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

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

3. 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.

4. 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.

5. 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.

6. 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

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

8. 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.

9. 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®)

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

11. Sedation Medication Guidelines
You must know
dosage limits
onset
duration of action
interactions
precautions
Policy link:

12. 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

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

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

15. 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

16. 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.

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

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

19. 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.

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

21. 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

22. 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.

23. 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

24. 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)

25. 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

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

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

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

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

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

31. Reference Information
Page 2
ASA Classifications
are defined

32. Reference Information
Page 2
NPO Guidelines

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

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

35. 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.

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

37. Addendum
Page 4
Adult/Pediatric
Pain Scale reference

38. 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.

39. 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:

40. 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.

41. 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