Transcript What is Conscious Sedation?

Conscious Sedation
台中榮民總醫院
內科部 加護中心
李博仁醫師
Case Presentation
吳xx, 74 year-old age man. C.C:PET whole body
scan:The area of increased FDG uptake at the
hepatic flexure of the colon can be due tumor
involvement or normal bowel activity
Further evaluation with CT scan is recommended
CREAT.
4.3 mg/dl
S-SCOPE + BX: 91/06/27 unpleasant
Unpleasant endoscopy
Unsedated endoscopy (43% refusal rate for upper GI
endoscopy with no sedation, 65-83% refusal rate for
unsedated colonoscopy )
Whereas other patients will need prolonged, more
stimulating therapeutic endoscopic procedures that
require total patient compliance.
Zaman A. A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin
videoendoscope. Gastrointest Endosc 1999; 49:279-284
Early DS:Patient attitudes toward undergoing colonoscopy without sedation. Am J Gastroenterol 1999;
94:1862-1865
Patient factors affecting tolerance
of unsedated endoscopy
509 patients undergoing unsedated diagnostic
gastroscopy aided by topical pharyngeal
anaesthesia
Gag reflex, young age, a high level of anxiety,
poor tolerance of previous examinations and
female sex
Rex DK: Patients willing to try endoscopy without sedation: associated clinical factors and results
of a randomized controlled trial. Gastrointest Endosc 1999; 49:554-559.
GI endoscopy complication
Bleeding, perforation, and infection
0.1% for upper endoscopy
0.2% for colonoscopy
Cardiopulmonary complications :21,011 procedures :5.4 per
1000 procedures
Aspiration
Oversedation
Hypoventilation
Vasovagal episodes
Airway obstruction
Rankin GB. Indications, contraindications and complications of colonoscopy. In Gastroenterologic
Endoscopy 1989
Endoscopic design and intubation
route
Ultrathin (5-6 mm) endoscopes
Less traumatic and easier to tolerate for
patients having UGIE without sedation
Nasal route provides a direct route to the
esophagus avoiding sensitive
oropharyngeal structures with less
stimulation of the gag reflex
Routine administration of sedation , The
incidence of unplanned absence from work the
day after outpatient colonoscopy has been
shown to be 4%
What is Conscious Sedation?
Altered state of consciousness
Minimizes pain and discomfort through the use
of pain relievers and sedatives
Able to speak and respond to verbal cues
throughout the procedure
Communicating any discomfort they experience
to the provider.
Amnesia may erase any memory of the
procedure.
Depth of Sedation: Definition of General
Anesthesia and Levels of Sedation/Analgesia
Non-Anest Practice Guidelines
for Sedation and Analgesia by
Non-Anesthesiologists
hesiologists
Anesthesiology 2002; 96:1004–17
Who Can Administer Conscious
Sedation?
Qualified providers
Certified Registered Nurse Anesthetists
(CRNAs)
Anesthesiologists
Physicians
Dentists
Oral surgeons are qualified providers of
conscious sedation
When is Conscious Sedation
Administered?
In hospitals, outpatient facilities, e.g., ambulatory
surgery centers, doctors offices
Breast biopsy
Vasectomy
Minor foot surgery
Minor bone fracture repair
Plastic/reconstructive surgery
Dental prosthetic/reconstructive surgery
Endoscopy (example: diagnostic studies and
treatment of stomach, colon and bladder )
Definition of Terms
Sedation and Analgesia describes a state that allows patients
to tolerate unpleasant procedures while maintaining adequate
cardiorespiratory function and the ability to respond
purposefully to verbal command and/or tactile stimulation.
Monitoring is the measurement of physiologic parameters,
including the use of mechanical devices as well as clinical
observations. The RN may delegate this function.
Assessment is the continuous, systematic collection,
validation, and communication of patient data for the purpose
of planning, implementing, and evaluating nursing care.
Assessment is directed toward the attainment of specific
patient outcomes. The RN should not delegate this function.
Assistive personnel are staff without a nursing license (e.g.,
GI assistants, medical technicians, respiratory therapists) who
have direct patient care responsibility and are supervised by
an RN.
Preprocedure evaluation
Patient Evaluation
strongly agree:history, physical examination increases the
likelihood of satisfactory sedation and decreases the
likelihood of adverse outcomes for both moderate and deep
sedation
(1) abnormalities of the major organ systems
(2) previous adverse experience with sedation/analgesia as
well as regional and general anesthesia
(3)drug allergies, current medications, and potential drug
Interactions
(4) time and nature of last oral intake; and
(5) history of tobacco, alcohol, or substance use or abuse
Preprocedure Preparation
Strongly agree that appropriate
preprocedure counseling of
patients regarding risks,
benefits, and alternatives to
sedation and analgesia
increases patient satisfaction
Guidelines for Preoperative
Fasting
(1) the target level of sedation
(2) whether the procedure
should be delayed
(3) whether the trachea should
be protected by intubation
Preprocedure Fasting Guidelines
Problems with sedation (sedation and
procedure-related complications )
Desaturation
Arrhythmias
Myocardial ischemic episodes
O2 saturation less than 95%
premorbid cardio-respiratory disease
Continuous electronic monitoring (oxygen saturation,
electrocardiogram (ECG), non-invasive blood pressure
(NIBP)
Froelich F, Thorens J, Schwizer W -- Gastrointest Endosc 1997; 45:1-9
Alcain G, Guillen P. Predictive factors of oxygen desaturation during upper
gastrointestinal endoscopy in nonsedated patients. Gastrointest Endosc 1998;
48:143-147
Airway Assessment Procedures for Sedation and
Analgesia
Monitoring
strongly agree : monitoring level of
consciousness reduces risks for both moderate
and deep sedation
be avoided if adverse drug responses are
detected and treated in a timely manner i.e.,
before the development of cardiovascular
decompensation or cerebral hypoxia
Pulmonary Ventilation
Oxygenation
Hemodynamics
Recording of Monitored
Parameters
(1) before the beginning of the procedure
(2) after administration of sedative–
analgesic agents
(3) at regular intervals ( 5-min) during the
procedure
(4) during initial recovery
(5) just before discharge
Pulmonary Ventilation
Capnography, measurement of carbon
dioxide retention, may be useful in
prolonged cases
Oxygenation
strongly agree : early detection of through
the use of oximetry
hypoxemia more likely to be detected by
oximetry than by clinical assessment alone
pitch “beep”alarms
Supplemental Oxygen
Hemodynamics
Blunt the appropriate autonomic compensation for
hypovolemia and procedure-related stresses or
inadequate (hypertension, tachycardia)
Response to verbal commands :control his airway
and take deep breaths
young children, mentally impaired or uncooperative
patients, oral surgery, upper endoscopy
Continously EKG
Blood pressure
Arrhythmias -- sedation in the
endoscopy
five- to sixfold higher in patients with preexisting cardiac disease
endoscope size
the presence of hypoxemia
premorbid cardiorespiratory disease
Emergency Equipment for Sedation and
Analgesia
(1)
Emergency Equipment for Sedation and
Analgesia
(2)
Availability of Emergency
Equipment
Suction, appropriately sized airway
equipment, means of positive- pressure
ventilation
Intravenous equipment, pharmacologic
antagonists, and basic resuscitative
medications
Defibrillator immediately available for
patients with cardiovascular disease
Training of Personnel
Strongly agree :education and training
(1) potentiation of sedative-induced respiratory
depression by concomitantly administered opioids
(2)inadequate time intervals between doses of
sedative or analgesic agents, resulting in a
cumulative overdose
(3) inadequate familiarity with the role of
pharmacologic antagonists for sedative and
analgesic agents
ACLS,BLS
Combinations of Sedative–
Analgesic Agents
Equivocal regarding :moderate sedation
Deep sedation, satisfactory: Intravenous
combinations of sedative–analgesic agent
Fixed combinations of sedative and
analgesic agents may not allow
Appropriately titrated: strongly agree that
incremental drug administration improves
patient comfort and decreases risks
Drugs used in conscious sedation
for endoscopy
Benzodiazepines
the majority of endoscopic procedures
relaxation , cooperation and anterograde amnesia
titrated
respiratory depression
synergistically increased with the use of intravenous
opiates, the midazolam dose should be reduced by 30%
0.5-2 mg given slowly intravenously
repeating doses every 2 to 3 minutes
total dose is 2.5 to 5 mg
Midazolam-Induced Sedation for Upper
Gastrointestinal Endoscopy: Assessment of
Endoscopist and Patient Satisfaction
352 patients upper gastrointestinal endoscopy were sedated with
midazolam given
Ages of the patients ranged between 16 and 79 years (average:
41.6 ± 12.7 years).
Anterograde memory was found in 310 (88.0%)
342 patients (98.0%) cooperated well
Side effects were rarely seen (3.6%), and included nausea, vertigo,
and vomiting
Acceptability of further endoscopy in 338 (96.0%)
No significant cardiopulmonary problems
Gastroenterology Nursing: Volume 26(4) July/August 2003 pp 164-167
Most patients and endoscopists prefer some form of premedication
be given (Bell, 1990)
Intravenous diazepam or midazolam have been used by the majority
of endoscopists (Wille et al., 2000)
Midazolam quickly gained popularity after it was introduced in the
mid-1980s (Zakko, Seifert, & Gross, 1999)
Many endoscopists prefer midazolam for conscious sedation
because it has short duration of action and efficient amnesic effect
(Whitwam, Al-Khudhairi, & McCloy, 1983;Wille et al., 2000)
Midazolam was accused of more than 40 sedation-related deaths,
which made its safety in the setting of conscious sedation
questionable (Zakko et al., 1999). These adverse events may have
been related to the fact that when midazolam was first used
Opiates --Fentanyl
Pain threshold, alters pain reception, and inhibits
ascending pain pathways
Sedation is 25 to 50 µg, repeated every 1 to 2
minutes
Total dose is 50 to 200 µg
Half-life is 2 to 4 hours
Opiates --Meperidine
pain threshold, alters pain reception, and inhibits
ascending pain pathways
sedation is routine procedures is 50 to 100 mg
Reversal Agents
Naloxone and flumazenil available
whenever opioids or benzodiazepines
administered
Special Considerations
* Age >60 years
* Inability to cooperate
* Significant
developmental delay
* Severe comorbidity (e.g.,
cardiac, pulmonary,
hepatic, renal, or central
nervous system disease)
* Morbid obesity
* History of sleep apnea
* History of drug or
alcohol abuse
* Pregnancy
* Emergency procedure
with lack of patient
preparation
* Airway anomalies
Recovery Criteria after Sedation
and Analgesia
1. Medical supervision of recovery and discharge after
moderate or deep sedation is the responsibility of the operating
practitioner or a licensed physician.
2. The recovery area should be equipped with, or have direct
access to, appropriate monitoring and resuscitation equipment
3. Patients receiving moderate or deep sedation should be
monitored until appropriate discharge criteria are satisfied .The
duration and frequency of monitoring should be individualized
depending on the level of sedation achieved .the overall
condition of the patient, and the nature of the intervention for
which sedation/analgesia was administered. Oxygenation
should be monitored until patients are no longer at risk for
respiratory depression
Recovery Criteria after Sedation
and Analgesia
4.Recovery area once vital signs are stable and the
patient has reached an appropriate level of
consciousness. Level of consciousness, vital signs, and
oxygenation (when indicated) should be recorded at
regular intervals.
5. A nurse or other individual trained to monitor
patients and recognize complications should be in
attendance until discharge criteria are fulfilled.
6. An individual capable of managing complications
(e.g. establishing a patent airway and providing
positive pressure ventilation) should be immediately
available until discharge criteria are fulfilled
Guidelines for discharge
1. Patients should be alert and oriented; infants and patients whose
mental status was initially abnormal should have returned to their
baseline status. Practitioners and parents must be aware that
pediatric patients are at risk for airway obstruction should the head
fall forward while the child is secured in a car seat.
2. Vital signs should be stable and within acceptable limits.
3. Use of scoring systems may assist in documentation of fitness for
discharge.
4. Sufficient time (up to 2 h) should have elapsed after the last
administration of reversal agents (naloxone, flumazenil) to ensure
that patients do not become resedated after reversal effects have
worn off.
5. Outpatients should be discharged in the presence of a responsible
adult who will accompany them home and be able to report any
postprocedure complications.
6. Outpatients and their escorts should be provided with written
instructions regarding postprocedure diet, medications, activities,
and a phone number to be called in case of emergency.
Discharge criteria after sedation
Evidence-Based Medicine
A focused history and physical is required prior to the administration
of moderate sedation. (C)
Routine monitoring of the patients pulse rate, blood pressure, oxygen
saturation are useful in identifying early problems. (B)
Monitoring of EKG recordings may be helpful in selected cases. (C)
Capnography, measurement of carbon dioxide retention, may be
useful in prolonged cases. (A)
The use of benzodiazepines and/or opiates will result in a satisfactory
outcome in nearly all patients. (B)
Endoscopists prefer the combination of these drugs, but it adds little
benefit from the patient's viewpoint. (A)
(A), Prospective controlled trials.
(B), Observational studies.
(C), Expert opinion
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