Presentation on theme: "Moderate Sedation & Analgesia"— Presentation transcript:
1 Moderate Sedation & Analgesia Lesson 1: IntroductionLesson 2: The Sedation ContinuumLesson 3: Guidelines & RegulationsErlinda C. Oracion, M.D., D.P.B.ADepartment of Anesthesiology
2 IntroductionWelcome to the introductory lesson on moderate sedation/analgesia . This lesson gives the course rationale, goals, and outline.
3 We watch while you sleep… And because our patients are our partners…..We watch while you sleep…
4 Course RationaleSedation and anesthesia are important risk factors for morbidity and mortality during procedures.Giving sedation safely is critical to:Help prevent negative outcomesComply with regulations
5 Course Rationale This course will teach you: How moderate sedation relates to other types of anesthetic services, and how this relates to patient safetyHow The Joint Commission expects accredited facilities to manage moderate sedation
6 Course Goals After completing this course, you should be able to: List the levels of the continuum of sedationIdentify key features of each levelRecognize the significance of the continuum for sedation safetyList the Joint Commission standards for moderate sedationIdentify key requirements of each standard
7 Over the last 15 years…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 as “safer than general anesthesia”, this may not be altogether correct.1984- Natof studied 40 ambulatory centers (87,492 patients)Complications 1: 106 (LA with sedation) vs 1:120 (GA)
9 Gastroenterology literature Walker JA.Am J Gastroent 2003;98:1744-50 NAPS (Nurse Administered Propofol Sedation)2000 patients- GI endoscopies (ASA 1 and 2)3- laryngospam11 desaturated <90% spO2 despite 4L/min O24 desaturated <85% spO2, were assumed apneic
10 Course Outline Lesson 1 provided the course rationale and goals will describe the sedation continuumLesson 3will list and explain the Joint Commission standards for moderate sedation
12 After completing this lesson, you should be able to: List the levels of the sedation continuumIdentify key features of each levelRecognize the significance of the sedation continuum
13 The Sedation Continuum Moderate sedation is on a continuum with other levels of sedation.The levels on this continuum are:Minimal sedation (anxiolysis )Moderate sedation/analgesia (formerly “conscious sedation”)Deep sedation/analgesiaGeneral AnesthesiaLet’s take a closer look at each level on the following screens
14 Minimal Sedation: Anxiolysis 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 Moderate Sedation & Analgesia In this drug-induced state:The patient has depression of consciousnessThe patient will respond purposefully to spoken words, or spoken words with a light touch.The airway remains patent without help.The patient’s breathing is adequate.Heart function is usually maintained.“Moderate sedation/analgesia” was called “conscious sedation.”For this definition, “purposeful” movement does not include reflex movement away from pain.
16 Deep Sedation/Analgesia 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 patient’s own breathing may not be adequate.Heart function is usually maintained.
17 General Anesthesia 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 Levels of Sedation GENERAL ANESTHESIA MINIMAL DEEP SEDATION MODERATE -anxiolysisMODERATESEDATION-conscious sedation
19 The Sedation Continuum: Summary This table summarizes the sedation continuum.Continuum of Depth of SedationMinimalSedation(anxiolysis)ModerateSedation/AnalgesiaDeep Sedation/GeneralAnesthesiaResponsivenessNormal response to speechPurposeful response to speech or touchPurposeful response to repeated or painful stimulationNo response, even to painAirwayUnaffectedRemains openMay need help to maintain airwayOften needs help to maintain airwayBreathingAdequateMay not be adequateOften require ventilatory supportHeart FunctionUsually maintainedMay be impaired
20 Levels of Anesthesia and Sedation- Minimal Sedation (Anxiolysis) 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 Levels of Anesthesia and Sedation- Moderate Sedation/Analgesia (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 Levels of Anesthesia and Sedation- Deep Sedation/ Analgesia 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 Levels of Anesthesia and Sedation- General Anesthesia 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 Levels of Sedation GENERAL ANESTHESIA MINIMAL DEEP SEDATION MODERATE -anxiolysisMODERATESEDATION-conscious sedation
25 Monitored Anesthesia Care (MAC) 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 levelsBecause sedation is a continuum, it is not always possible to predict how an individual patient will respond.Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended.
27 The Sedation Continuum: Summary This table summarizes the sedation continuum.Continuum of Depth of SedationMinimalSedation(anxiolysis)ModerateSedation/AnalgesiaDeep Sedation/GeneralAnesthesiaResponsivenessNormal response to speechPurposeful response to speech or touchPurposeful response to repeated or painful stimulationNo response, even to painAirwayUnaffectedRemains openMay need help to maintain airwayOften needs help to maintain airwayBreathingAdequateMay not be adequateOften require ventilatory supportHeart FunctionUsually maintainedMay be impaired
28 Significance of the Continuum Why is it important to understand the continuum of sedation? Because sedation is a continuum, the response of any one patient may be unpredictable.For example, a patient may be moderately sedated for a procedure. However, the patient may respond to the drug in an unexpected way, and enter a state of deep sedation instead.
29 Significance of the Continuum 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.This is the rationale for many of the regulations related to moderate sedation. Moderate sedation does not usually put a patient’s breathing or heart function at risk. But a moderately sedated patient may progress to deep sedation.
30 Review The best description of “moderate sedation” is: A risk-free treatmentA point on the continuum of sedationA lesser form of sedation than “minimal sedation”A treatment entirely different from general anesthesiaMULTIPLE CHOICE INTERACTIONCorrect: BA: Incorrect. Moderate sedation is not risk-free. The correct answer is B.B: CorrectC: Incorrect. Moderate sedation is deeper than minimal sedation. The correct answer is B.D: Incorrect. Moderate sedation and general anesthesia are both points on the continuum of sedation. The correct answer is B.
31 Summary 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 Moderate sedation/ analgesia Minimal sedation(anxiolysis)Moderate sedation/ analgesia(conscious sedation)Deep sedation/analgesiaGeneral AnesthesiaAdministering cliniciansRN, PhysiciansSedation trained RN, Credentialed physiciansAnesthesiologist onlyResponsivenessNormal response to verbal stimulationPurposeful** response to verbal or tactile stimulationPurposeful** response following repeated or painful stimulationUnarousable even with painful stimulusAirwayUnaffectedNo intervention requiredIntervention may be requiredIntervention often requiredSpontaneous ventilationAdequateMay be inadequateFrequently inadequateCardiovascular functionUsually maintainedMay be impaired
33 Objectives of Moderate Sedation Blunting of anxiety and fearElicit cooperation from the patientAfford amnesia for the patientIncrease the pain threshold
34 Individuals administering Moderate Sedation/Analgesia (“Conscious Sedation”) should be able to -rescue a patient who enters a state of deep sedation -manage a compromised airway -provide adequate oxygenation and ventilation
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 sedationIdentify key requirements of each standard
37 JCAHO COMPARABLE CARE MANDATE "conscious sedation" for non-operating room procedures represents a dynamic continuum significantly overlapping monitored anesthesia care (MAC), this implies that such areas must have processespresedation assessment,intraprocedure monitoring,discharge criteria,facilities, equipment, and personnel similar to those utilized for MAC delivered by qualified anesthesia providers.
38 JCAHO COMPARABLE CARE MANDATE 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 Standards 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 The Joint Commission Standards For Moderate sedation, these standards are:The patient must be re-assessed immediately before the sedation is given.The patient’s 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 Pre-sedation Assessment (1) 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 Pre-Sedation Assessment (2) The pre-sedation assessment should include information about the procedure and the patient.The Assessment should include:Indication for the procedureDetermination that the patient is an appropriate candidate for sedation and the procedure
44 Pre-Sedation Assessment (2) The Pre-sedation assessment should also include:Patient history—should include:Allergies or adverse drug eventsPrior sedative or anesthesia experiencesPotential for pregnancy
45 Pre-Sedation Assessment (2) Pre-sedation assessment should also include:Physical History—should include:Baseline vital signs and oxygen saturationWeightAirway statusAppropriate fasting intervalAspiration risk factorsStatus of cardiac, pulmonary, and neurologic systemsMental status and level of consciousnessAppropriate lab testsASA status
46 Pre-Sedation Assessment (3) The patient’s 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.An “E: is added to status number to designate an emergency operationAn organ donor is usually designated as Class 6
47 Pre-Sedation Assessment (3) 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 Pre-sedation Assessment (4) Conditions that will affect the use of moderate sedation:Indication for the procedureAltered mental statusAtypical airway anatomyObesityPregnancySleep apneaCurrent medicationsSubstance abuseCardiovascular diseaseRespiratory diseaseLiver diseaseKidney diseaseCentral nervous system dysfunction
49 Discussion of Options & Risks 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 Discussion of Options & Risks Patient education also should include information on:Resuming activityConsciousness checksDietary restrictionsWhen medications can be resumedPotential post-procedural complicationsWhom to contact for questions for help
51 Sedation Care PlanThe 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 Sedation Care Plan All providers should be informed of: The patient’s care needsThe sedation plan of careThe patient should be assessed againimmediately before moderate sedationis 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 Qualified Provider (1)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 sedationHow to give drugs for moderate sedationHow to monitor patients to keep them moderately sedatedHow to “rescue” patients from deep sedation
55 Qualified Provider (1)The ability to “rescue” patients from deep sedation includes training in:How to manage an airwayHow to give oxygen and ventilationHow to deliver appropriate reversal agents
56 Qualified Provider (2)“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 Qualified Provider (3)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 Qualified Provider (3)In addition to the LIP, there must be enough other qualified personnel to:Evaluate the patient before the sedationGive the sedationPerform the procedureMonitor the patientRecover and discharge the patient
59 MonitoringPatients 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 monitor Pulse oximeter Medications for sedation and reversal of effectBlood pressure determination unitOxygen source and administration equipmentBag-valve-maskStandard emergency equipment and drugs for resuscitationDefibrillatorSuction machineStethoscope
61 Monitoring The following need to be monitored in some or all patients: Heart rate and oxygenation—should be continuously monitored by pulse oximetry.Respiratory rate--& pulmonary ventilation should be continuously monitoredBlood pressure—should be measured at regular intervals.EKG—should be monitored:If the patient has significant cardiovascular diseaseIf cardiac arrhythmias are expected or detected.
62 Post-Sedation Assessment & Discharge Data from monitoring must be recorded in the patient’s medical record.After moderate sedation, patients must be:Assessed in the post-sedation recovery areaDischarged by a qualified LIP or according to established criteriaDischarged home with a responsible adultMeeting discharge criteria should be documentedin the medical record.
63 Review MULTIPLE CHOICE INTERACTION A provider qualified to give moderate sedation is trained in:How to evaluate patients before sedationHow to rescue patients from deep sedationHow to give drugs to achieve moderate sedationHow to monitor patients to keep them moderately sedatedAll the aboveCorrect: EA: Not quite. The best answer is E. A qualified provider is trained in all these areasB: Not quite. The best answer is E. A qualified provider is trained in all these areasC: Not quite. The best answer is E. A qualified provider is trained in all these areasD: Not quite. The best answer is E. A qualified provider is trained in all these areasE: Correct.
64 Review MULTIPLE CHOICE INTERACTION The physical status of a patient with well-controlled hypertension would be:ASA class IASA class IIASA class IIIASA class IVASA class VCorrect: BA: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.B: Correct. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.C: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.D: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.E: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.
65 SummaryRemember:Patients must be assessed before moderate sedation. ASA class should be determinedSedation options and risks must be discussed with each patient.A sedation care plan must be developed for each patient.You have completed the lesson on guidelines and regulations.
66 SummaryRemember: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.You have completed the lesson on guidelines and regulations.
67 [Moderate Sedation] Course Glossary # Term Definition 1. Analgesia Pain relief2.AnxiolysisThe use of drugs to lessen anxiety without lessening awareness3.ApneaNot breathing4.ASAAmerican Association of Anesthesiologists5.ContinuumOn a scale progressing from the smallest to the greatest amount6.CriteriaStandards or measures used to make a judgment or decision7.The Joint CommissionJoint Commission of the Accreditation of Healthcare Organizations8.Positive pressure ventilationArtificial breathing using positive pressure to maintain inflation of the lungs9.Reversal drugsDrugs that neutralize the effects of the drugs used to sedate the patient10.SedationSleepiness, or the act of cause sleepiness
68 Objectives completed List the levels of the continuum of sedation Identify key features of each levelRecognize the significance of the continuum for sedation safetyList the Joint Commission standards for moderate sedationIdentify key requirements of each standard
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