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Lesson 1: Introduction Lesson 2: The Sedation Continuum Lesson 3: Guidelines & Regulations Erlinda C. Oracion, M.D., D.P.B.A Department of Anesthesiology.

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Presentation on theme: "Lesson 1: Introduction Lesson 2: The Sedation Continuum Lesson 3: Guidelines & Regulations Erlinda C. Oracion, M.D., D.P.B.A Department of Anesthesiology."— Presentation transcript:

1 Lesson 1: Introduction Lesson 2: The Sedation Continuum Lesson 3: Guidelines & Regulations Erlinda C. Oracion, M.D., D.P.B.A Department of Anesthesiology Erlinda C. Oracion, M.D., D.P.B.A Department of Anesthesiology

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3 We watch while you sleep…

4 Sedation and anesthesia are important risk factors for morbidity and mortality during procedures. Giving sedation safely is critical to: Help prevent negative outcomes Comply with regulations

5 This course will teach you: How moderate sedation relates to other types of anesthetic services, and how this relates to patient safety How The Joint Commission expects accredited facilities to manage moderate sedation

6 After completing this course, you should be able to: List the levels of the continuum of sedation Identify key features of each level Recognize the significance of the continuum for sedation safety List the Joint Commission standards for moderate sedation Identify key requirements of each standard

7 Administration of sedatives and analgesics for performance of procedures is a significant independent risk factor for morbidity and mortality both inside and outside the OR.

8 Although sedation is often offered assafer than general anesthesia, this may not be altogether correct Natof studied 40 ambulatory centers (87,492 patients) Complications 1: 106 (LA with sedation) vs 1:120 (GA)

9 NAPS ( Nurse Administered Propofol Sedation ) 2000 patients- GI endoscopies (ASA 1 and 2) 3- laryngospam 11 desaturated <90% spO2 despite 4L/min O2 4 desaturated <85% spO2, were assumed apneic

10 Lesson 1 provided the course rationale and goals Lesson 2 will describe the sedation continuum Lesson 3 will list and explain the Joint Commission standards for moderate sedation

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12 After completing this lesson, you should be able to: List the levels of the sedation continuum Identify key features of each level Recognize the significance of the sedation continuum

13 Moderate sedation is on a continuum with other levels of sedation. The levels on this continuum are: Minimal sedation (anxiolysis ) Moderate sedation/analgesia (formerlyconscious sedation) Deep sedation/analgesia General Anesthesia

14 Minimal sedation is also called anxiolysis. In this drug-induced state: The patient feels relaxed. The patient responds normally to speech. Thinking and coordination may be affected. Breathing and heart function are not affected

15 In this drug-induced state: The patient has depression of consciousness The patient will respond purposefully to spoken words, or spoken words with a light touch. The airway remains patent without help. The patients breathing is adequate. Heart function is usually maintained.

16 Deep Sedation/Analgesia is the next level on the continuum. In this drug-induced state: The patient has depression of consciousness and is difficult to awaken. The patient will respond purposefully to repeated or painful stimulation. Reflex movement away from pain is not purposeful. The patient may need help to keep the airway open. The patients own breathing may not be adequate. Heart function is usually maintained.

17 General Anesthesia is the deepest form of sedation. In this drug-induced state: The patient loses consciousness. The patient cannot be awakened, even by painful stimuli. The patient often needs assistance maintaining the airway and ventilation. This often requires positive pressure ventilation. Heart function may be impaired.

18 M INIMAL SEDATION -anxiolysis MODERATE SEDATION -conscious sedation DEEP SEDATION GENERALANESTHESIAGENERALANESTHESIA

19 This table summarizes the sedation continuum. Minimal Sedation (anxiolysis) Moderate Sedation/ Analgesia Deep Sedation/ Analgesia General Anesthesia ResponsivenessNormal response to speech Purposeful response to speech or touch Purposeful response to repeated or painful stimulation No response, even to pain AirwayUnaffectedRemains openMay need help to maintain airway Often needs help to maintain airway BreathingUnaffectedAdequateMay not be adequate Often require ventilatory support Heart FunctionUnaffectedUsually maintained May be impaired Continuum of Depth of Sedation

20 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.

21 (conscious sedation): a drug-induced depression of consciousness during which the 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.

22 is 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 may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

23 A drug-induced loss of consciousness- patients not arousable, even by painful stimulation. Ability to maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of a depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

24 M INIMAL SEDATION -anxiolysis MODERATE SEDATION -conscious sedation DEEP SEDATION GENERALANESTHESIAGENERALANESTHESIA

25 MAC does not describe the continuum of depth of sedation; a specific anesthesia service in which an anesthesia provider has been requested to participate in the care of the patient undergoing a diagnostic/ therapeutic procedure.

26 Sedation is a continuum- not always possible to predict how an individual patient will respond. Skill required ability to rescue from deep sedation levels

27 This table summarizes the sedation continuum. Minimal Sedation (anxiolysis) Moderate Sedation/ Analgesia Deep Sedation/ Analgesia General Anesthesia ResponsivenessNormal response to speech Purposeful response to speech or touch Purposeful response to repeated or painful stimulation No response, even to pain AirwayUnaffectedRemains openMay need help to maintain airway Often needs help to maintain airway BreathingUnaffectedAdequateMay not be adequate Often require ventilatory support Heart FunctionUnaffectedUsually maintained May be impaired Continuum of Depth of Sedation

28 Why is it important to understand the continuum of sedation? Because sedation is a continuum, the response of any one patient may be unpredictable.

29 Why is it important to understand the continuum of sedation? A moderately sedated patient may progress to deep sedation. Therefore, moderate sedation must be monitored just as carefully as deep sedation and anesthesia.

30 The best description of moderate sedation is: a. A risk-free treatment b. A point on the continuum of sedation c. A lesser form of sedation than minimal sedation d. A treatment entirely different from general anesthesia

31 You have completed the lesson on the sedation continuum. Remember: Moderate sedation is a point on a continuum. It falls between minimal sedation and deep sedation. Because sedation is a continuum, the response of any patient is individual and may be unpredictable.

32 Minimal sedation (anxiolysis) Moderate sedation/ analgesia (conscious sedation) Deep sedation/ analgesia General Anesthesia Administering clinicians RN, PhysiciansSedation trained RN, Credentialed physicians Anesthesiologist only Responsiveness Normal response to verbal stimulation Purposeful** response to verbal or tactile stimulation Purposeful** response following repeated or painful stimulation Unarousable even with painful stimulus Airway UnaffectedNo intervention required Intervention may be required Intervention often required Spontaneous ventilation UnaffectedAdequateMay be inadequateFrequently inadequate Cardiovascular function UnaffectedUsually maintained May be impaired

33 1. Blunting of anxiety and fear 2. Elicit cooperation from the patient 3. Afford amnesia for the patient 4. Increase the pain threshold

34 should be able to -rescue a patient who enters a state of deep sedation -manage a compromised airway -provide adequate oxygenation and ventilation

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36 Introduction & Objectives Welcome to the lesson on guidelines and regulations. After completing this lesson, you should be able to: List the The Joint Commission standards related to moderate sedation Identify key requirements of each standard

37 "conscious sedation" for non-operating room procedures represents a dynamic continuum significantly overlapping monitored anesthesia care (MAC), this implies that such areas must have processes presedation assessment, intraprocedure monitoring, discharge criteria, facilities, equipment, and personnel similar to those utilized for MAC delivered by qualified anesthesia providers.

38 mandates that sedation practices throughout the hospital be "monitored and evaluated by the Department of Anesthesiology"

39 Question: Does the person administering sedation have to be qualified to monitor the patient if other staff who are present are qualified? Standard PC states, Sufficient numbers of qualified staff (in addition to the individual performing the procedure) are present… to evaluate, monitor, administer medication, assist with the procedure if needed and recover the patient.

40 The Joint Commission has several standards for anesthesia services, including moderate sedation. For Moderate sedation, these standards are: Moderate sedation must be given by a qualified provider. Patients who will receive moderate sedation must be assessed ahead of time. Sedation options and risks must be discussed with the patient and family prior to the sedation/procedure.

41 For Moderate sedation, these standards are: The patient must be re-assessed immediately before the sedation is given. The patients oxygenation, ventilation and circulation must be monitored during sedation. The patient must be assessed in the post-sedation recovery area before discharge. A qualified provider must discharge the patient from the post-sedation recovery area, or discharge must be based on established criteria.

42 All patients must be assessed before sedation. Hospitals with obstetric or emergency services should be able to perform an assessment quickly. These hospitals should be able to gather enough information to give moderate sedation safely within 30 minutes after deciding to sedate the patient. The patient must give informed consent before moderate sedation can be administered.

43 The pre-sedation assessment should include information about the procedure and the patient. The Assessment should include: Indication for the procedure Determination that the patient is an appropriate candidate for sedation and the procedure

44 The Pre-sedation assessment should also include: Patient historyshould include: Allergies or adverse drug events Prior sedative or anesthesia experiences Potential for pregnancy

45 Pre-sedation assessment should also include: Physical Historyshould include: Baseline vital signs and oxygen saturation Weight Airway status Appropriate fasting interval Aspiration risk factors Status of cardiac, pulmonary, and neurologic systems Mental status and level of consciousness Appropriate lab tests ASA status

46 The patients ASA status should be determined. The ASA describe five physical status classes: ASA Class I – A normal healthy patient. ASA Class II – A patient with mild systemic disease. ASA Class III – A patient with severe systemic disease. ASA Class IV - A patient with severe systemic disease that is a constant threat to life. ASA Class V – A moribund patient who is not expected to survive without the operation. ASA Class VI – A declared brain-dead patient whose organs are being removed for donor purposes.

47 Patients in ASA classes I and II can be given moderate sedation. Medical consultation is suggested for class III patients. Patients in ASA classes IV and V should not be given moderate sedation by a non anesthesia provider.

48 Conditions that will affect the use of moderate sedation: Indication for the procedure Altered mental status Atypical airway anatomy Obesity Pregnancy Sleep apnea Current medications Substance abuse Cardiovascular disease Respiratory disease Liver disease Kidney disease Central nervous system dysfunction

49 Sedation options and risks may be discussed with the patient and family before giving moderate sedation. Patients must give informed consent for any treatment. This includes moderate sedation. Part of informed consent is a full understanding of the options and risks of treatment. Discussing the sedation procedure ahead of time can also help calm patient fears.

50 Patient education also should include information on: Resuming activity Consciousness checks Dietary restrictions When medications can be resumed Potential post-procedural complications Whom to contact for questions for help

51 The moderate sedation of each patient must be carefully planned. The Plan of Care should: Take into account the physical status of the patient (ASA class) Meet any other patient needs identified during the pre-sedation assessment

52 All providers should be informed of: The patients care needs The sedation plan of care The patient should be assessed again immediately before moderate sedation is given.

53 Question: Are specific privileges to administer moderate sedation required? Standard PC EP 4 states that Individuals monitoring moderate or deep sedation are qualified and have the appropriate credentials to manage patients whatever level of sedation or anesthesia is achieved…

54 The qualified provider requirement covers the training and credentials of the provider who gives moderate sedation. A provider qualified to give moderate sedation must be trained in: How to evaluate patients before sedation How to give drugs for moderate sedation How to monitor patients to keep them moderately sedated How to rescue patients from deep sedation

55 The ability to rescue patients from deep sedation includes training in: How to manage an airway How to give oxygen and ventilation How to deliver appropriate reversal agents

56 Rescue of patients from sedation may also include the use of reversal drugs. Patients given reversal drugs must be monitored. Seizures or other heart and nervous system problems may occur. Note: The effect of the reversal drug may wear off before the effect of the sedating drug. Extended monitoring will be needed.

57 Moderate sedation procedures are performed by a licensed independent practitioner (LIP) The qualified provider requirement also covers the number of personnel during a procedure.

58 In addition to the LIP, there must be enough other qualified personnel to: Evaluate the patient before the sedation Give the sedation Perform the procedure Monitor the patient Recover and discharge the patient

59 Patients must be monitored during moderate sedation. The person monitoring the patient can not have additional assignments. Physiological monitoring is the only way to ensure that patients get the supportive treatment they need.

60 Mandatory equipment Cardiac monitorCardiac monitor Pulse oximeterPulse oximeter Medications for sedation and reversal of effectMedications for sedation and reversal of effect Blood pressure determination unitBlood pressure determination unit Oxygen source and administration equipmentOxygen source and administration equipment Bag-valve-maskBag-valve-mask Standard emergency equipment and drugs for resuscitationStandard emergency equipment and drugs for resuscitation DefibrillatorDefibrillator Suction machineSuction machine StethoscopeStethoscope

61 The following need to be monitored in some or all patients: Heart rate and oxygenationshould be continuously monitored by pulse oximetry. Respiratory rate--& pulmonary ventilation should be continuously monitored Blood pressureshould be measured at regular intervals. EKGshould be monitored: If the patient has significant cardiovascular disease If cardiac arrhythmias are expected or detected.

62 Data from monitoring must be recorded in the patients medical record. After moderate sedation, patients must be: Assessed in the post-sedation recovery area Discharged by a qualified LIP or according to established criteria Discharged home with a responsible adult Meeting discharge criteria should be documented in the medical record.

63 MULTIPLE CHOICE INTERACTION A provider qualified to give moderate sedation is trained in: a. How to evaluate patients before sedation b. How to rescue patients from deep sedation c. How to give drugs to achieve moderate sedation d. How to monitor patients to keep them moderately sedated e. All the above

64 MULTIPLE CHOICE INTERACTION The physical status of a patient with well-controlled hypertension would be: a. ASA class I b. ASA class II c. ASA class III d. ASA class IV e. ASA class V

65 Remember: Patients must be assessed before moderate sedation. ASA class should be determined Sedation options and risks must be discussed with each patient. A sedation care plan must be developed for each patient.

66 Remember: Moderate sedation must be given by a qualified provider. Patients must be monitored during sedation. Patients must be assessed after sedation. Note: They may be discharged from the post-sedation recovery area only by a qualified LIP or according to established criteria.

67 Course Glossary #TermDefinition 1.AnalgesiaPain relief 2.AnxiolysisThe use of drugs to lessen anxiety without lessening awareness 3.ApneaNot breathing 4.ASAAmerican Association of Anesthesiologists 5.ContinuumOn a scale progressing from the smallest to the greatest amount 6.CriteriaStandards or measures used to make a judgment or decision 7.The Joint Commission Joint Commission of the Accreditation of Healthcare Organizations 8.Positive pressure ventilation Artificial breathing using positive pressure to maintain inflation of the lungs 9.Reversal drugsDrugs that neutralize the effects of the drugs used to sedate the patient 10.SedationSleepiness, or the act of cause sleepiness

68 List the levels of the continuum of sedation Identify key features of each level Recognize the significance of the continuum for sedation safety List the Joint Commission standards for moderate sedation Identify key requirements of each standard

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