Presentation on theme: "Moderate Sedation Review 2008"— Presentation transcript:
1 Moderate Sedation Review 2008 Part 2: Pharmacology
2 Pharmacology --Introduction A variety of medications are used to induce the state of Moderate Sedation in the patient.These medications may be used alone, or in combination.It is important to remember that drugs used in combination may potentiate each other increasing the effects of the combination to four to ten-times that of the same drugs used individually.
3 Recall the Goals of Moderate Sedation 1. Maintain adequate sedation withminimal risk to the patient2. Relieve anxiety and produce amnesia3. Provide relief from pain and othernoxious stimuli
4 Characteristics of Medications Used in MS Agents used in moderate sedation will have:Short duration of actionRapid recoveryLack of cumulative effectsFew side effectsDesirable: analgesic effects last longer than sedative effects
5 Clinical Endpoints of Moderate Sedation Beginnings of slurred speechDecreased anxietyGoal of Moderate Sedation IS NOT unconsciousness or unresponsiveness!
6 End result of Moderate Sedation To produce a:Pain-free amnesic,Sedated patient whoRecovers rapidly withFew side-effects due to medication.
7 Medication Administration Key Points: · Give only amount necessary to render the patient calm, cooperative, able to followcommands· Administered according to Corporate medication policies· When additional medication is ordered for sedation after the initial dose:cumulative TOTAL dose will be communicated AUDIBLY to the practitioner (“I just gave 1-mg versed for a TOTAL dose of 2-mg given)
8 IV Administration Onset is rapid (20-30 seconds) Titration: injection of small increments of drug until desired effects are achievedContinuously monitor patient’s response.
9 RN must be knowledgeable about: Drug names and classificationsAppropriate dosages for patient’s age and conditionIndicationsContraindicationsRecommended dilutionOnset and duration of action.Expected actionsCompatibility with solutions, and other medicationsPossible side effects /adverse reactionsInterventions for side effectsEmergency management techniques
11 Opioids (e.g., morphine, Fentanyl) Opioids (morphine, Fentanyl®):Alter the process of pain sensation, and emotional response to painSide effects:CNS depressionRespiratory depressionNausea and vomitingHypotensionPruritisReversal Agent: Narcan®
12 Opioids Drug Dose Range IV Onset (minutes) Clinical Duration (hours) CommentsMorphine2-3 mg54Inject slowly over 4 to 5 minutesMay be diluted with water for injectiondose by 30%if given with another CNS depressantFentanyl0.3 – 0.5mcg/kg1-21Has fewer side effectsTitrate in 25 mcg increments every 2-3 minutesRemifentanilmcg/kg10 minutesRapid induction with rapid eliminationMust be given SLOWLY (over 1 minute)ReversalAgentNarcan®
14 Benzodiazepines Drug Dose Range IV Onset (minutes) Clinical Duration (hours)CommentsMidazolam(Versed®)2.5 mg1Titrate SLOWLYInitial dose should not exceed 2.5 mg administered over a min. of 2 minutesDO NOT bolusWait 2 minutes between doses to evaluate patient effectsDiazepam(Valium®)1-2 mg56Titrate SLOWLY (over 1 min. for each 5 mg) until slurred speech occursInitial titration should not exceed 10 mgIf administered with a narcotic, dose of narcotic by 1/3 titrated slowly.ReversalAgentRomazicon(flumazenil)
15 Reversal Agents Narcan® (Naloxone) Romazicon® (Flumazenil) Both may: Blocks effects of opiatesRomazicon® (Flumazenil)Blocks effects of benzodiazepinesBoth may:Precipitate withdrawal (seizures),cause increased sympathetic activities (tachycardia, hypertension, arrhythmias, pulmonary edema)Allow re-sedation to occur (duration of action of reversal agent is less than that of the sedatives they reverse)
16 Reversal Agents Drug Dose Range IV Onset (minutes) Clinical Duration (hours)CommentsNaloxone(Narcan®)0.4 – 2 mg21-4Titrate slowly to desired effectDilute 1 ml ampoule (0.4mg/ml) in 10 ml normal salineGive 1 ml (.04 mg) every 2-3 minutes until RESPIRATORY DEPRESSION is reversedPatient must be monitored for up to 90 min. after time of administrationFlumazenil(Romazicon®)Based on patient response1-2(80% of patients respond in 3 minutes)45-90 minutesAdminister through LARGE veinGive 0.2 mg increments (2 ml) over 15 seconds;May repeat at 1 minute intervalsTotal dose not to exceed 1 mg in 5 minutesMaximum dose: 3 mg in any 1-hour period
17 And now a word about PROPOFOL… For years used in the ED as sedative for reducing fractures, in EP lab for procedures, etc.Used in some instances to bring about a state of Moderate SedationPlease note: THE RULES HAVE CHANGED regarding the Nurse’s role in its administration
18 Procedural Administration of Propofol Urgent Nursing Practice Memo 12/7/07 issued by Nurse Executive Council, Quality and Patient Safety states:As per Kaleida IV Administration Policy TX.IV’s and MEDS_19, Propofol may be titrated and administered by an RN only when a patient’s respiratory status is supported by a mechanical ventilator.
19 What about for Moderate Sedation? The same Nursing Practice memo states:An RN may not participate in Moderate Sedation when propofol is utilized without active ventilator support
20 What if I am asked to assist with propofol? The short answer is to refuse.The longer answer is to discuss questions or concerns with your department manager.
21 The reason to refuse….Nursing non-compliance with this New York State Department of Education and Licensure regulation is a NYS reportable event which places your license to practice nursing in jeopardy.
22 If you need support for your refusal: In a memo to the CMOs dated 12/6/07 it was stated:An RN MAY NOT be the participant who is expected to push / titrate propofol OR assume the care / monitor the patient. It is the drug (propofol) which sets this situation apart.In the case in ED, EP lab etc. where propofol is being used for moderate sedation:A second provider (second ED attending, MOD) credentialed in moderate sedation will need to attend the patient, and provide monitoring, care, and documentation at the bedside.
23 Remember! Moderate Sedation occurs on a continuum: Awake Minimal Sedation MODERATE SEDATION Deep Sedation General Anesthesia
24 Remember!Patients can slip from one level to the next without warning.Practitioners must be qualified to rescue the patient from a lower state, i.e. deep sedation, and be skilled in airway management.Patients can slip from one level to the next without warning. Practitioners must be qualified to rescue the patient from a lower state, i.e. deep sedation, and be skilled in airway management.
25 Remember!Avoid standard mixes (e.g., x-mg of medication A, and x-mg of medication B)Treat the specific symptom (e.g., treat pain with more local anesthetic or narcotic)Titrate medication carefully—more medication can always be given, however they can never be retrieved.
26 Remember! Use reduced dose of agents in patients who are Debilitated At extremes of ageHypovolemicPatients with COPD are more susceptible to respiratory depressant effectsAvoid using “recipes”—no two patients will react the same to a given doseGive only the medication that is needed
27 Final Note The most important consideration is Regardless of:Type of procedureType of drugs usedType of venueThe most important consideration isThe safety of the patient!