1. Moderate Conscious Sedation

2. Objectives Upon completion of this learning module, the nurse
should be able to:
1. Define moderate conscious sedation. 2. Identify nursing responsibilities before, during, and after a procedure involving moderate conscious sedation. 3. Review medications commonly used in moderate sedation.
The purpose of this self learning study is to review and
update the nurse on moderate conscious sedation.

3. Definition
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.

4. Moderate Sedation is used for diagnostic, therapeutic, and invasive procedures
Bone marrows
Bone reduction
EGD/colonoscopy
Chest tube insertion
Wound debridement
Heart lab procedures (ie. heart cath, TEE, EP studies, etc…)
Minimally invasive surgical procedures
Cardioversion

5. Moderate Conscious Sedation does not apply to:
Patients who are mechanically ventilated or whose cardiovascular and respiratory status are continuously monitored and documented in an ICU or PACU.
Patients who receive anxiolytic or analgesic agents that are routinely administered to alleviate pain and agitation.
Management of seizures.

6. Staff Qualifications
Conscious sedation is the responsibility of a licensed independent practitioner (LIP) privileged in moderate sedation.
LIP must be qualified and have the appropriate credentials as defined by the medical staff to manage patients at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.
Sufficient numbers of qualified personnel are present to assist and document.
*Physicians exempt from providing proof of training for moderate conscious
sedation are intensivists, emergency medicine physicians, and anesthesiologists.

7. Moderate sedation is administered in the following units:
Operating Room
Pediatrics
Heart Lab
Oncology
Stepdown Units
Intensive Care Units
Outpatient services
Radiology
Pain Management
Emergency Department

8. Equipment
Appropriate equipment for monitoring including heart, blood pressure, respiratory rate, and oxygenation using pulse oximetry
Cardiac arrest resuscitative equipment, reversal agents, and a code cart must be in the department where the procedure is performed
EKG is monitored as ordered by the physician for patients with heart disease or if arrhythmias are present or anticipated

9. Documentation of Moderate Sedation
is completed on form
Post-procedure vital signs
And Aldrette scoring
Post-procedure
and discharge
Pre-procedure and
Intra-procedure

10. Pre-Procedure Responsibilities: Physician
History and Physical including airway assessment
Plan for moderate sedation and post procedure care
Current medications
Documents NPO status
-Adults should be NPO for 4 hours
-Pediatric patients should have no solids or non-human
milk for 4 hours prior to the procedure
Obtains and documents informed consent for procedure and sedation
*In extreme emergencies the physician may determine it to be necessary to proceed with an intervention without completing the above steps.

11. Pre-Procedure Responsibilities: Hospital Staff and Nursing
Verifies informed consent, H&P, and reassessment has been done prior to procedure.
Verifies availability of emergency equipment, including O2 and suction.
Establishes venous access.
Assess patient’s VS, O2 sat, LOC, and Aldrete score and document on the moderate sedation flow sheet.
If the patient is an outpatient- complete outpatient nursing assessment record.

12. Intra-Procedure Responsibilities: Physician
Assumes full responsibility for the management of the procedure and sedation

13. Intra-Procedure Responsibilities: Hospital Staff and Nursing Role
Conducts and documents time out with physician present as well as the procedure team.
Monitors and documents the patient’s VS and O2 sat every 5 minutes or more frequently prn.
Continuous assessment and documentation while assessing for changes in condition.

14. Post Procedure Responsibilities: Physician
Documents a post procedure/anesthesia note, including pre and post procedure diagnosis, procedure findings, complications, blood loss or specimen removed, plan of care, and discharge instructions
EBL

15. Post Procedure Responsibilities: Hospital Staff and Nursing Role
Monitors and documents the patient’s VS and O2 sat immediately post procedure and every 15 minutes post procedure until it is a minimum of 30 minutes post narcotic/sedative dose, the patient’s Aldrete score is 12 or equivalent to his/her pre procedure Aldrete score, or by physician order

16. Aldrete Scoring System

17. Post Procedure Responsibilities: Hospital Staff and Nursing Role continued…
If the patient has received a reversal agent, monitor VS q 15 min. for 2 hours.
Notify the physician immediately if the patient doesn’t meet the Aldrete score after 1 hour post procedure or if there is a significant variation in the patient’s physiological parameters.

18. Discharge Criteria Discharge to hospital unit
Discharge from the hospital
Aldrete score of 12, or pre procedure status, or by physician order
Minimal nausea
At least 1 hour from last dose of narcotic, hypnotic, antiemetic
At least 2 hours from the last dose of reversal agent
Pain rated less than 4, equal to the pre procedure score, or tolerable for the patient
Accompanied by a responsible adult
Minimum 30 minutes since the last dose of narcotic or sedative
Aldrete score of 12, or pre procedure status, or by physician order

19. Medications used for Moderate Conscious Sedation
Individualize dose per recommendations.
Do not give by rapid or single bolus IV administration.
Use small increments to achieve the appropriate level of sedation.
Titrate medication and dose to patient response. Expect to vary with age, physical status, concomitant medications.
Allow time for drug to circulate and to have an effect after each incremental dose.
Consider routine medications the patient has taken pre procedure; they may potentiate and prolong the effects of the medications used for conscious sedation.

20. Onset, Peak, and Duration
Opiods
Drug
IV Dosing
Guidelines
Onset, Peak, and Duration
Comments
Morphine
2-4 mg. increments q 5 min.
max dose of mg.
Peds: mg/kg
Onset- 1-3 min.
Peak- 20 min.
Duration- 2-4 hrs.
Slower onset and longer duration than Fentanyl
Histamine release assoc. with hypotension and itching
*Fentanyl
(Sublimaze)
1-3 mcg/kg, given in increments of mcg
max of 250 mcg
Peds: 1-2 mcg/kg total dose- given in increments up to 50 mcg max dose
Onset- 1-2 min.
Peak min.
Duration min.
Advantages include quick onset and short duration
Causes less histamine release and less side effects as compared with morphine but 100 times more potent
Demerol
(Meperidine)
10-25 mg increments
max of 150 mg
Peds: 1-2 mg./kg.
Onset 1-5min.
Peak 1-3 hrs.
Nausea and vomiting common
Risk of seizures

21. Sedatives *Versed (Midazolam) Valium (Diazapam) Drug IV Dosing
Guidelines
Onset, Peak,
and Duration
Comments
*Versed
(Midazolam)
1-3 mg increments every 2-3 min.
Max of 5 mg.
Peds: mg/kg IV or IM
Give in increments: total dose not to exceed 0.4mg/kg
Onset- 1-3 min.
Peak- 5-7 min.
Duration min. (may need to redose)
Quick onset and short duration
Retrograde and antegrade amnesia
Valium
(Diazapam)
1-2 mg increments
Max of 10 mg.
Peds: mg/kg
Onset 1-5 min.
Duration 2-8 hrs.
Respiratory depression with narcotics
Irritates veins
Long duration

22. Reversal Agents Narcan (Nalaxone) Romazicon (Flumazenil) Drug
IV Dosing
Guidelines
Onset, Peak,
and Duration
Comments
Narcan
(Nalaxone)
mg IV q 2-3 minutes prn
Peds: mg q 2-3 minutes prn
Onset- 1-2 min.
Duration- 30 min. when given IV
Reverses narcotics only
Reversal effect may not outlast narcotic
Give slowly
Romazicon
(Flumazenil)
0.2 mg over 15 seconds. After an interval of 45 seconds, a second dose of 0.2 mg may be given. Repeat at 60 second intervals until 1 mg. total.
Peds: 0.01mg/kg IV over 15 seconds, may repeat in 45 seconds
Onset- 1-2 min. with peak effect within 10 min.
Duration min.
Reverses Benzodiazapines
- ie. Versed
- not narcotics
Reversal may not out last sedative, monitor for 1 hr. after reversal

23. Questions?
The Interpretive Guidelines for Moderate Sedation (updated June 2010) are available through the Ohio Board of Nursing at: Mod-Sedation.pdf
You may also call Cindie Berbari at #35341 or at

24. References
Reed, Lynn. (2007, October). Aultman Moderate (Conscious) Sedation/Analgesia Policy.
Volles, D. (2005, March) Adult and Geriatric Sedation/Analgesia for Diagnostic and Therapeutic Procedures.
Comparing the duration of action of opiods, sedatives, and reversal agents. American Society of Anesthesiologists.
Cindie Berbari RN, BSN