1. . Moderate Sedation Review 2009 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 with minimal risk to the patient 2. Relieve anxiety and produce amnesia 3. Provide relief from pain and other noxious stimuli

4. . Characteristics of Medications Used in MS Agents used in moderate sedation will have: Short duration of action Rapid recovery Lack of cumulative effects Few side effects Desirable: analgesic effects last longer than sedative effects

5. . IMPORTANT!! Per policy CL.46. All female patients age 9 (nine) and older must have a negative pregnancy test unless menopausal surgically menopausal, or currently pregnant. Before proceeding with moderate sedation....Is your patient pregnant?

6. . IMPORTANT The medications used to cause moderate sedation have been shown to have adverse affects on the fetus!! BEFORE THE PROCEDURE IS STARTED. All female patients 9-years-old or older, that are not menopausal, MUST HAVE HCG TESTING DONE AND NEGATIVE RESULTS RECEIVED BEFORE THE PROCEDURE IS STARTED.

7. . Clinical Endpoints of Moderate Sedation Beginnings of slurred speech Decreased anxiety Goal of Moderate Sedation IS NOT unconsciousness or unresponsiveness!

8. . End result of Moderate Sedation To produce a: Pain-free amnesic, Sedated patient who Recovers rapidly with Few side-effects due to medication.

9. . IMPORTANT!! Per policy CL.46. All female patients age 9 (nine) and older must have a negative pregnancy test unless menopausal surgically menopausal, or currently pregnant. Before proceeding with moderate sedation....Is your patient pregnant?

10. . Medication Administration Key Points:  Give only amount necessary to render the patient calm, cooperative, able to follow commands  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)

11. . IV Administration Onset is rapid (20- 30 seconds) Titration: injection of small increments of drug until desired effects are achieved Continuously monitor patient’s response.

12. . RN must be knowledgeable about: Drug names and classifications Appropriate dosages for patient’s age and condition Indications Contraindications Recommended dilution Onset and duration of action. Expected actions Compatibility with solutions, and other medications Possible side effects /adverse reactions Interventions for side effects Emergency management techniques

13. . Classes of Agents Sedatives Opioids ( morphine, Fentanyl ® ): Benzodiazepines (Versed ®, Valium ® ): Reversal Agents Narcan ® Romazicon ®

14. . Opioids (e.g., morphine, Fentanyl) Opioids ( morphine, Fentanyl ® ): Alter the process of pain sensation, and emotional response to pain Side effects: CNS depression Respiratory depression Nausea and vomiting Hypotension Pruritis Reversal Agent: Narcan ®

15. . Opioids DrugDose Range IV Onset (minutes) Clinical Duration (hours) Comments Morphine2-3 mg54 Inject slowly over 4 to 5 minutes May be diluted with water for injection  dose by 30%if given with another CNS depressant Fentanyl0.3 – 0.5 mcg/kg 1-21 Has fewer side effects Titrate in 25 mcg increments every 2-3 minutes Remifentanil0.1-0.25 mcg/kg 110 minutes Rapid induction with rapid elimination Must be given SLOWLY (over 1 minute) Reversal AgentNarcan®

16. . Benzodiazepines (e.g., Versed ®, Valium ® ) Depress CNS producing muscle relaxation, and anti- anxiety effects. Side effects: Drowsiness, ataxia, confusion Fatigue, headache, weakness Dizziness, vertigo, syncope Antegrade amnesia Reversal Agent: Romazicon ®

17. . Benzodiazepines DrugDose Range IV Onset (minutes) Clinical Duration (hours) Comments Midazolam (Versed®) 2.5 mg11 Titrate SLOWLY Initial dose should not exceed 2.5 mg administered over a min. of 2 minutes DO NOT bolus Wait 2 minutes between doses to evaluate patient effects Diazepam (Valium®) 1-2 mg56 Titrate SLOWLY (over 1 min. for each 5 mg) until slurred speech occurs Initial titration should not exceed 10 mg If administered with a narcotic,  dose of narcotic by 1/3 titrated slowly. Reversal Agent Romazicon (flumazenil)

18. . Reversal Agents Narcan® ( Naloxone) Blocks effects of opiates Romazicon® (Flumazenil) Blocks effects of benzodiazepines Both 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)

19. . Reversal Agents DrugDose Range IV Onset (minutes) Clinical Duration (hours) Comments Naloxone (Narcan®) 0.4 – 2 mg21-4 Titrate slowly to desired effect Dilute 1 ml ampoule (0.4mg/ml) in 10 ml normal saline Give 1 ml (.04 mg) every 2-3 minutes until RESPIRATORY DEPRESSION is reversed Patient must be monitored for up to 90 min. after time of administration Flumazenil (Romazicon®) Based on patient response 1-2 (80% of patients respond in 3 minutes) 45-90 minutes Administer through LARGE vein Give 0.2 mg increments (2 ml) over 15 seconds; May repeat at 1 minute intervals Total dose not to exceed 1 mg in 5 minutes Maximum dose: 3 mg in any 1- hour period Patient must be monitored for up to 90 min. after time of administration

20. . 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 Sedation Please note: THE RULES HAVE CHANGED regarding the Nurse’s role in its administration

21. . 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.

22. . 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

23. . What does participate mean? The nurse MAY NOT be responsible for: Administering bolus of Propofol Titration of Propofol Maintenance of the airway Care and monitoring of the patient

24. . The Nurse MAY Act as scribe, writing down information on the record form Act as “extra hands”, for example, by providing needed equipment, supplies

25. . What if I am asked to assist with propofol in a more active patient monitoring role? The short answer is to refuse. The longer answer is to discuss questions or concerns with your department manager.

26. . 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.

27. . 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.

28. . Remember! Moderate Sedation occurs on a continuum: Awake  Minimal Sedation  MODERATE SEDATION MODERATE SEDATION  Deep Sedation  General Anesthesia

29. . 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.

30. . 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 it can never be retrieved.

31. . Remember! Use reduced dose of agents in patients who are Debilitated At extremes of age Hypovolemic Patients with COPD are more susceptible to respiratory depressant effects Avoid using “recipes”—no two patients will react the same to a given dose Give only the medication that is needed

32. . Final Note Regardless of: Type of procedure Type of drugs used Type of venue