1. Procedural Sedation
Keir Swisher, D.O.
May 13, 2010

2. 2011 Superbowl Champions Kansas City Chiefs

3. Objectives State the definitions of sedation according to JCAHO
List pre-procedural patient assessments
Understand common sedation complications and their management
Post-procedural patient care
Sedation medications and appropriate reversal agents

4. …Get Grandpa

5. Sedation is a continuum moving from one state of conscious to another and is dose-related depending on the individual patient response

6. Levels of Sedation and Anesthesia

7. Levels of Sedation and Anesthesia
Level 0: No Sedation
Level 1: Light/Minimal sedation (anxiolysis)
Level II: Moderate sedation
Level III: Deep sedation
Level IV: General Anesthesia

8. Level 0: No Sedation
Patients undergoing diagnostic procedures without sedation
Arousal: No alteration in level of consciousness
These patients should be able to lie still and are anxiety/pain free throughout procedure

9. Level I: Light or minimal sedation
Administration of medications to reduce potential anxiety
Arousal: Patient responds normally to verbal commands although cognitive function and coordination may be impaired
Respiratory function: unaffected

10. Level II: Moderate Sedation/Procedural sedation
Arousal: Respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation
Respiratory function: No interventions required to maintain a patent airway, spontaneous ventilation is adequate

11. Level III: Deep sedation
Arousal: Cannot be easily aroused but responds purposefully after repeated or painful stimulation
Respiratory function: may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate

12. Level IV: Anesthesia
Arousal: Loss of consciousness during which patients are not arousable, even by painful stimulations
Respiratory function: Ability to independently maintain ventilatory function impaired, requires assistance to maintain patent airway and often requires positive pressure ventilation

13. Pre-Procedural Evaluation
History and Physical exam
Airway assessment
Review current medications, prior sedation history, allergies, pregnancy status, history of substance abuse, pain assessment, laboratory results, vital signs, Aldrete score and current level of consciousness
NPO status
ASA classification

14. Fasting Guidelines Intake Category
Fasting Period for Low Risk Patients
Fasting Period for High Risk Patients
Clear Liquids
2 hours
8 hours
Breast Milk
4 hours
Infant Formula
6 hours
Non-human Milk
Regular Meal

15. Airway Assessment: Mallampati
Class 1: soft palate, fauces, uvula, pillars
Class 2: soft palate, fauces, portion of uvula
Class 3: soft palate, base of uvula
Class 4: hard palate only

17. ASA Classification Class I: Normal healthy patient
Class II: Patient with mild systemic disease
Class III: Patient with severe systemic disease
Class IV: Patient with severe systemic disease that is a constant threat to life
Class V: Moribund patient not expected to survive without operation
*E can be added for emergency procedures

18. Class II: Patient with mild systemic disease
No functional limitations
Well-controlled disease of one body system
Controlled hypertension or diabetes without systemic effects
Cigarette smoking without chronic obstructive pulmonary disease (COPD)
Mild obesity
Pregnancy

19. Class III: Patient with severe systemic disease
Some functional limitation
Controlled disease of more than one body system or one major system
No immediate danger of death
Controlled congestive heart failure (CHF), stable angina, old heart attack, poorly controlled hypertension, morbid obesity, chronic renal failure; bronchospastic disease with intermittent symptoms

20. Class IV: Patient with severe systemic disease that is a constant threat to life
Has at least one severe disease that is poorly controlled or at end stage
Possible risk of death
Heart disease showing marked signs of cardiac insufficiency, unstable angina
Advanced degrees of pulmonary, hepatic, renal, or endocrine insufficiency

22. Informed Consent
Physician is to review the objectives, risks benefits, and alternatives to the procedure with the patient

23. Pre-Procedure Time Out
Completed before the first dose of sedation
All participants including patient must agree
Verify
Correct patient
Correct procedure
Correct site
Correct/Special equipment

24. Intra-Procedural Monitoring
Documentation must include vital signs (BP, pulse, respirations, pulse oximetry) and level of consciousness prior to, during and post-procedure
Vital signs must be monitored every 5 minutes and documented every 15 minutes if vitals remain stable
Oxygen may be administered throughout the procedure and recovery period

25. In case of emergency….. Emergency equipment
Oxygen with nasal cannula/mask
Ambu bag with mask
Suction
Crash cart
Airway box
Reversal agents

27. Intra-Procedural Cardio-Respiratory Monitoring
Cardiac monitoring must be available for all patients
Pediatric patients (birth to 18 years) continuous SpO2 monitoring must be used regardless of sedation level
Adult patients continuous SpO2 monitoring is based on:
patient clinical assessment
invasiveness and length of planned procedure
medication and degree of sedation used

28. Potential Complications
Usually related to medications/patient response
Most common is respiratory depression
Patient stimulation often successful
Consider use of emergency equipment such as bag-valve mask and oxygen
Aspiration
Suction
May have silent aspiration. Monitor skin color and SpO2.
Hemodynamic instability
Consider fluid bolus.
Consider ACLS guidelines for any complication
If significant respiratory depression and/or hemodynamic instability occurs, consider use of reversal agents.

29. Choosing appropriate medications
Agents should be chosen based on the desired pharmacological response (anxiolysis, analgesia, amnesia).
Adverse effects: the potential side effects of any medication in a particular patient must be considered.
Pharmacokinetic considerations:
Onset and duration
Elimination route
Accumulation
Drug interactions/potentiations
Cross-tolerance

30. Pharmacokinetics Drug Onset time (min) Duration Ketamine 0.3 5-10 mins
Midazolam (Versed®)
3-5
1-2 hours
Lorazepam
(Ativan®)
10-20
4-6 hours
Fentanyl
1-2
0.5-1 hours
Morphine
5-10
2-4 hours
Propofol
(Diprivan®)
0.5-2
10-15 mins

31. Midazolam metabolites
Route of elimination
Hepatic
Renal
Ketamine
Diazepam metabolites
Midazolam (Versed®)
Midazolam metabolites
Lorazepam (Ativan®)
Morphine metabolites
Fentanyl
Morphine
Propofol (Diprivan®)

32. Reversal Agents Naloxone (Narcan®) Opioid antagonist
Dosing: mg q 2-3 min, up to 10 mg
Onset time: 1-2 min
Duration of effect: min
Adverse effects: precipitate withdrawal, pulmonary edema
Flumazenil (Romazicon®)
Benzodiazepine antagonist
Dosing: 0.2 mg q 1 min, up to 1 mg
Duration of effect: min
Adverse effects: seizures
Reversing BZD-induced hypoventilation has not been established

33. Post-procedure Monitoring
Patients will be assessed immediately post-procedure and a minimum of every 15 minutes x 2.
If a reversal agent has been used, monitor at least every 15 minutes x 4.
Patients will be monitored every 5 minutes if still moderately or deeply sedated.

34. Recovery Criteria: Inpatient
Aldrete score of 8 or equal to their pre-procedure score.
Cardiovascular function and airway patency are satisfactory and stable.
Patient is easily aroused, protective reflexes (gag and cough) are intact.
Patient can communicate at pre-sedation level.
Patient can tolerate food and fluids.
Pain is at an acceptable level.

35. Discharge criteria: Outpatient
In addition to the recovery criteria:
Department-specific discharge criteria must be met.
Stable vital signs.
Patient must have a responsible person drive him/her home and assume responsibilities for the patient after discharge.
Pain is at an acceptable level.
Adequate discharge instructions (avoid driving for 24 hours, avoid alcoholic beverages for 24 hours, etc.)
Patient can sit up without support and/or walk at pre-sedation level.

36. Aldrete Score Aldrete Score Pre Post
Able to move 4 extremities voluntarily or on command = 2
Able to move 2 extremities voluntarily or on command = 1
Able to move 0 extremities voluntarily or on command = 0
ACTIVITY
Able to deep breathe and cough freely = 2
Dyspnea or limited breathing = 1
Apneic = 0
RESPIRATION
BP +/- 20% of Pre-anesthesia level = 2
BP +/ % of Pre-anesthesia level = 1
BP +/- 50% of Pre-anesthesia level = 0
CIRCULATION
Fully awake = 2
Arousable on calling = 1
Not responding = 0
CONSCIOUSNESS
Pink = 2
Pale, dusky, blotchy, jaundiced, other = 1
Cyanotic = 0
COLOR

38. Documentation
Should reflect evidence of baseline and continued assessment, patient response, and intervention.
Informed consent
Relevant history and physical assessment
ASA and Mallampati classification
Medication, dosage, route
Location and number of attempts to establish IV access
All fluids administered
Physiologic data (BP, HR, RR, O2 saturation, pain score), Aldrete score

39. Question I
Documentation of vital signs should occur how often during procedural sedation?
A. Every minute
B. Every 5 minutes if they stay stable
C. Every 15 minutes if they remain stable, yet monitored every 5 minutes
D. Beginning and end of procedure

40. Question 2
A 30 year old male dislocates his shoulder playing basketball. During his procedural sedation he is arousable only to painful stimuli, has normal oxygen saturation and chest wall excursion. What level of sedation is he in?
A. Level 0
B. Level I
C. Level II
D. Level III
E. Level IV

41. Question 3
8 year old male requires procedural sedation for a complex laceration repair. During the sedation the patient has an acute decrease in end tidal CO2, with desaturation to 88%. He does not respond to painful stimulus and has shallow respirations. What level of sedation does he fall under?
A. Level 0
B. Level I
C. Level II
D. Level III
E. Level IV

42. Question 4
A 42 year old male inpatient is receiving procedural sedation for a paracentesis. He responds to verbal stimuli, has normal vital signs. What level of sedation has been achieved?
A. Level 0
B. Level I
C. Level II
D. Level III
E. Level IV

43. Question 5
You are sedating a 16 year old female for PICC line placement. During sedation she has oxygen desaturations to 91%, with painful stimulus she improves her saturations to 99%. What level of sedation was she in?
A. Level 0
B. Level I
C. Level II
D. Level III
E. Level IV

44. Question 6
You are providing procedural sedation for a 72 year old female with a dislocated hip. During sedation, she has desaturations to 85%, does not respond to painful stimuli, and requires bagging for 3 minutes before she resumes appropriate ventilation. What level of sedation was she in?
A. Level 0
B. Level I
C. Level II
D. Level III
E. Level IV

46. Question 7
The appropriate minimum fasting time for a healthy patient undergoing elective moderate sedation on a clear liquid diet is?
A. 1 hour
B. 2 hours
C. 4 hours
D. 6 hours
E. 8 hours

47. Question 8
During the pre-procedural evaluation the soft palate, fauces and a portion of the uvula are visible. Which Mallampati airway classification should be assigned?
A. Class 1
B. Class 2
C. Class 3
E. Class 4

48. Question 9
A 60 year-old female with a history of diabetes and hypertension controlled with medications is scheduled for colonoscopy. What ASA classification should be assigned?
A. ASA I
B. ASA II
C. ASA III
D. ASA IV
E. ASA V

49. Question 10
A 65 year-old male with a history of COPD requiring home oxygen and chronic renal insufficiency is in the ICU for upper gastrointestinal bleeding. She is currently hypotensive and being transfused for acute blood loss anemia. The patient is scheduled for emergent endoscopy. What ASA classification should be assigned?
A. ASA III E
B. ASA IV
C. ASA IV E
D. ASA V
E. ASA V E

50. Question 11 Which is not required for the pre-procedural time out?
A. Correct patient
B. Correct time
C. Correct procedure
D. Correct site

51. Question 12
During a moderate sedation procedure, the patient begins to have increased oxygen requirements and desaturations. He is only intermittently responding to noxious stimuli and experiencing periods of apnea. What is the next appropriate step in this patients management?
A. Nothing, continue with procedure
B. Immediate intubation
C. Administer naloxone
D. Airway support with oral airway and bag-mask ventilation

52. Question 13
Joe Brown is a 60-year-old otherwise healthy male who is to have a closed reduction of a distal radial fracture under moderate sedation. Pre-procedural vitals include BP 140/80, P78, R18, SpO2 98%. After administration of the medications, Mr. Brown’s BP drops to 106/60 and his pulse rises to 98. What should be the first intervention provided?
A. Fluid bolus
B. Flumazenil 0.2 mg IVP
C. Narcan 0.4 mg IVP
D. Immediately cancel the procedure.

53. Question 14
During a hip reduction, you order Morphine 6 mg IV. Within a few minutes, the patient’s oxygen saturation drops to 92%. You should immediately:
A. Insert an oropharyngeal airway
B. Stimulate the patient
C. Begin bagging the patient with a bag- valve mask
D. Give a fluid bolus

54. Question 15
What is the usual Midazolam onset time and what is the time interval that should elapse before a second dose should be administered?
A. 30 seconds, 5 minutes
B. 1 minute, 1 minute
C minutes, 5 minutes
D. 10 minutes, 20 minutes

55. Question 16
What is the expected duration of effect of a single bolus of Morphine?
A hours
B hours
C hour
D hours

56. Question 17
What is the duration of effect of Naloxone and what is the minimum amount of time after the dose that the patient should be monitored?
A. 30 min to 1 hour, 30 minutes
B. 30 min to 1 hour, 1 hour
C. 1 to 2 hours, 1 hour
D. 1 to 2 hours, 2 hours

57. Question 18
After procedural sedation to reduce a distal radial fracture, your patient states that she is ready to go home. Which of the following would indicate that she is not ready to be discharged?
A. Dizziness when first standing
B. Systolic BP for the past hour
C. Wrist pain, reported 3/10
D. Aldrete score 2 below pre-procedural score.

58. Question 19
Your patient’s mother has not arrived to drive her daughter home after procedural sedation. The patient states that she feels fine and would really like to leave now. What should the nurse do?
A. Send the patient home in a cab.
B. Wait another 30 minutes, then allow the patient to take a bus home.
C. Release the patient only after a responsible person is present to drive.
D. Allow the patient to drive herself home.

59. Question 20
Which of the following information should be included in the discharge information when a patient is discharged within 24 hours of receiving procedural sedation?
A. Return to your normal activities
B. Do not drive for 24 hours
C. Avoid alcoholic beverages for the next 2 hours
D. Clear liquid diet for 24 hours

60. Answers 1: C 15: C 2: D 16: D 3: E 17. B 4: B 18. D 5: D 19. C

61. References
ASA (2002) Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology, 96:
JCAHO Standards, Comprehensive Accreditation Manual for Hospitals: The Official Handbook, Jan 2007:PC42-44.
OSF Saint Francis Medical Center ORGANIZATIONAL POLICY: PROVISION OF CARE, Procedural Sedation/Analgesia by Non-Anesthesiologists, 12/08.
Procedural Sedation for Clinicians, Teaching Module for Initial Appointment, Barnes-Jewish Hospital, 5/08.
Sedation by Non-Anesthesia Personnel for Procedures. (2007) BJH Policy/Procedure/Guideline.