1. Moderate Sedation Review 2008
Part 2: Pharmacology

2. Pharmacology --Introduction
A variety of medications are used to induce the state of Moderate Sedation in the patient.
These medications may be used alone, or in combination.
It is important to remember that drugs used in combination may potentiate each other increasing the effects of the combination to four to ten-times that of the same drugs used individually.

3. Recall the Goals of Moderate Sedation
1.     Maintain adequate sedation with
minimal risk to the patient
2.      Relieve anxiety and produce amnesia
3.      Provide relief from pain and other
noxious stimuli

4. Characteristics of Medications Used in MS
Agents used in moderate sedation will have:
Short duration of action
Rapid recovery
Lack of cumulative effects
Few side effects
Desirable: analgesic effects last longer than sedative effects

5. Clinical Endpoints of Moderate Sedation
Beginnings of slurred speech
Decreased anxiety
Goal of Moderate Sedation IS NOT unconsciousness or unresponsiveness!

6. End result of Moderate Sedation
To produce a:
Pain-free amnesic,
Sedated patient who
Recovers rapidly with
Few side-effects due to medication.

7. Medication Administration Key Points:
·  Give only amount necessary to render the patient calm, cooperative, able to follow
commands
·   Administered according to Corporate medication policies
·   When additional medication is ordered for sedation after the initial dose:
cumulative TOTAL dose will be communicated AUDIBLY to the practitioner (“I just gave 1-mg versed for a TOTAL dose of 2-mg given)

8. IV Administration Onset is rapid (20-30 seconds)
Titration: injection of small increments of drug until desired effects are achieved
Continuously monitor patient’s response.

9. RN must be knowledgeable about:
Drug names and classifications
Appropriate dosages for patient’s age and condition
Indications
Contraindications
Recommended dilution
Onset and duration of action.
Expected actions
Compatibility with solutions, and other medications
Possible side effects /adverse reactions
Interventions for side effects
Emergency management techniques

10. Classes of Agents Sedatives Opioids (morphine, Fentanyl®):
Benzodiazepines (Versed®, Valium®):
Reversal Agents
Narcan®
Romazicon®

11. Opioids (e.g., morphine, Fentanyl)
Opioids (morphine, Fentanyl®):
Alter the process of pain sensation, and emotional response to pain
Side effects:
CNS depression
Respiratory depression
Nausea and vomiting
Hypotension
Pruritis
Reversal Agent: Narcan®

12. Opioids Drug Dose Range IV Onset (minutes) Clinical Duration (hours)
Comments
Morphine
2-3 mg 5 4
Inject slowly over 4 to 5 minutes
May be diluted with water for injection
dose by 30%if given with another CNS depressant
Fentanyl
0.3 – 0.5
mcg/kg
1-2 1
Has fewer side effects
Titrate in 25 mcg increments every 2-3 minutes
Remifentanil
mcg/kg
10 minutes
Rapid induction with rapid elimination
Must be given SLOWLY (over 1 minute)
Reversal
Agent
Narcan®

13. Benzodiazepines (e.g., Versed®, Valium®)
Depress CNS producing muscle relaxation, and anti-anxiety effects.
Side effects:
Drowsiness, ataxia, confusion
Fatigue, headache, weakness
Dizziness, vertigo, syncope
Antegrade amnesia
Reversal Agent: Romazicon®

14. Benzodiazepines Drug Dose Range IV Onset (minutes) Clinical Duration
(hours)
Comments
Midazolam
(Versed®)
2.5 mg 1
Titrate SLOWLY
Initial dose should not exceed 2.5 mg administered over a min. of 2 minutes
DO NOT bolus
Wait 2 minutes between doses to evaluate patient effects
Diazepam
(Valium®)
1-2 mg 5 6
Titrate SLOWLY (over 1 min. for each 5 mg) until slurred speech occurs
Initial titration should not exceed 10 mg
If administered with a narcotic, dose of narcotic by 1/3 titrated slowly.
Reversal
Agent
Romazicon
(flumazenil)

15. Reversal Agents Narcan® (Naloxone) Romazicon® (Flumazenil) Both may:
Blocks effects of opiates
Romazicon® (Flumazenil)
Blocks effects of benzodiazepines
Both may:
Precipitate withdrawal (seizures),
cause increased sympathetic activities (tachycardia, hypertension, arrhythmias, pulmonary edema)
Allow re-sedation to occur (duration of action of reversal agent is less than that of the sedatives they reverse)

16. Reversal Agents Drug Dose Range IV Onset (minutes) Clinical Duration
(hours)
Comments
Naloxone
(Narcan®)
0.4 – 2 mg 2
1-4
Titrate slowly to desired effect
Dilute 1 ml ampoule (0.4mg/ml) in 10 ml normal saline
Give 1 ml (.04 mg) every 2-3 minutes until RESPIRATORY DEPRESSION is reversed
Patient must be monitored for up to 90 min. after time of administration
Flumazenil
(Romazicon®)
Based on patient response
1-2
(80% of patients respond in 3 minutes)
45-90 minutes
Administer through LARGE vein
Give 0.2 mg increments (2 ml) over 15 seconds;
May repeat at 1 minute intervals
Total dose not to exceed 1 mg in 5 minutes
Maximum dose: 3 mg in any 1-hour period

17. And now a word about PROPOFOL…
For years used in the ED as sedative for reducing fractures, in EP lab for procedures, etc.
Used in some instances to bring about a state of Moderate Sedation
Please note: THE RULES HAVE CHANGED regarding the Nurse’s role in its administration

18. Procedural Administration of Propofol
Urgent Nursing Practice Memo 12/7/07 issued by Nurse Executive Council, Quality and Patient Safety states:
As per Kaleida IV Administration Policy TX.IV’s and MEDS_19, Propofol may be titrated and administered by an RN only when a patient’s respiratory status is supported by a mechanical ventilator.

19. What about for Moderate Sedation?
The same Nursing Practice memo states:
An RN may not participate in Moderate Sedation when propofol is utilized without active ventilator support

20. What if I am asked to assist with propofol?
The short answer is to refuse.
The longer answer is to discuss questions or concerns with your department manager.

21. The reason to refuse….
Nursing non-compliance with this New York State Department of Education and Licensure regulation is a NYS reportable event which places your license to practice nursing in jeopardy.

22. If you need support for your refusal:
In a memo to the CMOs dated 12/6/07 it was stated:
An RN MAY NOT be the participant who is expected to push / titrate propofol OR assume the care / monitor the patient. It is the drug (propofol) which sets this situation apart.
In the case in ED, EP lab etc. where propofol is being used for moderate sedation:
A second provider (second ED attending, MOD) credentialed in moderate sedation will need to attend the patient, and provide monitoring, care, and documentation at the bedside.

23. Remember! Moderate Sedation occurs on a continuum: Awake 
Minimal Sedation 
MODERATE SEDATION 
Deep Sedation 
General Anesthesia

24. Remember!
Patients can slip from one level to the next without warning.
Practitioners must be qualified to rescue the patient from a lower state, i.e. deep sedation, and be skilled in airway management.
Patients can slip from one level to the next without warning. Practitioners must be qualified to rescue the patient from a lower state, i.e. deep sedation, and be skilled in airway management.

25. Remember!
Avoid standard mixes (e.g., x-mg of medication A, and x-mg of medication B)
Treat the specific symptom (e.g., treat pain with more local anesthetic or narcotic)
Titrate medication carefully—more medication can always be given, however they can never be retrieved.

26. Remember! Use reduced dose of agents in patients who are Debilitated
At extremes of age
Hypovolemic
Patients with COPD are more susceptible to respiratory depressant effects
Avoid using “recipes”—no two patients will react the same to a given dose
Give only the medication that is needed

27. Final Note The most important consideration is
Regardless of:
Type of procedure
Type of drugs used
Type of venue
The most important consideration is
The safety of the patient!