Transcript Conscious Sedation in Ob/Gyn Office Practice

Conscious Sedation:
What You Need to Know
Michael Sugarman, MD
Visiting Professor of Anesthesiology
Montefiore Medical Center
Albert Einstein College of Medicine
Conscious Sedation
 Introduction
 New JCAHO Standards are here!
 How to...
 Continuum of Sedation
 Medications
 Quality/Risk Management
“Conscious SeaDation”
JCAHO
JCAHO (Joint Commission on
Accreditation of Healthcare
Organizations) directs institutions to
develop individual policies, protocols
and procedures and provides direction
for the content.
JCAHO Standards
 Pre-procedure Medical Evaluation
 Informed Consent
 Credentials of Personnel
 Qualified Staff Present
 Necessary Equipment
 Required Documentation
 Recovery
 Quality Management System
JCAHO Scoring of
Institutions
 Has the patient received proper informed
consent?
 Has the patient received a proper preprocedure medical evaluation?
 Is moderate or deep sedation provided by
qualified individuals?
 Are sufficient numbers of qualified
personnel available to perform the
procedure and monitor the patient?
JCAHO
Scoring(Continued)
 Is appropriate equipment available to
monitor the patient’s heart rate, respiratory
rate, and oxygenation?
 Is each patient’s status monitored while
undergoing moderate or deep sedation and
documented in the medical record?
 Are outcomes of patients undergoing
moderate or deep sedation collected and
analyzed?
How to...
 Logistics
 Patient Evaluation
 Equipment & Monitoring
 Managing Complications
 Recovery
Credentials
 Procedural sedation must be administered
by or under supervision of a credentialed
member of the staff
 Appropriate supporting personnel in
attendance.
 The protocol should describe:
Training Requirements
Experience Requirements
Demonstration of capability in resuscitation
and emergency airway management.
Staffing
 The minimum number of staff required to
conduct procedural sedation is two, the
operator and a qualified assistant to monitor
and provide supportive care of the patient.
Equipment
 Oxygen
 Airway rescue equipment
 Suction
 Defibrillator
 Blood pressure
 EKG
 Pulse oxymetry
Monitoring
 Record at intervals  15 minutes
Time of day
Pulse and respiratory rates
Oxygen saturation
Level of consciousness
Dose of each medication administered
 These will be recorded minimally at pre-
and post-procedure.
Patient Evaluation
Patient interview to review:
Medical history
Anesthesia history
Medication history
NPO Status
Appropriate physical examination
Review of objective diagnostic data (e.g.,
laboratory, ECG, X-ray)
Formulation and discussion of a plan with the
patient and/or responsible adult
Informed Consent
 Informed consent is to be obtained by a
physician or his/her designee and the record
will reflect that the patient was informed of
the indications for and accepted the risks
associated with procedural sedation
 The plan of care must be discussed with and
approved by an Attending physician.
Recovery and Outcomes
 Post-procedure and sedation monitoring and
evaluation should indicate the elements of
decision-making leading to return to routine
nursing care, transfer or discharge of each
patient.
 Outcomes should be collected and analyzed
for quality of care.
Continuum of Sedation
 Minimal Sedation (Anxiolysis)
 Light Sedation/Analgesia (Conscious
Sedation)
 Deep Sedation/Analgesia
 General Anesthesia
Managing the Continuum
 Not always possible to predict how an
individual will respond
 Practitioners intending to produce a given
level of sedation should be able to rescue
patients whose level of sedation becomes
deeper than initially intended
Minimal Sedation
(Anxiolysis)
 Drug-induced state
 Normal response to verbal commands
 Cognitive function may be impaired
 Coordination may be impaired
 Cardiovascular function unaffected
 Respiratory function unaffected
Moderate
Sedation/Analgesia
(Conscious Sedation)
 Drug-induced depression of consciousness
 Purposeful response to verbal commands
 Reflex withdrawal from pain persists
 Impairment of independent ventilatory
function
 Cardiovascular function is usually
maintained
Deep Sedation/Analgesia
 Drug-induced depression of consciousness
 Difficult to arouse
 Respond purposefully following repeated or
painful stimulation
 Ability to maintain ventilatory function
independently may be compromised
 Cardiovascular function is usually
maintained
General Anesthesia
 Drug-induced loss of consciousness
 Cannot be aroused following repeated or
painful stimulation
 Ventilatory function is often impaired with
patients often requiring assistance in
maintaining a patent airway
General Anesthesia
(Continued)
 Positive pressure ventilation may be
necessary because neuromuscular function
may be depressed
 Cardiovascular function may be impaired
Continuum of Depth of
Sedation
Minimal
Sedation
(Anxiolysis)
Normal
response to
Responsiveness
verbal
stimulation
Airway
Unaffected
Spontaneous
Unaffected
Ventilation
Cardiovascular
Unaffected
Function
Moderate
Deep
General
Sedation/ Analgesia
Sedation/ Analgesia Anesthesia
("Conscious Sedation")
Unarousable
Purposeful**response to Purposeful**response
even with
verbal or tactile
following repeated or
painful
stimulation
painful stimulation
stimulus
Intervention may be Intervention
no intervention required
required
often required
Frequently
Adequate
May be inadequate
inadequate
May be
Usually maintained
Usually maintained
impaired
** reflex withdrawal from a painful stimulus is NOT a purposeful response
Rescue
 Individuals administering Moderate
Sedation/Analgesia should be able to rescue
patients who enter a state of Deep
Sedation/Analgesia
 Individuals administering Deep
Sedation/Analgesia should be able to rescue
patients who enter a state of General
Anesthesia
Managing Complications
 Light Sedation vs. Deep Sedation
 Hypotension - NPO effects
 Hypertension
Anxiety
Pain
Bladder Distention
 Cardiac Dysrhythmias
Managing Complications
(Continued)
 Respiratory Compromise
Narcotic Induced
Benzodiazepine Induced
Upper Airway Obstruction
Bronchospasm
Laryngospasm
 Nausea and Vomiting
Recovery
 Loss of procedural stimulation
 Oxygen therapy immediately available
 Urinary Retention
 Ability to take PO
Discharge Criteria
 Adequate respiratory function
 Level of consciousness
 Intact protective reflexes
 Vital signs stable
 Mobility consistent with pre-procedural
level
 Satisfactory skin color and
condition/peripheral circulation
Discharge Criteria
(Continued)
 Acceptable nausea/vomiting status
 Acceptable pain management
 Stable operative area
 Understanding by patient and/or significant
other of Discharge Instructions
Medications
 Sedatives
 Narcotics
 Reversal Agents
Sedatives
Drug
Diazepam (Valium)
Dosing
Onset/Duration

Onset: 30 seconds to
Titrate 1-2
2 minutes
mg. until
desired effect
is achieved. Duration: 2-4 hours

There is a
great
variation in
individual
response,
titrate
carefully. -10
mg end point
for healthy
adult, 5 mg
for elderly
and
debilitated.

Kids: 0.1-0.2
mg/kg
Comments

Respiratory
depression synergistic
with
narcotics...reduce
dose by 1/3

Irritates veins...can
cause phlebitis,
thrombosis, swelling,
local
inflammation...use
large veins

Precipitates when
mixed

Contraindicatedacute narrow
glaucoma pts.
Sedatives (Continued)
Drug
Midazolam (Versed)
Dosing



Chloral Hydrate
(Noctec)
Onset/Duration
Titrate 0.5-1 mg Onset: 3-5 minutes
until desired
Duration: max. effect
effect is
about 5 minutes,
achieved.
gradually declining over
Titrate slowly, the next 30-40 minutes.
allowing 2
Gross recovery within 6
minutes
between doses hrs.
to evaluate full
effect
Because of
short duration
of action,
maintenance
doses of 0.25 to
1 mg may need
to be titrated.

Kids: 0.02-1.0
mg/kg IV or
IM, 0.02-0.08
mg/kg PO or
nasally

Sedation onset: 40
Kids: 25-100
mg/kg orally or minutes
Duration: 4-8 hours
rectally
Comments

Synergistic action with
narcotics.

Retrograde and
antegrade amnesia.

Reduce dose in elderly
and debilitated.

Reduce dose in pts. with
compromised kidney
function.

Does not irritate veins

Dilution is suggested for
accurate dosing (4 ml of
NS with 1 ml [5 mg]
Versed = 1 mg/ml)

? reversibility

Best used in scheduled
out-patient situations in
healthy children
Other Sedatives
(Induction Agents)
 Propofol
Achieve deep sedation quickly
Apnea occurs frequently
Rapid passage to general anesthesia
 Ketamine
Produces a dissociative state with profound
analgesia
Copious secretions
Emergence delerium
Narcotics
Drug
Morphine
sulfate
Dosing

Onset: 1-3 minutes
1-2 mg.
Increments, titrate
Duration: 4 hours
to effect
Comments

Assess for respiratory
depression.

Assess for hypotension,
especially if
hypovolemic

Kids: 0.1-0.2
mg/kg

The standard
against which all
other opioids are
compared
1 mg increments,
titrate to effect

Assess for nausea &
vomiting, be sure
suction is readily
available
10 mg increments, Onset: 1-3 minutes
titrate to effect
Duration: 1-3 hours
Kids: 1-2 mg/kg

Assess for respiratory
depression.

Assess for hypotension,
especially if
hypovolemic.

Meperidine
(Demerol)
Onset/Duration



Less potent than
Morphine
Assess for nausea & vomiting.
May cause more than Morphine.
Be sure suction is readily
available.
Narcotics (Continued)
Drug
Fentanyl
(Sublimaze)
Dosing




Onset/Duration
Onset of sedation:
0.05 ug/kg.
increments up to 2 1-3 minutes
ug/kg total dose.
Onset of analgesia:
(70 kg adult....... may take several
0.05 ug/kg =3-4 ug minutes.
2 ug/kg =140 ug.)
Duration of
Kids: 1-2 mcg/kg analgesia: 30-60
minutes
About 100 times
Duration of
as potent as
respiratory
Morphine
depression: can
exceed one hour
Dosed in
micrograms
Comments

Rapid IV infusion can
cause chest wall rigidity

Assess for respiratory
depression.

Assess for hypotension,
especially if
hypovolemic

Assess for nausea &
vomiting, be sure
suction is readily
available
Reversal Agents
Drug
Naloxone (Narcan)
Dosing


Nalmefene (Revex)



Onset/Duration
Comments
Onset: 1-2 minutes
0.1 to 0.2 mg
slowly titrated to
patient response Duration: 30
minutes when
Reversal effect given IV
may not out last
narcotic
effect....consider
giving an IM
dose


Contraindicated in drug
abusers or chronic pain
patients who regularly
take narcotics.
Duration: half life
is 9 times longer
May repeat dose than Narcan
at 2 minute and 5
minute interval

"Reverses" narcotics
only
0.25 ug/kg IV
Max dose- 1
ug/kg

"Reverses" narcotics
only
Rapid administration
can produce nausea,
sweating, hypertension
and dysrhythmias.
Reversal Agents
(Continued)
Drug
Flumazenil
(Romazicon)
Dosing

0.2 mg given
over 15 seconds.
After an interval
of 45 seconds, a
second dose of
0.2 mg may be
given. Repeat at
60 second
intervals until 1
mg total is
reached. No
more than 3 mg.
in 1 hr.
Onset/
Duration
Onset: 1-2 minutes
with peak effect
occurring within
10 minutes.
Comments

"Reverses"
Benzodiazapines...not
narcotics

Reversal effect may not
out last
sedative....monitor for
one hour after reversal.

Resedation may occur
requiring additional
doses.

Question administration
to patients who take
benzodiazapines
regularly...may cause
seizures in these
patients.
Duration: 30-60
minutes
Quality Management
 Risk Management
 Quality Management
Reporting
Sample Indicators
Risk Management
 Mechanisms to Reduce Medical
Malpractice Related to the Administration
of Conscious Sedation
Education, Preparation & Requirements for the
Conscious Sedation Providers
Quality Management Database
Data Driven Continuous Quality Improvement
Quality Improvement
Monitoring and
Reporting
 The clinical department must regularly reviews
 Quality indicator thresholds should be
specifically established
 Clear corrective processes should be established
when these thresholds have been exceeded
 Quality Reports will be completed and
forwarded to the Quality Office when any of the
pre-determined adverse outcome criteria are met
Sample Components of a
Conscious Sedation
Database
 ANY use of a Reversal Agent
 ANY patient requiring Assisted Ventilation
(Bag Breathing)
 ANY new cardiac arrhythmia
 ANY desaturation of O2 below 90%
sustained for 5 minutes
More Sample
Components of a
Conscious Sedation
Database
 ANY decrease of VS by 30%
 ANY failure to return to baseline
 ANY case with unplanned admission
resulting from sedation
 ANY case wherein review is thought to be
beneficial