Procedural Sedation Lutheran Medical Center v.2011-12

1. Definitions along the Sedation Continuum Note: Press F11 to maximize 1. Definitions along the Sedation Continuum Minimal Sedation “Anxiolysis” Procedural Sedation “Conscious Sedation” Deep Sedation General Anesthesia Responsiveness Normal response to verbal stimulation Purposeful response to verbal or tactile stimulation Purposeful response following repeated or painful stimulation Unarousable even with painful stimulus Airway Unaffected No intervention required Intervention may be required Intervention often required Spontaneous Ventilation Adequate May be inadequate Frequently inadequate Cardiovascular Function Usually maintained May be impaired To verbal or tactile stimulation Following repeated or painful stimulation No Maybe Adequate May be inadequate Usually maintained Usually maintained Specific differences: Procedural and Deep Response? Airway intervention required? Ventilation? Cardiovascular function? for both

2. Verification of Provider Credentials (prior to EVERY procedure even if the physician performed the procedure yesterday) Call Medical Staff Services or the Hospital Supervisor if you cannot obtain this information Login to the Portal (my.exempla.org) Open the Delivering Care tab Choose the Privileges link Choose appropriate hospital from the dropdown list Enter search criteria Click Submit Click the provider’s name to see: Privileges granted Suspension status Other information For more details concerning requirements for specific privileges: Click the Medical Staff tab Choose Privileges Sheets link in the top right corner of the page Open the appropriate list to see further definitions of the privileges granted

3a. Prerequisites tasks for the licensed independent practitioner (LIP) History Baseline Physical Examination Upper Airway Assessment ASA Score Plan of Care – rationale for procedure and sedation plan Informed Consent COR status Re-assessment – immediately before the administration of sedation Discharge criteria

3b. NPO Status Recommendations - Elective and Emergent Procedures Age More than 8 years 3 - 8 years 6 months to 3 years Less than 6 months Solids & Non-Clear Liquids* Clear Liquids** 8 hours 4 hours 6 hours 3 hours 6 hours 2 hours 4 hours 2 hours * Non-clear liquid = breast milk, formula ** Clear liquids = water, clear juices, black coffee and tea (no milk) NPO status for emergent and urgent procedures is determined by: patient’s status procedural risk and type degree of sedation anticipated

4a. RN Responsibilities: Acts under the direction of a credentialed Medical Staff Member Reviews/completes pre-procedure & post-procedure assessment Administers medications for sedation/analgesia Monitors patient Completes required documentation Ensures patient/family education

4a. Respiratory Therapist Responsibilities: Acts under the direction of a credentialed Medical Staff Member Completes required documentation Ensures patient/family education

4b. RN Qualifications / Requirements Acts within hospital approved Scope of Practice Has successfully completed: Current Basic Life Support (BCLS) Procedural Sedation Clinical Competency Nursing Adult and Pediatric  RNS Departmental Competencies as required If Applicable, has successfully completed: Advanced Cardiac Life Support (ACLS) Neonatal Resuscitation Program (NRP) Pediatric Advanced Life Support (PALS)

4b. Respiratory Therapist Qualifications / Requirements Acts within hospital approved Scope of Practice Has successfully completed: Current Basic Life Support (BCLS) Procedural Sedation Clinical Competency Departmental Competencies as required If Applicable, has successfully completed: Advanced Cardiac Life Support (ACLS)

5. Needed supplies and equipment Oxygen a positive pressure system that is capable of administering > 90% Oxygen at a 15 liter per minute flow rate for > than one hour (2 E cylinders) Face mask and/or nasal prongs Pulse oximeter Intravenous equipment Blood pressure equipment Bag valve mask (ambu) Oral/Nasal airway Defibrillator & Cardiac monitor Suction equipment Emergency Medications Atropine and reversal agents (i.e. Narcan and Flumazenil) Advanced airway management equipment laryngoscope handles and blades endotracheal tubes and stylets On COR Cart

6. Monitoring requirements Parameter During the Procedure After the Procedure Vital Signs: BP Respiratory rate Oxygen saturation Heart rate Every 15 min At least 20 minutes after last dose of IV medication and until discharge criteria are met,       OR For at least 1 hour after the last dose of a reversal agent and until discharge criteria are met Responsiveness to commands: Richmond Agitation Sedation Scale Pain: Adult  1-10 Neonatal Neonatal Infant Pain Scale (NIPS) As needed After the procedure Cardiac Monitoring: If needed, staff with rhythm recognition skills must be present The decision to monitor the cardiac rhythm is based on: Clinical indicators, history of significant cardiac disease, likelihood that procedure might result in rhythm changes, physician’s discretion.

Abnormal assessment findings and when to notify a LIP When patient is: Exhibiting signs of deep sedation, purposeful response only to repeated or painful stimuli Rass score of –4 or –5 O2 Sat <92% during or > 30 min after last dose of medication BP increase or decrease by 20% from baseline Arrhythmias Apnea Any change in respiratory or circulatory parameter

General principles in administration of Sedatives & Analgesics Combination of sedatives and analgesics increase the risk of respiratory depression and apnea Medications should be administered: one at a time in incremental doses with sufficient time to evaluate (generally over 2 minutes and wait 2-5 minutes to evaluate) Titrate narcotics to obtain pain relief and sedatives to decrease anxiety

8a. Age Specific Considerations for medication Pediatric patients Geriatric patients Medication dosage by weight Preferred routes PO or IV Knowledge of age specific vital sign normals/abnormals is essential Oxygen desaturation occurs faster Faster drug clearance due to increased renal/hepatic blood flow Increased body fat therefore increased storage Increased susceptibility to airway obstruction. (S/S of respiratory distress includes cyanosis, grunting, retractions, and nasal flaring.) Available airway equipment must be appropriate size Sniff position for infants Increased sensitivity to medications, adjust dosage appropriately Less oxygen reserve Decreased drug metabolism from decreased renal and hepatic flow Slower circulation time of medications Decreased muscle tone (stiff neck) Increased musculoskeletal disorders

8b. Disease Considerations for medication Renal/Liver patients Obesity Diminished drug clearance Poor venous access Inaccurate blood pressure Hypertension Difficult airway management Respiratory insufficiency, diaphragm pushed up by abdomen Positioning difficulties Storage of medication in adipose tissue Co-morbidity: diabetes resulting in circulatory disorders

8c. Usual dosage for medication Initial doses IV over 2 minutes unless indicated MEDICATION ADULT PEDIATRIC NEONATE GERIATRIC MIDAZOLAM (VersedTM) Onset 2-5 min Duration 60-90 min 0.5-2 mg 0.01-0.02 mg/kg 0.5-1 mg DIAZEPAM (ValiumTM) Duration 6-8 hours 2-5 mg 0.04 mg/kg over 5 min 2 mg LORAZEPAM (AtivanTM) Onset 5-10 min Duration 4-6 hours 0.05mg/kg 0.02-0.05 mg/kg 0.01 mg/kg 0.05 mg/kg FENTANYL (SublimazeTM) Onset immediate Duration 30-60 min 50-100 mcg 0.5-1 mcg/kg 25-50 mcg MORPHINE Onset 5 min Duration 4-5 hours 0.05-0.1 mg/kg 0.05-0.2 1-2 mg KETAMINE (KetalarTM) Onset 1-2 min Duration 1-2 hours 1-2 mg/kg over 2-3 min Benzodiazepines Narcotics Other Refer to policy for repeat doses and other vital information

8d. Considerations & precautions for meds Reduce dosage if used with narcotics Reversal agent is flumazenil Lorazepam may have longer onset of action up to 10 minutes Major side effects and respiratory depression hypotension (averted if drug administered slowly) Lorazepam injection must be diluted with = amount of diluent before IV use Benzodiazepines Will potentiate effects of benodiazepines May need increased dose of naloxone to reverse CNS/resp. effects of fentanyl Caution use in patients with asthma and/or COPD Narcotics

8d. Considerations & precautions for meds (continued) Observe for sedation for a minimum of one to two hours Monitor blood pressure, heart rate, respiratory rate. Close cardiac monitoring for patients with history of hypotension or cardiac decompensation Contraindicated in patients with elevated intracranial pressure, uncontrolled hypertension, aneurysms, thyrotoxicosis, CHF, angina Caution in patients with coronary artery disease, tachycardia Ketamine

8c. Usually dosage for medications specific to the ED and ICU ONLY for ED and ICU use 8c. Usually dosage for medications specific to the ED and ICU Initial doses IV MEDICATION ADULT PEDIATRIC NEONATE GERIATRIC ETOMIDATE Onset 30-60 sec Duration 3-5 min 0.1-0.2 mg/kg over 30-60 sec Not recommended for Children under 10 years, 0.1-0.2 mg/kg over 60 sec Refer to policy for repeat doses and other vital information 9. RN administration MUST be under direct supervision of credentialed physician and RT or 2nd physician not involved in the procedure. MUST be monitoring airway.

Considerations Precautions ONLY for ED and ICU use 8d. Considerations & precautions for medications specific to the ED & ICU Considerations Precautions RN administration restricted to ED and ICU Monitor blood pressure, heart rate, respiratory rate Caution in patients with serious asthma, hypotension, myoclonus, and nausea/vomiting Etomidate

8c. Usually dosage for medications specific to the ED, ICU and GI Lab Propofol is used in the GI Lab as well as the ED and ICU 8c. Usually dosage for medications specific to the ED, ICU and GI Lab Initial doses IV MEDICATION ADULT PEDIATRIC NEONATE GERIATRIC PROPOFOL Onset 30 sec Duration 3-10 min 0.5-1 mg/kg slow 0.5 mg/kg slow Refer to policy for repeat doses and other vital information MUST be administered only by an anesthesiologist.

Benzodiazepine Antagonist 10. Identify appropriate interventions if pt. progresses to deep sedation 11. Describe REVERSAL agents, their actions and criteria for use Initial doses IV over 15 seconds MEDICATION ADULT PEDIATRIC NEONATE GERIATRIC FLUMAZENIL (RomaziconTM) Onset 30 sec Duration 3-10 min 0.2 mg 0.01 mg/kg (Max initial = 0.2 mg) 0.002-0.01 mg/kg NALOXONE (NarcanTM) Onset 1-2 min Duration 1-4 hours 0.1-0.4 mg 0.1 mg/kg 0.1-2 mg Benzodiazepine Antagonist Narcotic Antagonist Refer to policy for repeat doses and other vital information

Considerations Precautions Benzodiazepine Antagonist 10. Identify appropriate interventions if pt. progresses to deep sedation 11. Describe REVERSAL agents, their actions and criteria for use Considerations Precautions Observe for re-sedation for a minimum of one to two hours Caution in patients addicted to benzodiazepines Caution in patients with history of seizures Caution in patients with history of panic attacks FLUMZAENIL Benzodiazepine Antagonist Observe for re-narcotization for a minimum of one to two hours Titrate to avoid excessive reduction in analgesia Caution use in patients addicted to narcotics May need higher doses with fentanyl May not reverse cardiovascular effects of narcotics Naloxone associated non-cardiogenic pulmonary edema has been reported throughout dose range Narcotic Antagonist NALOXONE

12. Potential complications related to the procedure Complication Treatment Airway obstruction Monitor pulse oximeter continuously Stimulate patient to breathe Position head appropriately Chin lift and jaw thrust Administer supplemental oxygen Administer reversal agents Oral or nasal airway Suction airway if needed Ventilate manually with bag valve mask device

12. Potential complications related to the procedure Complication Treatment Bradycardia (caused by hypoxemia, vagal stimulation) Oxygen Medications as ordered and indicated If patient develops shortness of breath or chest pain, obtain EKG

12. Potential complications related to the procedure Complication Treatment Tachycardia (caused by pain, anxiety, hypoxemia, hypovolemia) Notify MD of tachycardia Administer pain medication as ordered by MD performing procedure Administer O2 as needed Administer IV fluids as ordered by MD

12. Potential complications related to the procedure Complication Treatment Other dysrhythmias Atrial dysrythmias, PVC’s (caused by hypoxemia & hypovolemia ) Notify MD of dysrhythmias Administer medication as ordered by MD Look for underlying causes such as hypoxemia and hypovolemia and report to MD

12. Potential complications related to the procedure Complication Treatment Hypotension (caused by pre-existing condition, response to medications, hypovolemia ) As indicated and ordered: Administer reversal medications Administer fluids Administer vasopressors

12. Potential complications related to the procedure Complication Treatment Hypertension (caused by pre-existing conditions, pain, stress) As indicated and ordered: Administer additional sedation Administer analgesia Administer patient medications for hypertension

13. Criteria for discharging a patient Stability of vital signs = BP and Pulse within 20 points for 3 consecutive observations (in the absence of significant hypertension or hypotension. ) SPO2 meets or exceeds oxygen saturation guidelines (greater than 90 % on room air or with supplemental oxygen or within baseline measurements) Body temperature at or greater than 96.8 degrees Patient orientation to name, place and day or to similar orientation present pre-procedure Patient able to move all four extremities on command or in a manner similar to that present pre-procedure Absence, control or MD awareness of: Pain, nausea and vomiting, wound drainage and bleeding Airway patency and respiratory function must be adequate and appropriate for discharge

13. Criteria for discharging a patient (continued) Fluids balanced, taking into account previous NPO status and underlying conditions Physician if needed and desired contacted prior to discharge Vital signs remain stable after oxygen has been removed for 15 to 20 minutes Patient will remain at least 20 minutes after IV analgesic, providing other discharge criteria have been met Final nursing assessment and evaluation of patient condition will be performed and documented Primary nurse will inform unit nurse, if applicable, in an organized report of patient condition and procedural experience Patients not meeting pre-determined discharge criteria requires a specific physician order for discharge (Nurses notes will explain criteria not met and interventions)

13. Criteria for discharging a patient (continued) Discharge to Patient Care Unit Vital signs monitored every 15 minutes after procedure until: Patient has met specified criteria  or per physician order  Transfer order written by physician  

13. Criteria for discharging a patient Discharge from Hospital When criteria for discharging a patient has been met Control of pain acceptable to the patient Control of nausea Ambulation in a manner consistent with the procedure and previous ability Arrangements for safe transportation from the facility Patient and responsible adult should verbalize an understanding of instructions Patients should be evaluated for the need for provision of additional resources to contact if any problems arise Patients are to be discharged per a physician’s order A copy of the post procedure discharge instructions should accompany the patient home It is recommended that the patient have a responsible adult with them for 24 hours post procedure

14. Documentation ELECTIVE PROCEDURE H&P An H&P must be in the patient chart prior to the procedure An H&P Update must be completed if the original H&P was done prior to patient admission Appropriate Informed Consent for the procedure must be in the patient chart Emergent procedures must contain appropriate physician documentation

DURING TREATMENT & POST-PROCEDURE RECOVERY 14. Documentation DURING TREATMENT & POST-PROCEDURE RECOVERY Amount of medication used, including dosage, route, and times given Notation if supplemental oxygen was given Monitors employed Oxygen saturation and vital signs at required intervals Any complication and subsequent management Level of consciousness and general appearance Any restraints or protective devices used Use of reversal agents Response to the procedure Condition of any dressings, procedure sites, or drainage Orders for transfer/discharge Discharge instructions given if discharged from facility

DURING TREATMENT & POST-PROCEDURE RECOVERY 14. Documentation DURING TREATMENT & POST-PROCEDURE RECOVERY Select appropriate areas for your department and complete Doc Flow Sheets

DURING TREATMENT & POST-PROCEDURE RECOVERY 14. Documentation DURING TREATMENT & POST-PROCEDURE RECOVERY For charting vitals, select specific Intra-Procedural Doc Flow sheet for your area

DURING TREATMENT & POST-PROCEDURE RECOVERY 14. Documentation DURING TREATMENT & POST-PROCEDURE RECOVERY Complete Vital Signs/Pain flow sheet, charting medications administered in the MAR

Conclusion You have completed the training content for this lesson. You should now be able to: Differentiate between procedural and deep sedation Demonstrate correct timing and process of verification of provider credentials Identify prerequisites tasks for the licensed independent practitioner (LIP) Describe RN/RT prerequisite tasks Describe needed supplies and equipment Identify monitoring requirements Recognize abnormal assessment findings and know when to notify a LIP Describe usually dosage and age specific considerations for medication Identify appropriate staff who must be in the room and who can supervise a RN administering medications Identify appropriate interventions if patient progresses to deep sedation Describe reversal agents, their actions and criteria for use List potential complications Describe criteria for discharging a patient Describe essential elements to document in the patient’s medical record Evaluate the procedure by completing the procedure review form Interventions over a 7 month period reduced the rate of medication errors by 70% and ADE’s by 15% Rozich JD, Resar RK. JCOM 2001; 8(10): 27-34 “Medications not reconciled at transition points may account for as many as 50% of all medication errors and up to 20% of acverse drug events seen both in the hospital and later in outpatient settings” – Institute for Healthcare Improvement (IHI). Variances from home meds to admission orders range from 30% to 70% Most common discrepancy in reconciliation found to be omissions of home medications Many of the omissions had potential for serious harm

Click the EXIT button in the upper right hand corner to close this window Interventions over a 7 month period reduced the rate of medication errors by 70% and ADE’s by 15% Rozich JD, Resar RK. JCOM 2001; 8(10): 27-34 “Medications not reconciled at transition points may account for as many as 50% of all medication errors and up to 20% of acverse drug events seen both in the hospital and later in outpatient settings” – Institute for Healthcare Improvement (IHI). Variances from home meds to admission orders range from 30% to 70% Most common discrepancy in reconciliation found to be omissions of home medications Many of the omissions had potential for serious harm