1. Moderate Sedation

2. 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.
Moderate sedation/analgesia (“conscious sedation, procedural 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 maintained.
Deep Sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation maybe inadequate. Cardiovascular function is usually maintained.
Anesthesia: Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain 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. Anesthesia is restricted to use by an anesthesia provider.

3. ASA Classification:
The physician is responsible for assigning the patient an ASA classification and documentation of the classification level.
ASA Categories:
ASA 1: Normal healthy patient
ASA 2: Patient with mild to moderate systemic disease. (Well controlled hypertension or diabetes mellitus)
ASA 3: Patient with severe systemic disease with functional limitation that is not incapacitating. (Severe diabetes with systemic complications, history of myocardial infarction, angina pectoris, or poorly controlled hypertension)
ASA 4: Patient with sever systemic disease that is incapacitating, and life threatening. (Severe cardiopulmonary, renal, hepatic, or endocrine dysfunction)
ASA 5: Moribund patient, who is not expected to survive without surgical intervention. (Surgery is done as a last recourse or resuscitative effort, major multi-system trauma, ruptured aneurysm or large pulmonary embolus)
ASA 6: Declared brain dead patient/organ donor.

4. Intent and Goals of Procedural Sedation
The patient remains:
Anxiety & pain free
Arousable, but relaxed
Cooperative on demand
Intact protective reflexes
Staff Role: Review, assess & document H & P, review consent, assess airway, obtain baseline VS % pain rating, IV access, TIME OUT immediately before starting procedure.
Sedation Medication Guidelines
You must know:
Dosage limits, onset, duration of action, interactions, and precautions

5. Pre- Procedure Nursing
The Registered Nurse should perform and document a physical assessment immediately before administration of sedative drugs to include but not limited to the following aspects:
1. Verify:
Patient identification
Appropriate informed consent
Patient allergies, medical condition, and history
Required equipment present and functioning per equipment requirements
NPO status of a recommended time of at least 6 hours or per physician written orders
Physician sedation privileges
Procedure and procedure site is marked as applicable
2. Patient education is given
3. Previous sedation/anesthesia complications or family history of sedation/anesthesia complications
4. Pre-procedure diagnosis
5. Current medication, illicit drug, tobacco, and alcohol use
6. Systems evaluation, level of alertness/sedation scale and level of comfort via pain scale, complete baseline Aldrete scale.
7. Review of sedation plan and physical status classification as assigned by physician.
8. Review of diagnostic/laboratory; abnormal findings reported to physician
9. Attach cardiac monitor, blood pressure device, and oximeter to patient
10. Assess and document the patient’s vital signs, immediately prior to initiation of sedation: baseline blood pressure, heart rate, heart rhythm, oxygen saturation, height, weight, and age
11. Establish and/or confirm patent venous access
12. Administer oxygen per nasal cannula or mask if oxygen saturation decreased by 5% or more from baseline rate or below 92% saturation or per physician order

6. Equipment
1. Pulse Oximeter 2. Blood pressure device 3. Cardiac monitor 4. Oxygen supplies 5. Suction equipment 6. Intubation equipment; appropriate to patient age/size 7. Code cart with defibrillator, ambu bag with appropriate size valve/mask 8. Medications ordered by physician with appropriate sedative reversal agent 9. Code light or telephone within immediate area 10. All life-sustaining equipment will use electrical outlets connected to emergency power system

7. Procedure During the Procedure
a. The attending physician or physician performing/supervising the procedure must be present for assistance as needed.
b. Continuous monitoring of heart rate and rhythm, and oxygen saturation by pulse oximetry. Documentation and assessment of heart rate, rhythm, O2 saturation, respiratory status, and blood pressure should occur a minimum of every 5 minutes x 30 minutes, then every 15 minutes.
c. Performance and documentation will reflect evidence of assessment, planning, implementation, and evaluation of care. The documentation will include, but not limited to:
Medications, including oxygen, given with dosage, route, time, and person administering
Sedation scale, pediatric patients will be evaluated according to developmental and age appropriate responsiveness
Level of pain per pain scale; age appropriate
Significant events with corrective actions and the results of the actions
d. Observe for and report any changes as defined in policy to the physicians such as: changes in vital signs, cardiac rate/rhythm changes, abnormal oxygen saturation, restlessness, cyanosis, pallor, flushing, diaphoresis, nausea, and palpitations
e. Provide emotional support throughout case (appropriate touch and voice).

8. Post-procedure/ Recovery Phase
a. Vital signs, sedation scale, and pain level every 15 minutes until stable or until discharge criteria are met. b. Monitoring by staff competent in sedation shall be maintained a minimum of 30 minutes after the last dose of sedation. c. Patient’s receiving reversal agents (Naloxone and Flumazenil) require an extended recovery period of at east sixty (60) minutes following the last dose of a reversal agent. Reassess the patient after 60 minutes to determine patient readiness for release. No sedatives (Benzodiazepines, Narcotics) should be given for at least one hour after any reversal agent has been administered. d. Continuous pulse oximetry and cardiac monitoring until discharge criteria are met. e. Aldrete Scale will be performed a minimum of every 30 minutes, and immediately prior to transfer or discharge. Monitoring for sedation may be discontinued when the patient achieves a score of 9/10 or equal to pre-procedure score on the Aldrete Scale or upon physician order. f. Vital signs must be documented at the time immediately prior to transfer or discharge. g. If oxygen is utilized, monitoring shall continue 20 minutes post discontinuance of oxygen, with saturation of 92% or at baseline.

9. Summary Goal: Provide safe patient care
All sedatives have potential complications
Know how to define your role in procedural sedation (pre, intra, and post procedures)
Provide safe administration of medication
Provide ongoing monitoring until discharge from sedation
Be prepared to “rescue the patient”
Complete all documentation for sedation care