2 Level of Sedation Awake Conscious sedation ( sedoanalgesia) Deep sedationGeneral anesthesia
3 Conscious SedationA minimally depressed level of consciousness which allows the patient to independently and continuously maintain a patent airway and respond appropriately to verbal commandsAnxiolysisModerate Sedation
4 ConsciousnessProtective reflexesPatent air wayVerbal contact
5 Deep SedationA controlled state of depressed consciousness accompanied by a partial loss ofprotective reflexes andthe ability to respond appropriately to verbal commands
12 Diphenhydramine Antihistamine that works at H-1 receptors. Used for mild sedation & its antihistamine properties.May cause paradoxical excitement.May produce hypotension, tachycardia, and urinary retention.Use with caution in infants and young children.
13 Provider Responsibilities Pre-Procedure Patient AssessmentVital SignsAllergiesContacts/DenturesNPO statusAir wayChanges in medical historyURIHospitalizationsSick family members
14 Airway AssessmentThis picture represents a Mallampati Class One airway. The entire uvula and tonsillar pillars are seen. This individual should be easy to mask ventilate or to intubate with a laryngoscope and endotracheal tube.
15 Airway AssessmentThis picture represents a Mallampati Class Three airway. None of the uvula or tonsillar pillars are seen. This individual may hard to mask ventilate, and quite difficult to intubate.
16 Airway AssessmentThis image is representative of an extremely short thyromental distance, indicating tremendous difficulty in tracheal intubation, and possible difficulty establishing a satisfactory mask seal.
17 Special Considerations Pediatric patientsNot “little adults”Geriatric patientsUnique subclass of patients with physiological changes complicating treatment
18 “Show Stoppers” Food or fluid intake 6 hours prior to surgery Clear fluid intake within 2 hours of surgeryCan read newspaper print when looking through liquidRecent alcohol ingestionRecreational drug usePregnancyThyroid Dysfunction
19 “Show Stoppers” Recent asthma attack or respiratory failure Treatment with MAO inhibitorsTricyclic AntidepressantsAdrenal DysfunctionRenal Dysfunction
20 Provider Responsibilities Pre-Procedure Patient AssessmentInformed ConsentEscort PresentEstablishes patient’s mental statusUnder the influence of alcohol or drugsOriented to person, place, timeDocumentation
21 A.S.A physical status classification Class I A normal, healthy patient.Class II A patient with mild systemic disease.Class III A patient with severe systemic disease.Class IV A patient with disease that is a constant threat to his life.Class V A moribund patient who is not expected to survive without operation.
22 Provider Responsibilities Intraoperative ResponsibilitiesInformed consent signed prior to sedationName, dose, route and time of all medications documentedProcedure begin and end timesPrior adverse reactionsPre-medication time and effect
24 Provider Responsibilities Post-operative ResponsibilitiesVital Signs at least every 5 minutesBPHeart RateRespiratory RateOxygen SaturationLevel of ConsciousnessSedated patients must be continuously monitored until discharged
26 FACILITIESThe location should be of adequate size equipped to deal witha cardiopulmonary emergency. This must include:Tilted operating table, trolley or chair. Adequate suction and room lighting.A supply of oxygen and suitable devices.
27 FACILITIES (2)Adequate equipments for artificial ventilation and airway management- Appropriate drugs for cardiopulmonary resuscitation.- Intravenous equipment.- Pulse oxymeter.- Defibrillator.
28 FACILITIES (3) Emergency drugs should include at least the following: Adrenaline, atropineDextrose 50%LignocaineNaloxone, Flumazenil
30 The following values are indicative of the “normal” adult patient 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
31 Blood Pressure Specifically mean arterial pressure (MAP) MAP Systolic BP – Diastolic BP/3 + Diastolic BPAlso written as Diastolic BP + 1/3 Pulse PressureNormalBody loses auto regulatory capacity at a MAP less than 50 or greater than 150
34 Oxygen Saturation Must be greater than 90% Supplemental oxygen via nasal canulaInitially 2-3 liters/minute
35 OXYGENATION Degrees of hypoxemia occur frequently during intravenous sedation without oxygen supplementation.Oxygen administrationPulse oxymetry
36 Recommended Alarm Limits Low HighSystolic BPDiastolic BPRate BPMSP O
37 Level of Consciousness Must be able to respond to verbal stimuli by the surgeon in the clinicMay be greatly sedated or unable to arouse by verbal stimuli in the operating room
38 Provider Responsibilities Post-operative ResponsibilitiesALDRETE Post-Operative Scoring SystemA cumulative score of 8 or above is necessary for discontinuation of monitoringWe generally use a goal of 10 as necessary for dismissal from clinicSum of standardized measurements of movement, respiration, circulation, color and level of consciousness
39 MovementMove all 4 extremitiesMove 2 extremities 1No control
40 RespirationBreathe deep and cough 2Dyspnea 1No respirations
55 Nitrous oxide Minimum oxygen flow of 2.5 litres/minute. Maximum flow of 10 litres/minute of nitrous oxide.Minimum of 30% oxygen.Ability for 100% oxygen.
56 Nitrous oxideAbility to cut off nitrous oxide, and opens the system to allow the patient to breathe room air.Non-return valve to prevent re-breathing.Reservoir bag.Ability of scavenging of expired gases .Low gas flow alarm.Risks of chronic exposure to nitrous oxide .
63 Flumazenil (Romazicon) Benzodiazepine antagonistVersed reversal agentInitial dose – 0.2mgMay repeat at 1 minute intervals to dose of 1mgOnset of action within 1-2 minutesMust monitor for re-sedationMay be repeated at 20 minute intervals as needed
64 Naloxone (Narcan) Narcotic antagonist Initial dose – 0.4mg Fentanyl reversal agentInitial dose – 0.4mgMay repeat every 2-3 minutes at doses of mgMonitor for re-sedation
65 Esmolol (Brevibloc) Antihypertensive Beta blocker Initial dose 0.25 –1.0 mg/kg over 30 secondsShort half-life of approximately 10 minutes
66 Ephedrine Used for hypotension Sympathomimetic Initial dose 5-10mg Action may not be seen for several minutes
67 Atropine Significant bradycardia or asystole Anticholinergic Slow heart beat or NO heartbeatAnticholinergicInitial dose 0.25 – 1.0 mgMay repeat every 3-5 minutesMaximum total dose .03 mg/kg
68 Epinephrine True emergency medication Administration should be preceded by activation of the emergency response system
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