1. Moderate Sedation/ Analgesia (Conscious Sedation)
Dr moradi

2. Introduction
These guidelines are designed to be applicable to procedures performed in a variety of settings by practitioners who are not specialists in anesthesiology.The purpose of these is to allow clinicians to provide their patients with the benefits of sedation /analgesia, while minimizing associated risks.These guidelines are intended to be general in their application and broad in scope.

3. Depth of Sedation Minimal Sedation (Anxiolysis)
- is 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. Depth of Sedation Moderate Sedation/Analgesia (Conscious Sedation)
- is 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. Depth of Sedation Deep Sedation/Analgesia
- is drug induced loss of consciousness during which patients cannot be easily aroused but respond purposefully* following repeated stimulation. The ability to independently maintain ventilatory function is often impaired.Patients may require assistance in maintaining a patent airway and positive pressure ventilation may be required. Cardiovascular function may be impaired.

6. Depth of Sedation 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 is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required. Cardiovascular function may be impaired.

7. Depth of Sedation
Protective airway reflexes-includes the ability of an individual to counteract noxious events, especially to defend breathing passages against foreign material.
Reflex withdrawal from a painful stimulus is NOT considered a purposeful response
Sedation is a continuum, it is not always possible to predict how an individual will respond.
Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended.

8. Locations of M.S./Analgesia
Radiology Department
Medical Special Procedures
Dental Clinic
Emergency Department
Progressive Care Units
Procedure Unit E-Yellow
Critical Care Units
Echocardiology Lab
Cardiac Catheterization Lab
Clinics (Audiology, Neurology)
Pre-operative holding area

9. Patient Evaluation History/ Physical exam Airway evaluation
Abnormalities of the major organ systems
Previous adverse experience with sedation
Drug allergies, current meds.,potential interaction
Focused physical exam- vital signs, auscultation of heart and lungs, evaluation of the airway
NPO status
Lab data

10. Patient Evaluation Airway Evaluation Mallampati Classification
Relates tongue size to pharyngeal size
Performed with the patient in the sitting position, the head held in a neutral position, the mouth wide open, and the tongue protruding to the maximum
May vary if the patient is in the supine position (instead of sitting)
If the patients phonates, this falsely improves the view.
If the patient arches his or her tongue, the uvula is falsely obscured.

11. Patient Evaluation Airway Evaluation Mallampati Classification
Class I = visualization of the soft palate, fauces, uvula, anterior and posterior pillars. Class II = visualization of the soft palate, fauces and uvula. Class III = visualization of the soft palate and the base of the uvula. Class IV = soft palate is not visible at all.

12. ASA Physical Status Class I- normal, healthy
Class II- mild systemic disease
Class III- severe systemic disease, e.g. HTN COPD,
Class IV-severe systemic disease that is a constant threat to life, e.g. unstable angina
Class V- moribund patient not expected to live with or without the procedure

13. Patient Evaluation When an anesthesiologist or other specialist may be needed.
ASA class III or higher
Airway abnormalities
Morbid obesity
Sleep apnea
Previously failed sedation
Major allergy or anaphylactic reaction
Complex procedure
Prolonged sedation needed
New procedure
Unusual position
Unusual location

14. Pre procedure preparation
Informed consent
Pre op fasting
Clear liquids 2h
Breast milk 4h
Infant formula 6h
Milk 6h
Light meal 6h

15. Equipment Self inflating bag and mask Oxygen – 2 outlets
Suction ( working )
Pulse oximeter, ECG monitor, BP. Monitor
? Capnometer
Pharmacologic antagonists
Emergency equipment – airway kit (age appropriate) crash cart, defibrillator

16. Monitoring and Documentation
Pre-procedure
-V.S., SpO2
Procedure
-Continuous SpO2, E.C.G.
-V.S. q 5 min.
-L.O.C. q 5 min.(level of consciousness)
Post Procedure
-Continuous SpO2, V.S. q 5 min. for 15 min., then q 15 min. until discharge criteria met

17. Personnel The minimal number of available personnel should be two:
The operator (performs procedure)
The monitor (administers drugs, monitors airway and vital signs.
The second individual may assist with minor interruptible tasks.
Both personnel must be credentialed in Moderate Sedation/ Analgesia

18. Personnel
Personnel who can administer Moderate Sedation/ Analgesia or monitor a patient, include:
- A physician, or dentist who has been credentialed
Under the supervision of the above, the following persons may administer M.S.
- CRNA, or a student CRNA,
- resident physician or resident dentist
-registered nurse, under special situations.

19. Training of Personnel
Individuals responsible for patients should understand the pharmacology of agents used for sedation and antagonists for opiates and benzodiazepines.
Individuals monitoring patients should be able to recognize associated complications.
One individual capable of estabilishing a patent airway and positive pressure ventilation should be present.
All personnel must be ACLS certified.

20. Discharge Criteria
Patients will be discharged according to the Aldrete score. The patients must have a score of ten.
Aldrete score is printed at the end of the Moderate sedation/Analgesia record
Patients who receive reversal agents need to remain in the procedure area for at least one hour after the last dose.

21. Drugs Drugs commonly used for M.S.
Meperidine (Demerol)
Morphine
Fentanyl (Sublimaze)
Ketamine
Diazepam (Valium)
Midazolam (Versed)
Droperidol (Inapsine)
Phenobarbital
Naloxone (Narcan)
Flumazenil (Romazicon)

22. Drugs Drugs EXCLUDED for M.S./ Analgesia by non-anesthesia staff are:
Sodium Thiopental
Propofol
Brevital (metho hexital)
Etomidate
Sufentanil
Remifentanil

23. Combinations of Drugs
IV.drugs should be given in small, incremental doses, titrated to end points of analgesia/sedation.
Allow time for onset before repeating
Benzo. and opiates have synergistic effects
Non IV routes, eg. Oral,rectal,im.,tm.-allow adequate time for absorption. Repeat doses not recommended(unpredictable absorption)

24. Synergy
Effects of Benzodiazepine and Opiate are additive (synergistic)
For example, 2 mg. Midazolam or 10 mg. Morphine equals no apnea
1 mg Midazolam plus 5 mg morphine equals apnea

25. Basic Considerations Low cardiac output equals slow onset
Consider the age of the brain
Consider the physical condition of the patient
What effect is desired?
Is post-procedure pain control needed?
When in trouble, back out
Titrate drugs to effect, wait for onset.

26. Reversal agents
Specific antagonists, naloxone/flumazenil should be available
May be administered if apnea or hypoxemia develops, but routine use is strongly discouraged.
Patients need to be observed longer in recovery (at least 2 hrs.) if reversal agents are used.

27. Opiates
Dose-dependent binding to opioid receptors (especially mu) leads to:
Analgesia
Sedation
Respiratory Depression
Side effects:
Nausea/vomiting
Miosis
Decreased Peristalsis

28. Morphine Average Dose: 5-15 mg Incremental Dose: 2.5 mg
Time Between Doses: min
Onset Time: min
Duration of Effect: hrs
Paradoxical Reaction
Pruritis
Anaphylactoid Reaction
Active Metabolites

29. Meperidine (Demerol) Average Dose: 50-150 mg Incremental Dose: 25 mg
Time Between Doses: 5 min
Onset Time: min
Duration of Effect: hrs
Caution: Not used with MAO Inhibitors, Antidepressants, Antiparkinsonian drugs
Remember “Libby Zion”
Active Metabolite can accumulate with renal dysfunction

30. Benzodiazepines Enhance GABA transmission in CNS
Most are lipid soluble only (except midazolam)
Effects:
Amnesia
Anticonvulsant
Anxiolytic
Behavioral disinhibition
Muscle relaxant

31. Diazepam Average Dose: 5-20 mg Incremental Dose: 2.5 mg
Time Between Doses: 2-3 min
Onset Time: min
Duration of Effect: hrs
Several active metabolites prolong effects
Elimination t1/ hrs

32. Midazolam (Versed) Average Dose: 1-5 mg Incremental Dose: 0.5-1 mg
Time Between Doses: 3-5 min
Onset Time: min
Duration of Effect: hrs
Water and lipid soluble
Active metabolites, which are less potent
Elimination t½; 2-4 hrs

33. Diphenydramine Sedating antihistamine with anticholinergic properties
PO/IV/IM
Maximum sedative effect 1-3 hrs, duration; 4-7 hrs
Elimination t1/2: 2-8 hrs

34. Fentanyl (Sublimaze) Average Dose: 0.025-0.15 mg
Incremental Dose: mg
Time Between Doses: 2-3 min
Onset Time: min
Duration of Effect: hrs
Elimination t1/2: hrs
May cause muscle rigidity

35. Naloxone (Narcan) Reversal of opiates Side effects: Pain Hypertension
Tachycardia
Ventricular dsyrhythmias
Pulmonary Edema
Re-narcotization –Delayed respiratory depression

36. Naloxone (Narcan) Average Dose: 0.4 mg Incremental Dose: 0.04 mg
Time Between Doses: 2-3 min
Onset Time: min
Duration of Effect: hrs

37. Flumazenil (Romazicon)
Average Dose: 1 mg
Incremental Dose: 0.2 mg
Time Between Doses: 1 min
Onset Time: min
Duration of Effect: hrs
Resedation
Seizures

38. Performance Improvement
All departments are responsible for PI activities related to moderate sedation
Data collection monthly, quarterly reporting of complications on 6 PI indicators
All complications must be reported to Department of Anesthesiology PI representative A copy of the record needs to be sent to Dr. A Patel
Moderate sedation data is presented at the Invasive Procedure Committee and Hospital PI committee

39. P.I. Indicators
Respiratory complications- need for oral airway, bag mask ventilation, intubation etc.
Cardiovascular complications- hypotension, arrythmias, etc.
Use of reversal drugs
Admission to hospital,if outpatient
Pre sedation evaluation done
Discharge criteria documented