Transcript Intravenous Sedation

Intravenous Sedation Monitoring
59 AMDG/Dental Squadron
Technician Orientation Module
Training Objectives
• Verification of current BLS training
• Use of automated monitoring equipment
• Physiologic norms and overview of
medications
• Overview of medical emergencies
• “Code Blue” procedures and “Crash Cart”
familiarization
Levels of Anesthesia
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Local anesthesia
Conscious Sedation
Deep Sedation
General Anesthesia
Local Anesthesia
• Elimination of sensations, particularly pain,
by the administration of a topical
application or regional administration or
injection of a drug
Conscious Sedation
• A minimally depressed level of
consciousness which allows the patient to
independently and continuously maintain a
patent airway and respond appropriately to
verbal commands
– Anxiolysis
– Moderate Sedation
Deep Sedation
• A controlled state of depressed
consciousness accompanied by a partial loss
of protective reflexes and the ability to
respond appropriately to verbal commands
General Anesthesia
• The elimination of all sensation
accompanied by the loss of consciousness
Stages of General Anesthesia
• Stage I
– Analgesia
• Stage II
– Delirium
• Stage III
– Surgical anesthesia
• 4 planes of surgical anesthesia
Stages of General Anesthesia
• Stage IV
– Medullary paralysis
Level of Anesthesia
• In the OMFS clinic, Dunn Dental Clinic and
MacKown Dental Clinic …..
– Stage I
• Otherwise known as “Conscious Sedation”
• In the Wilford Hall Medical Center OSOR
– Stage III
• “Deep Sedation”
• General Anesthesia
Provider Training
• Must be able to safely manage 1 level of
anesthesia beyond plane to be achieved
– If practicing Deep Sedation you must be able to
manage general anesthesia
Technician Responsibilities
• Pre-Procedure
– Equipment
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Instruments
Venipuncture
Monitors
Emergency Supplies
– “Crash Cart”
– Cardiac Monitor
– Medications
Technician Responsibilities
• Pre-Procedure Patient Assessment
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Vital Signs
Allergies
Contacts/Dentures
NPO status
Changes in medical history
• URI
• Hospitalizations
• Sick family members
Special Considerations
• Pediatric patients
– Not “little adults”
• Geriatric patients
– Unique subclass of patients with physiological
changes complicating treatment
“Show Stoppers”
• Food or fluid intake 6 hours prior to surgery
• Clear fluid intake within 2 hours of surgery
– Can read newspaper print when looking
through liquid
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Recent alcohol ingestion
Recreational drug use
Pregnancy
Thyroid Dysfunction
“Show Stoppers”
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Recent asthma attack or respiratory failure
Treatment with MAO inhibitors
Tricyclic Antidepressants
Adrenal Dysfunction
Renal Dysfunction
Technician Responsibilities
• Pre-Procedure Patient Assessment
– Informed Consent
– Escort Present
– Establishes patient’s mental status
• Under the influence of alcohol or drugs
• Oriented to person, place, time
– Document on AF 1417
• Clinical Sedation record
Technician Responsibilities
• Pre-Procedure Patient Assessment
– Supplemental oxygen applied
– Suction functioning
Technician Responsibilities
• Intraoperative Responsibilities – “Float”
– Informed consent signed prior to sedation
– Name, dose, route and time of all medications
documented
– Procedure begin and end times
– Prior adverse reactions
– Pre-medication time and effect
Technician Responsibilities
• Intraoperative Responsibilities – “Float”
– Vital Signs
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BP
Heart Rate
Respiratory Rate
Oxygen Saturation
Level of Consciousness
Technician Responsibilities
• Post-operative Responsibilities – “Float”
– Vital Signs at least every 5 minutes
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BP
Heart Rate
Respiratory Rate
Oxygen Saturation
Level of Consciousness
• Sedated patients must be continuously
monitored until discharged
The following values are
indicative of the “normal” adult
patient. Pediatric and Geriatric
patients have different values and
unique characteristics for which
the anesthesiologist/surgeon must
be aware
Blood Pressure
• Specifically mean arterial pressure (MAP)
– MAP
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Systolic BP – Diastolic BP/3 + Diastolic BP
Also written as Diastolic BP + 1/3 Pulse Pressure
Normal 80-100
Body loses autoregulatory capacity at a MAP less
than 50 or greater than 150
Heart Rate
• Normal range 60-90
Respiratory Rate
• Normal range 10-16 per minute
Oxygen Saturation
• Must be greater than 90%
• Supplemental oxygen via nasal cannula is
required in the OMFS clinic during sedation
– Initially 2-3 liters/minute
• In the OSOR supplemental oxygen is
supplied by nasal cannula or endotracheal
tube
Recommended Alarm Limits
Low
High
Systolic BP
85
150
Diastolic BP
50
100
Rate BPM
50
110
SP O2
92
100
Level of Consciousness
• Must be able to respond to verbal stimuli by
the surgeon in the clinic
• May be greatly sedated or unable to arouse
by verbal stimuli in the operating room
Technician Responsibilities
• Post-operative Responsibilities – “Float”
– ALDRETE Post-Operative Scoring System
• A cumulative score of 8 or above is
necessary for discontinuation of monitoring
– We generally use a goal of 10 as necessary for
dismissal from clinic
– Sum of standardized measurements of
movement, respiration, circulation, color and
level of consciousness
Movement
• Move all 4 extremities
• Move 2 extremities
• No control
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Respiration
• Breathe deep and cough
• Dyspnea
• No respirations
2
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Circulation
• BP +/- 20% pre-sedation level
• BP +/- 21-50% pre-sedation level
• BP +/- > 50% pre-sedation level
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Consciousness
• Fully alert
• Arousable
• No response
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Color
• Pink
• Pale, Dusky, Blotchy
• Cardboard
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The Key to Sedation
• Local Anesthesia
– If a poor local
anesthetic block has
been given, the patient
will continue to feel
pain throughout the
procedure
Valium (Diazepam)
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Benzodiazepine
Produces sleepiness and relief of apprehension
Onset of action 1-5 minutes
Half-life
– 30 hours
– Active metabolites
• Average sedative dose
– 10-12 mg
Versed (Midazolam)
• Short acting benzodiazepine
– 4 times more potent than Valium
• Produces sleepiness and relief of apprehension
• Onset of action 3-5 minutes
• Half-life
– 1.2-12.3 hours
• Average sedative dose
– 2.5-7.5 mg
Demerol (Meperidine)
• Narcotic
• Pain attenuation and some sedation
• Onset of action
– 3-5 minutes
• Half-life
– 30-45 minutes
• Average dose
– 20-50 mg
Fentanyl (Sublimaze)
• Narcotic/Opiod agonist
– 100 times more potent than Morphine
• Pain attenuation and some sedation
• Onset of action around 1 minute
• Half-life
– 30-60 minutes
• Average dose
– 0.05 – 0.06 mg
Additional Medications
• Likely to be seen in scenarios where deeper
levels of sedation are being performed
– Propofol (Diprivan)
– Robinul (Glycopyrrolate)
Propofol (Diprivan)
• Intravenous anesthetic/sedative hypnotic
• Sedative, anesthetic and some antiemetic
properties
• Onset of action within 30 seconds
• Half-life
– 2-4 minutes
• Average sedative dose
– Varies
Robinul (Glycopyrrolate)
• Anticholinergic
– Heart rate increases
– Salivary secretions decrease
• Dose 0.1-0.2 mg
• Onset of action within 1 minute
Medical Emergency
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Syncope
Hypoglycemia
Hypotension
Hypertension
Bronchospasm
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Laryngospasm
Apnea
Myocardial infarction
Stroke
Medical Emergency
• Know when and how to activate a “Code Blue”
• Location of Crash Cart
– Medications
– Monitors
• Location of emergency medications
• BLS
Medical Emergency
• Know how to prevent, recognize, and treat
syncope (fainting)
– Supplemental O2
– Elevation of lower extremities
– Trendelenburg
• Be prepared to assist in airway management
Emergency Drugs
• These are included for
reference only
• Technicians should not
be administering
medications to patients
without advanced
training in ACLS and
direct provider
supervision
Emergency Drugs
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Flumazenil (Romazicon)
Naloxone (Narcan)
Esmolol (Brevibloc)
Ephedrine
Epinephrine
Atropine
Flumazenil (Romazicon)
• Benzodiazepine antagonist
– Versed reversal agent
• Initial dose – 0.2mg
– May repeat at 1 minute intervals to dose of 1mg
• Onset of action within 1-2 minutes
• Must monitor for re-sedation
– May be repeated at 20 minute intervals as
needed
Naloxone (Narcan)
• Narcotic antagonist
– Fentanyl reversal agent
• Initial dose – 0.4mg
– May repeat every 2-3 minutes at doses of 0.42mg
• Monitor for re-sedation
Esmolol (Brevibloc)
• Antihypertensive
• Beta blocker
• Initial dose 0.25 –1.0 mg/kg over 30
seconds
– Short half-life of approximately 10 minutes
Ephedrine
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Used for hypotension
Sympathomimetic
Initial dose 5-10mg
Action may not be seen for several minutes
Atropine
• Significant bradycardia or asystole
– Slow heart beat or NO heartbeat
• Anticholinergic
• Initial dose 0.25 – 1.0 mg
– May repeat every 3-5 minutes
– Maximum total dose .03 mg/kg
Epinephrine
• True emergency medication
• Administration should be preceded by
activation of the 911 emergency response
system
Questions