1. Procedural Sedation Changes Go live: APRIL 24th

2. Why These Changes? Per the Cal Dept of Public Health (ie, the “state”) and CMS (federal) nurses cannot push an anesthetic drug for procedural sedation. This includes propofol, ketamine, barbituates and etomidate. On April 24 th we will change our process to meet this regulation.

3. What can RNs do? Moderate sedation- ONLY Those performing moderate sedation must have attended SMCS sedation class AND have current ACLS or PALS Regardless of intent of sedation, some drugs are defined as agents of deep sedation and can NOT be administered by an RN for procedural sedation Ketamine, Propofol, Barbituates and Etomidate

4. BRN Position Statement for RN RN only task. Can not be delegated to non licensed personnel Recognize emergency situations and institute emergency procedures Assess if sedation by RN is in pt’s best interest Airway management skills and training 1:1 care RN is patient’s advocate.

5. Sedation Privileging- MD Up to date list of privileges located on SHIPER RN to check privileges before starting procedure MD are privileged by the Department of Anesthesia Exception: ED MDs maintain privileges per their department

6. What will MDs do? The physicians must push the drug or push the button on a pre-programmed IV pump for these drugs, or give an IM shot of ketamine. For longer orthopedic procedures, the doctor may ask you to program an on-going infusion, then they will start the drug after they see the confirmation screen on the IV pump.

7. Does this effect RSI and infusion of vented patients? You will still be allowed to push propofol and/or etomidate for a rapid sequence intubation (RSI) because the doctor is there to intubate the patient. This does NOTeffect infusions of propofol in the vented ICU patient. This regulation applies to procedural sedation.

8. New order set developed Must be used on Med-sug/ tele units Verify patent IV Hang NS 1000 ml May administer 250 ml bolus for hypotension Reversal agents prechecked on sheet

10. Why? Pulse Oximetry and ETCO2 American Society of Anesthesiologists requires use of ETCO2 on all case of MODERATE and DEEP sedation. Funding for more ETCO2 monitors has been approved.

11. Respiration and Ventilation Respiration Exchange of 02 and CO2 dependant on Ventilation Ventilation Movement of air in and out of thoracic cavity Control of ventilation Brainstem Phrenic nerve Diaphragm, intercostals, accessory muscles Ventilation!

12. Pulse Oximetry Arterial oxygen saturation Measures respiration, NOT ventilation Decreased O2 Saturation is a very late sign of hypoventilation

13. ETCO2 ETCO2 is required for ALL sedation cases- moderate and deep! Place on pt prior to sedation Establish their baseline Normal 35- 45

14. ETCO2 Measures Ventilation Normal CO2 is 35-45 CO2 will rise 6 – 8 mm Hg during the first minute of apnea CO2 - early indicator Pulse oximetry - late indicator

15. TCM Monitoring - Pediatrics Transcutaneous monitoring non-invasive technique Probe heats site to 41-45 degrees C to ↑ diffusion Takes a few minutes to equillibrate continuous monitoring of the partial pressure of arterialized capillary blood. Typically this will be the PCO2 level.

16. TCM Monitoring May keep on site for 8 h Have available when deep sedation is planned. patients 5 years and under Small body mass more accurate

17. Rising ETCO2 Pt may become agitated and start pulling off ETCO2, IVs ect. Critical Thinking Needed: is this under medication or is this increasing ETCO2. Increasing ETCO2 = Treatment is Ventilation!! Under medication= administer more meds.

18. Programming a pump for MD administration

19. Medication administration by MD For short procedures: Draw up and label syringe for Physician administration For longer procedures: MD may want to have a bolus administered via infusion pump followed by a continuous infusion during the procedure With all new procedures there is a learning curve…. Be prepared with NS one liter hanging for hypotension induced by too rapid administration of the drug!!

20. Propofol – Recommendations for longer procedures Initiate moderate sedation with Fentanyl and Versed. Follow with continuous infusion of Propofol during the procedure. Recommended dosage is 25 – 75 mcg/kg/min for adults. MONITOR airway and ventilation!! Stop infusion at the end of the procedure.

21. Anesthesia Recommendations Short procedures: single dose of Propofol 0.5 mg/kg IV over 1-2 minutes using a syringe. An additional 20-40 mg IV may be needed for some patients. Longer procedures (adult patient): Have the RN administer Versed 1 mg IV and Fentanyl 50 mcg IV to provide baseline moderate sedation while preparing for the procedure. Have the RN set up a Propofol drip on an infusion pump and connect to the patient’s IV. Determine the dosing of Propofol you wish to administer for your procedure. Anesthesia recommends a continuous dose of Propofol 25 to 75µg/kg/min, with a dose of 50µg/kg/min working well for most patients. Stop the Propofol at the end of the procedure.

22. Programming a bolus dose: Confirm with the MD that you are giving a BOLUS and the amount they wish to give. They must hit the YES button

23. This would be the confirmation screen the doctor will see when you want to run an infusion. The doctor must push YES

24. Documentation Document all medications administered on the appropriate procedural sedation flowsheet or departmental documentation tool.procedural sedation flowsheet For medications administered by physicians, please document the name, dose, route, and name of administering physician. Ask the physician to sign the order set and/or the flowsheet in the appropriate location.

25. Anesthetic Review Etomidate Ketamine Propofol Pentobarbitol

26. Adult medication review

27. Etomidate IV anesthetic Commonly used for rapid sequence intubation NO analgesic effect; produces hypnotic state in about 1 minute Minimal hemodynamic effects May have myoclonic contraction Benzodiazapines may ↓

28. Etomidate Adult Dose: 300 mcg/kg Elderly or Hepatic 150- 200 mcg/kg Children May require 30% MORE than adult dose May be used IV only as bolus or slow push 10mg/ min Onset:< 1 minute Duration:6- 10 minutes

29. Propofol (Diprivan) Sedative hypnotic for anesthesia Little to no analgesic effect No anti- anxiety effet Has negative inotropic effect – can lead to hypotension Can progress easily and rapidly to general anesthesia May be given as S L O W IV push or for non intubated patients (infuse over at least 3-5 min) Don’t give to patients who are allergic to eggs or soybeans.

30. Propofol Adult Dose: 0.5 mg/ kg IV over 3- 5 min for bolus dosing Incremental boluses 10- 20 mg Continuous infusion for procedural sedation: 25 – 75 mcg/kg/min Onset: < 30 seconds Duration: 3 -10 minutes ½ life:5 - 10 minutes May cause allergic reaction in those with allergy to eggs or soybean

31. Ketamine (Ketalar) An anesthetic agent with a short half-life Disassociative anesthesia, Trance like state, Pts eyes may be open Amnesia Provides analgesia ↑ muscle tone Stimulates the CV system so may increase BP and pulse Emergence reactions can occur and are more common in adolescents, with large doses of drug, and following rapid IV administration of drug.

32. Ketamine May increase oral secretions - Watch airway Give atropine or glycopyrrolate to help decrease oral secretions.

33. Ketamine Hallucinations with awakening or emergence (5- 30%) May give benzodiazepine to prevent emergence hallucinations in older children. Limit verbal, tactile, & visual stimulation Peds may not recognize caregivers during the post procedure duration

34. Ketamine Abuse– 1979; sexual assaults Special K, Horse tranquilizer, animal tranq, elephant tranq, green, honey oil, jet fuel, Kay Jay, Ket, Keta, Kit Kat, Lady K, Purple, special la coke, super acid, Super C, Vitamin K, Super K Hallucinogenic effects, disassociative, out of body experiences

35. Ketamine Pediatric Dose - IV: 0.25 – 0.5 mg/kg (give over 1 minute) Titrate with 0.25 – 0.5 mg/kg every 5 – 10 minutes Onset: 1 - 2 minutes Peak: 2 - 5 minutes Duration:15 - 45 minutes IM: 2 – 4 mg/kg Onset:2 - 5 minutes Peak:5 -10 minutes Duration:15 - 45 minutes This can be given IM or IV with IM doses providing sedation for approximately 15 - 45 minutes and IV doses 15-45 minutes

36. Ketamine (Ketalar) Contraindicated in patients with increased intracranial, systemic or intraocular hypertension.

37. Pentobarbital ( Nembutal)  Infants > 6 months and children:  IV- 0.5-3mg/kg titrate slowly over 5 minutes to max dose of 6 mg/kg or 100mg whichever is less.  PO Administer 15- 30 min prior to procedure  2-6 mg/kg max 100 mg/dose  IV Onset:1 – 15 min  IV Duration: 15 – 30 min  PO onset 15 - 60 minutes  PO duration 1 – 4 hour  May be preferred for pts. with increased ICP  Limited information is available for use in infants < 6 months

38. Propofol (Diprivan) Sedative hypnotic for anesthesia Little to no analgesic, no anti-anxiety effect Can progress easily and rapidly to general anesthesia. May be given as S L O W IV push or short continuous drip for non intubated patients (infuse over at least 3-5 mins) May cause allergic reaction in those with allergy to eggs or soybean

39. Propofol Pediatric Dose 0.5 mg/ kg, IV over 3- 5 min Titrate to effect Onset: < 30 seconds Peak: 1 min Duration: 3-10 min ½ life:5- 10 min