending
physician.
Part 5: Airway
Management
Applicable Anatomy and
Physiology of Airway
•The upper airway obstruction
(problems with structures above the
vocal cords) is the most common cause
of ventilation difficulties in sedated
patients, and is usually due to the
reduction of the space between the
posterior pharyngeal wall and the base
of the tongue.
•The pharynx, epiglottis, and vocal
cords play a role in protecting the lower
airway from aspiration. The most
important function is the glottic closure
reflex in response to direct glottic or
supraglottic stimulation, or as a reflex
response to visceral stimulation. The
physiologic exaggeration of this reflex,
laryngospasm can compromise
ventilation during a procedure.
Evaluation in the Airway
•The primary goal of airway examination is to predict
possible difficulties with spontaneous ventilation of sedated
patients as well as with positive pressure ventilation /
intubation, if it becomes necessary.
•Every airway examination should include:
–Oral cavity evaluation
–Temporo-mandibular joint evaluation
–Thyromental distance evaluation
–Atlanto-occipital movement evaluation
–Evaluation of the relationship between the tongue and other
structures of the oral cavity (Mallampati classification)
Evaluation of the Airway: Part 1
•Oral cavity evaluation: check the mouth opening (should be
at least 2 fingerbreadth to allow intubation in case of
emergency), presence of loose, chipped, broken, capped
teeth, dentures, tumors, gross deformities.
•Temporo-mandibular joint evaluation: assess mobility by
asking the patient to open the mouth as wide as possible
while palpating the temporo-mandibular joints in an attempt
to identify a limited range of motion or joint "locking".
•Thyromental distance evaluation: represents the straight
distance from the notch of the thyroid cartilage to the tip of
the mentum; if this distance is less than 6 cm or three
fingerbreadths (receding mandible, short muscular neck), the
larynx will be positioned anteriorly making intubation difficult.
Evaluation of the Airway: Part 2
•Atlanto-occipital movement evaluation: may be performed
by having the patient sit facing the examiner, then tilt the
head back as far as possible extending the atlanto-occipital
joint (normally at least 35 degree). Failure to adequately
extend the neck will make visualization of the glottis difficult
or impossible.
•Mallampati classification: based on the size of the tongue
and pharyngeal structures visible on mouth opening. The
bigger the tongue (higher MP class), the more difficult to
get a glottic view during laryngoscopy and the higher the
chances of airway obstruction with sedation.
Mallampati classification
•Class I = visualization of the soft palate, uvula, and pillars
•Class II = visualization of the soft palate and uvula
•Class III = visualization of the soft palate and the base of the uvula
•Class IV = soft palate is not visible at all
Equipment for Airway Management
Prior to any sedation procedure, necessary airway
equipment should be prepared and its condition
checked. At least the following equipment should
be available:
•Oxygen administration devices (nasal cannula,
simple face mask, Ambu bag)
•Nasal/Oral airways of different sizes
•Water-soluble lubricating gel
•Tongue blade
•Adequate oropharyngeal suction
Nasal and Oral Airway
•Nasal Airway
–displaces the tongue from the posterior pharyngeal wall
–the size of the nasal airway indicates the internal diameter in millimeters
–needed length is determined by measuring the distance from the tip of
the nares to the lobe of the ear
–usually better tolerated than oral airway
–not recommended in the presence of anticoagulants, cerebrospinal fluid
rhinorrhea, septal deformity, nasal polyps
–should always be lubricated prior to insertion and should never be
forced if resistance is felt
–long nasal airway may cause cough and laryngospasm
•Oral Airway
–displaces the tongue from the posterior pharyngeal wall
–may be the only possible solutions when the nasal airways are
contraindicated or impossible to place
–may stimulate the gag reflex or/and cause retching resulting in HTN and
tachycardia, bradycardia (vagal response), laryngospasm, dental
damage, pharyngeal or lip laceration
Effects of Sedatives/Analgesics on
the Airway
•Decrease hypoxic and hypercarbic respiratory drive
•Cause loss of the upper airway muscle tone with
subsequent narrowing of the upper airway lumen
•Cause obstruction of the airway by the soft tissues as the
muscles supporting the soft tissue of the pharynx (tongue,
epiglottis) lose their normal tone
•Decrease activity of the brain cortex allowing disinhibition
of the protective reflexes in response to airway stimulation
by saliva / foreign materials and leading to laryngospasm
Airway Management in Sedated
Patients
The following action sequence is recommended to restore
adequate ventilation and oxygenation in case of upper
airway obstruction during sedation/analgesia:
1. Auditory/tactile stimulation of the patient.
2. Lateral head tilt (results in tongue displacement to the side, away from the
posterior pharynx).
3. Chin lift (permits anterior movement of the mandible with elevation of the
airway soft tissue anteriorly).
4. Jaw thrust (provides significant anterior displacement of the mandible,
stretches the neck, moves supra-epiglottic soft tissue anteriorly.
Airway obstruction not relieved by above mentioned
measures signifies oversedation and may require
immediate consultation by an anesthesiologist!
5. Nasal/oral airway insertion
6. Pharmacological reversal of sedative/analgesics
Dealing with Laryngospasm
•This is uncontrolled spasm (glottic closure) of the vocal cords.
•May be provoked by mucus, blood, saliva, locally instilled drugs, acrid
smell, manipulation of airway, pain, or visceral distention.
•May be incomplete (some air movement is present, inspiratory stridor,
accessory respiratory muscles use) or complete (complete airway
obstruction, no respiratory sounds; chest & diaphragm movement may
be present, but not effective - "paradoxical breathing")
•Treatment (procedures and sequence):
1.Stop the procedure to avoid any additional stimulation
2. Suction oropharynx if the local irritants are suspected to be the
cause of laryngospasm.
3. Call Anesthesiologist or in house airway management resource
stat while attempting a jaw thrust and mask ventilation with 100% 02
4. Consider Lidocaine IV bolus 0.5-0.8 mg/kg
Part 6: Common Complications
of Sedation
Hypoxia
•Definition: Sp02 <90%
•Diagnosis of hypoxia (auscultation, palpation, visualization):
–Continuously monitor the patient's respiration (mask fogging, chest
movement, etc.)
–Go with pulse oximetry, NOT color of the skin since cyanosis is a late
sign of hypoxia and develops only at Sp02<70%
–Never disable monitor alarms! Keep pulse oximeter signal loud!
–Have all the rescue airway devices checked and ready
•Treatment:
–Abort the procedure if possible and administer supplemental 02
–Proceed with airway manipulation to maintain its patency Institute
mask ventilation if needed
–Administration of pharmacologic reversal agents may be needed
Hypotension
•Definition: decrease of the BP below 30% of the patient's
baseline (know the patients' "usual" blood pressure!)
•Diagnosis:
•Monitor NIBP every 3-5 min and use the correct size cuff
•Check pulse if the BP reading is questionable
•Check pulse oximeter plethysmogram - it reflects peripheral tissue
perfusion
•Treat sudden mental status change or nausea as a sign of low BP until
proven otherwise!
•Treatment:
•Abort the procedure if possible
•Address the most probable cause first (hypoxia, hypovolemia,
peritoneal stretching, etc.)
•Administer IV fluid bolus
•If the problem persists despite abovementioned measures request
immediate anesthesiologist consult or in-house airway management
resource stat
Aspiration
•Definition: Inhalation of the gastric contents into the tracheo-bronchial
tree
•Diagnosis: Presence of stomach content in the mouth, coughing,
laryngospasm, sudden hypoxia, bronchospasm, dyspnea
•Treatment:
–Stop the procedure immediately, turn the patient's head to the side and suction the
oropharynx
–Consider placing the patient in the Trendelenburg position to prevent flooding of the
airway with the stomach content
–Once airway is cleared, apply 100% 02 by face mask and check for bilateral breathing
sounds
–If the patient remains hypoxic, proceed with hospital admitting for 24 hrs observation
–If (and only if) particular matter aspiration is suspected, the patient will need intubation
and bronchoscopy to remove the aspirated material from the trachea and large bronchi
–Empirical antibiotic treatment is recommended only in immunocompromised patients, or
if the patient aspirated feculent materials
–No benefit from empirical steroids administration after aspiration has been
demonstrated
•Prevention:
–Identify the at risk patients and premedicate with antacid, H2 blocker, metoclopramide;
delay non-emergent cases if patients are not NPO
–In emergency situations, consider lighter plan of sedation or consult an anesthesiologist
for securing the airway in a controlled fashion.
Documenting Complications
•The Moderate Sedation Tracking form should be completed for every moderate
sedation/analgesia procedure and submitted to the Clinical Quality Management.
These forms are utilized for statistical purposes as well as for determining a
provider specific / department-specific complication rate in order to improve the
quality of care.
•The cases in which any of the following events occur will be reported as
complications to the service/section chief and to the Quality Management:
•All cases in which naloxone or flumazenil is administered
•All cases requiring assisted ventilation
•All unanticipated hospital admissions secondary to moderate sedation
•All cases in which Sp02 was 10% below baseline for more than 5 minutes, including the
recovery period
•All cases of unanticipated hemodynamic instability, such as deviation of the blood
pressure >30% from the patient's baseline, onset of new dysrhythmias, a pulse rate of
120 or higher for 5 minutes or more unless this is the patient's baseline (e.g.: a patient
arriving to the EP lab for cardioversion / ablation)
•Every reported complication will be reviewed by the VAMC Moderate
Sedation Committee to determine the nature and severity of the
complication. If the Committee determines that there is a relationship
between the reported event and sedation administration, a meeting with
the sedation providers will be arranged to discuss the case in detail and
to develop a strategy to avoid similar problems in the future.
Part 7: Post-sedation
Patient Care
Recovery: Phase 1
Phase I represents initial recovery immediately after
completing the procedure.
• Phase I should be completed in a designated area, or if
such area is not available, in the post-anesthesia care unit
(PACU).
•Depending on the patient's status and procedure, this
period can be as short as 15 minutes.
•The Post-Anesthesia Recovery Score (PARS) of _> 9 or
return to baseline status are used as criteria to determine
that the patient has completed Phase I.
•If transportation to the remote recovery area is needed,
the patient must be accompanied by qualified personnel
and adequately monitored during the transportation.
Post-Anesthesia Recovery Scoring System
After patients completed Phase I of recovery they are eligible for discharge to a
less intensive setting if the total score from the following categories equals 9 or 10:
ACTIVITY (able to move voluntarily or on command)
RESPIRATION
4 extremities
2
Able to breathe deeply and cough freely
2
2 extremities
1
Dyspnea, shallow , or limited breathing
1
0 extremities
0
Apneic
0
CIRCULATION
CONSCIOUSNESS
BP +1- 20 mmHg pre-sedation level
2
Fully awake
2
BP +/- 20 - 50 mmHg pre-sedation level
1
Arousable on calling, mostly sleeping
1
BP +/- 50 mmHg pre-sedation level
0
Not responding or only responds to
painful stimuli
0
OXYGEN SATURATION
Able to maintain Oxygen saturation > 92%
on room air
2
Needs supplementary Oxygen to maintain
Oxygen saturation > 90%
1
Oxygen saturation < 90% even with
supplementary Oxygen
0
Some patients will be unable to score 9 or 10 due to a pre-anesthetic deficit. These patients must return to their baseline
prior to discharge
A score of 0 in any category excludes eligibility for discharge unless approved by a physician.
Recovery: Phase 2
•Phase II represents the time after the patient completed Phase I until the
patient is ready to be safely discharged home from Same Day Procedure
Unit ("Home Readiness"). For inpatients, Phase II is completed at their
assigned hospital areas (hospital wards).
•All outpatients will be discharged home by a qualified licensed
independent practitioner who is familiar with the patient or by using
established discharge criteria.
•Outpatients will always be discharged to the care of a competent adult. It
is the responsibility of the physician to ensure that this is accomplished.
The availability of a designated driver or assistant documented prior to
starting the procedure.
•No moderate or deep sedation/analgesia procedures should be
performed if a driver's or assistant's availability is not confirmed and
not documented on the day of the expected procedure.
•Under certain circumstances, when the patient does not have a
responsible adult to assist with home transportation, overnight lodging or
23-hrs observation admission should be arranged by the supervising
physician.
Post- Anesthesia Discharge Scoring System
(PADS) for Determining Home Readiness
A patient has completed Phase II of recovery when total score from the following categories equals 9 or 10.
VITAL SIGNS ( Vital signs must be stable for 1 hour and
consistent with age and preoperative baseline)
NAUSEA AND VOMITING (The patient should have
minimal nausea and vomiting before discharge)
BP and pulse within 20% of preoperative baseline
2
Minimal: successfully treated with PO
medication
2
BP and pulse 20 - 40% of preoperative baseline
1
Moderate: successfully treated with IM
1
BP and pulse > 40% of preoperative baseline
0
Severe: continues after repeated treatment
0
SURGICAL BLEEDING ( Postoperative bleeding should be
consistent with expected blood loss for the procedure)
ACTIVITY LEVEL
Minimal: does not require dressing change
2
Steady gait (no dizziness for 15 min or meets
preoperative level)
2
Moderate: up to 2 dressing changes required
1
Requires Assistance
1
Severe: more than 3 dressing
0
Unable to Ambulate
0
PAIN (The patient should have minimal or no pain before discharge. The level of pain that the patient has should be
acceptable to the patient. Pain should be controllable by oral analgesics. The location, type and intensity of pain should be
consistent with the anticipated postoperative discomfort)
Minimal
2
Moderate
1
Severe
0
Some patients will be unable to score 9 or 10 due to a pre-anesthetic deficit. These patients must return to their baseline
prior to discharge
A score of 0 in any category excludes eligibility for discharge unless approved by a physician.
Part 8: Sedation of
the Geriatric Patient
Effect of Aging on Sedation/Analgesia
Pharmacology
•Delayed response (up to 6-8 min) to the drugs, but increased magnitude
of the response due to increased CNS sensitivity to drugs
•BDZ:
–Effect is enhanced by increased sensitivity and decreased hepatic enzymes
activity.
–Generally a dose reduction of 30-50% is recommended
•Opioids:
–Increased sensitivity and decreased clearance leading to prolonged action and
enhanced effect.
–There is a higher risk of sudden hypotension and bradycardia with the
administration of opioids
•The risk of post-procedure delirium is high in this age group secondary to
physical limitations of the patients (hearing and visual loss), unfamiliar
environment, and prolonged drug effect. Maintaining voice contact and
careful drug titration may help to decrease the frequency of confusion
•Overall, the anatomic and physiologic changes associated with
aging predispose geriatric patients to pharmacologic
hypersensitivity that can easily lead to cardio-pulmonary collapse.
Dose reduction and longer intervals between administrations are
needed to avoid oversedation.
End Of Course!
•You have completed the course content. You must take the exam to
receive credit for this course.
•Version 1, June 2006
•Sources of Information:
–Joint Commission: Standards for Operative or Other High-Risk Procedures and/or the
Administration of Moderate or Deep Sedation or Anesthesia, January, 2004
–Dallas VA Hospital Policy for the administration of Moderate Sedation / Analgesia
(Conscious Sedation)
–Scammon FL, Klein SL, Choi WW: Conscious sedation for procedures under local or
topical anesthesia. Ann Otol Rhinol Laryngol. 1985;94:21
–Michael Kost: Moderate sedation/analgesia core competencies for practice, 2nd ed.
2004
–American Society of Anesthesiologists Task Force on Sedation and Analgesia by
Non-Anesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists. Anesthesiology. 2002;96(4):1006, 1013
–Barash PG, Cullen BF, Stoelting RK: Clinical Anesthesia, 4th edition 2000,
–Hurford WE et al: Clinical Anesthesia Procedure of the Massachusetts General
Hospital, 5th edition, 1997
–Morgan GE, MikhailmSM: Clinical Anesthesiology, 2rd edition, 1996.