A Universal Approach at MUSC Updated 1/10/2007 Moderate Sedation A Universal Approach at MUSC Updated 1/10/2007

Four Levels of Sedation & Anesthesia Sedation occurs along a continuum Minimal sedation (anxiolysis) Moderate sedation Deep sedation General Anesthesia

Definition: 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.

Definition: Moderate Sedation ● A drug-induced depression of consciousness during which 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.

Definition: Deep Sedation See Deep Sedation policy C-108 ● A drug-induced depression of consciousness during which patients: 1. cannot be easily aroused 2. respond purposefully to repeated or painful stimulation. 3. respiratory effort may be impaired. Patients may require assistance to maintain an open airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

Definition: General Anesthesia (Consists of general anesthesia and spinal or major regional anesthesia. Local Anesthesia not included) A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. Independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Requires Anesthesiologist or CRNA

Intent and Goals of Moderate Sedation The patient remains: Anxiety & pain free Arousable, but relaxed Cooperative on demand Intact protective reflexes

Personnel and Staffing Requirements Licensed Independent Practitioner (LIP) or Advanced Practice Nurse (APN) must be present during the sedation procedure Only RNs or Registered Respiratory Therapists with documented competency participate in moderate sedation care. Residents must be supervised by an Attending MD/DDS who is credentialed for moderate sedation.

Staff Role – Pre procedure Must have a signed Consent for Sedation JCAHO requires 100% compliance Immediate access to the following is required: Ambu bag (correct size for patient) Non Invasive blood pressure Pulse oximeter Oxygen and Suction with set up – ready to go Mayday cart immediately accessible Reversal Agents easily accessible Naloxone (NARCAN®) Flumazenil (Romazicon®)

Medication Guidelines http://www. musc This information may may be printed for clinical use at the above link.

Sedation Medication Guidelines You must know dosage limits onset duration of action interactions precautions Policy link: http://www.musc.edu/medcenter/policy/Med/C44.pdf

Safe Administration of Drugs “start low and go slow” Begin with lower dosage Titrate slowly Caution- when you are combining two classes of drugs Individualize dose Know drug to drug interactions Practice alert! Check if patient has recently received opioids or sedation

Drug Facts - Opiate Agonists Alter perception of pain, analgesic, useful in preoperative sedation ■Fentanyl (Sublimaze®) ■ Meperidine (Demerol®) ■ Morphine

Drug Facts: Adverse Effects of Opiate Agonists Hypotension Nausea and vomiting Over sedation Respiratory depression Respiratory arrest

Caution in Administering - Opiate Agonists to Patients with: Acute asthma COPD Elderly or debilitated Obesity or “short neck” Hepatic or Renal disease Hypothyroidism Head Injury

Drug to Drug Interactions with Opiates Contraindicated with MAO inhibitors –(like Nardil®) Do not mix Demerol with Aminophylline Heparin Barbiturates Phenytoin Methicillin Alcohol Intoxicated patients may have additive effect when given narcotics.

Function of Benodiazepines (Sedatives) Pre-operative sedation, to induce sleepiness and reduce anxiety Midazolam (Versed®) Diazepam (Valium®) Lorazepam (Ativan®)

Effects of Benzodiazepines Slurred speech Nystagmus Amnesia- 3 minutes antegrade Altered judgment

Adverse Effects of Benzodiazepines Respiratory depression Paradoxical behavior Over sedation Vein irritation/phlebitis (Valium®) Practice Alert! Assign patient as Fall Risk when given Benzodiazepines. These patients have a higher fall risk than those not taking similar medication.

Caution with Benzodiazepines Reduce dose with: Elderly or debilitated Acute alcohol intoxication Acute angle glaucoma - midazolam (Versed®) COPD

Other Agents ketamine (Ketalar®)-anesthetic adjunct chloral hydrate - sedative hypnotic, half life > 10 hours (See specific wakefulness test in peds) diphenhydramine (Benadryl®)-aids sleep pentobarbital (Nembutal®)-preoperative sedation droperidol (Inapsine®)-tranquilize/sedate- use with extreme caution, FDA warning Practice Alert! There are NO reversal agents for these drugs

Reversal Agents for Opioids Naloxone (Narcan®) Medications that reverse or improve respiratory suppression due to over sedation naloxone (Narcan®)-Reverses opiates Replaces narcotics from receptors, no other action Observe for tachypnea, pain, and agitation Practice Alert: After 20 minutes the reversal agent can wear off and the patient can re-sedate with a return of respiratory insufficiency.

Reversal Agent for Benzodiazepines Flumazenil (Romazicon®) Inhibits the action of the benzodiazepine Does not necessarily correct respiratory depression Use cautiously in patients at high risk for seizure or arrhythmia Monitor for re-sedation Observe for dizziness, nausea, vomiting Drug-drug interaction includes anti-depressants

Treating Unexpected Events Respiratory Depression Stimulate the patient Open airway Chin lift Jaw thrust maneuver Oxygen as indicated Support patient ventilation (Ambu, CPAP) Initiate CPR Call for assistance to place airway (MET or Mayday team)

Treating Unexpected Events Hypotension Leg elevation Fluid challenge (with M.D. order) Reversal agents (with M.D. order) Nausea & Vomiting Side position Modified trendelenberg Suction

Nursing Assessment, Physician History & Physical Page 1 Attending Physician Signature Required

Nursing assessment key points . . . Page 1 Location: where moderate sedation is performed Initial Patient Identifiers Note significant results in this section, or utilize Oacis

Nursing assessment key points . . . including patient medical history Page 1

Required - H&P by physician, review of systems and airway assessment Page 1

Reference Information, Airway Assessment Page 2 No documentation is necessary on this page, contains reference information only

Reference Information Page 2 ASA Classifications are defined

Reference Information Page 2 NPO Guidelines

Procedure Documentation Page 3 Note: Use Initials Correct patient Correct procedure Consent obtained Correct site-in some cases Time Out

Procedure Documentation Page 3 Vital signs, including pain score, documented every 5 to 15 minutes

Procedure Documentation Page 3 Assign Modified Aldrete Scores prior to sedation immediately post procedure prior to discharge from sedation (required) If patient is transferred to another site for recovery, the recovery RN must complete the discharge from sedation information Historically, audits show poor compliance with discharge from sedation documentation.

Procedure Documentation Page 3 Space for (PRE) vital signs-prior to sedation Check box for Addendum: Continued on page 4

Addendum Page 4 Adult/Pediatric Pain Scale reference

Recovery and Discharge from Sedation Modified Aldrete Scale - utilized to document recovery status of patient Completion of recovery from sedation signifies “discharge” from moderate sedation protocol Patient may or may not be discharged from the unit or other MUHA location at this time Practice Alert: MD discharge from sedation is required if a reversal agent was administered post sedation.

Evaluation & Monitoring NORA- Non-Operating Room Anesthesia Committee meets quarterly for review of Patient Safety Net reports Reference information: MUHA Intranet Training and Staff Education- “Sedation” resource web page at: www.musc.edu/medcenter/trainingToolbox/sedation/index.htm

PATIENT SAFETY NET (PSN) INSTRUCTIONS All adverse events related to sedation or use of reversal agents must be submitted in the Patient Safety Net (PSN) Examples including but not limited to: Prolonged or recurrent desaturation Use of reversal agent Post procedure - Altered mental status, difficulty awakening, resedation Urgent Airway care, Arrhythmia, Mayday, emergency drugs administered Rescue from inadvertent deeper sedation How to Report: Select F: Complication of procedure treatment or test Then select #2 Anesthesia/Sedation Event If Adverse event involves medication or reversal agents notify Pharmacy as consult department.

Summary Goal: Provide safe patient care Sedation is a continuum Know how to define your role in moderate sedation (pre, intra and post procedure) Provide safe administration of medication Provide ongoing monitoring until discharged from sedation Be prepared to “rescue the patient” Complete all documentation for sedation care