Policy for the Care of Patients Sedated for Procedures

Transcription

1 I. Sedatin Plicy Table f Cntents a. Purpse b. Definitins c. JCAHO Standard PC d. JCAHO Standard PC e. JCAHO Standard PC f. Authrity g. Rle f the Department f Anesthesia h. Anesthesia Cnsultatin i. Equipment j. Persnnel k. Pathway: Sedatin Prcedure l. Quality Management & Prcess Imprvement Page 2 Page 3 Page 4-6 Page 6 Page 6 Page 7 Page 7 Page 8 Page 9 Page 10 Page Page 13 II. Appendices a. ASA Physical Status Classificatin b. Airway Assessment fr Sedatin c. Fasting Prtcls fr Elective Prcedures d. Factrs Assciated with Increased Risk f Aspiratin e. Suggested Drugs and Dsages fr Sedatin f. Anesthetics g. Sedatin Recrd Example h. NYSSA Article i. Bibligraphy Page 14 Page 15 Page 16 Page 17 Page Page 21 Page Page Page Page 1 f 33

2 PURPOSE: Thse patients sedated fr prcedures are cared fr: By prviders wh are prperly trained and qualified per JCAHO standards PC.13.20, PC.13.30, and PC In an envirnment designed and supplied t make the sedatin & prcedure safe. Via an intake, sedatin, mnitring and dispsitin/discharge system that prvides a unifrm, safe standard f care. Page 2 f 33

3 DEFINITIONS: Minimal sedatin (anxilysis): (Taken frm Jint Cmmissin Standards) A drug-induced state during which patients respnd nrmally t verbal cmmands. Althugh cgnitive functin and crdinatin may be impaired, ventilatry and cardivascular functins are unaffected. Mderate sedatin / analgesia ( cnscius sedatin ): A drug-induced depressin f cnsciusness during which patients respnd purpsefully t verbal cmmands, either alne r accmpanied by light tactile stimulatin. N interventins are required t maintain a patent airway, and spntaneus ventilatin is adequate. Cardivascular functin is usually maintained. Deep sedatin / analgesia: A drug-induced depressin f cnsciusness during which patients cannt be easily arused but respnd purpsefully fllwing repeated r painful stimulatin. The ability t independently maintain ventilatry functin maybe impaired. Patients may require assistance in maintaining a patent airway and spntaneus ventilatin may be inadequate. Cardivascular functin is usually maintained. Anesthesia Cnsists f general anesthesia and spinal r majr reginal anesthesia. It des nt include lcal anesthesia. General anesthesia is a drug-induced lss f cnsciusness during which patients are nt arusable, even by painful stimulatin. The ability t independently maintain ventilatry functin is ften impaired. Patients ften require assistance in maintaining a patent airway, and psitive pressure ventilatin may be required because f depressed spntaneus ventilatin r drug-induced depressin f neurmuscular functin. Cardivascular functin may be impaired. Page 3 f 33

4 JCAHO Standard PC Hspital Prvisin f Care, Treatment, and Services Standards fr Operative r Other High-Risk Prcedures and/r the Administratin f Mderate r Deep Sedatin r Anesthesia Operative r ther prcedures and the administratin f sedatin r anesthesia ften ccur simultaneusly. Hwever, prcedures d ccur withut sedatin, and sedatin r anesthesia is administered fr nninvasive prcedures (hyperbaric treatment, CT scan, MRI). Therefre, the fllwing standards address bth perative r ther prcedures and/r the administratin f mderate r deep sedatin r anesthesia. Whenever an perative r ther prcedure is cnducted, whether r nt sedatin r anesthesia is administered, apprpriate staff must be invlved in planning fr and prviding care t the patient. All prcedures carry risk, but that risk is increased when sedatin r anesthesia is administered. The standards fr anesthesia care apply when patients/clients/residents in any setting, receive, fr any purpse, by any rute, the fllwing: General, spinal, r ther majr reginal sedatin and anesthesia r Mderate r deep sedatin (with r withut analgesia) that, in the manner used, may be reasnably expected t result in the lss f prtective reflexes Because sedatin is a cntinuum, it is nt always pssible t predict hw an individual patient/client/resident receiving sedatin will respnd. Therefre, each rganizatin develps specific, apprpriate prtcls fr the care f patients/clients/residents receiving sedatin. These prtcls are cnsistent with prfessinal standards and address at least the fllwing: Sufficient qualified individuals present t perfrm the prcedure and t mnitr the patient/client/resident thrughut administratin and recvery. The individuals prviding mderate r deep sedatin and anesthesia have at a minimum had cmpetency-based educatin, training, and experience in the fllwing: 1. Evaluating patients/clients/residents befre perfrming mderate r deep sedatin and anesthesia. Page 4 f 33

5 2. Perfrming the mderate r deep sedatin and anesthesia, including rescuing patients/clients/residents wh slip int a deeper-than-desired level f sedatin r analgesia. These include the fllwing: 1. Mderate sedatin are qualified t rescue patients/ clients/residents frm deep sedatin and are cmpetent t manage a cmprmised airway and t prvide adequate xygenatin and ventilatin 2. Deep sedatin are qualified t rescue patients/clients/ residents frm general anesthesia and are cmpetent t manage an unstable cardivascular system as well as a cmprmised airway and inadequate xygenatin and ventilatin Apprpriate equipment fr care and resuscitatin Apprpriate mnitring f vital signs including, but nt limited t heart and respiratry rate s and xygenatin using pulse ximetry equipment, respiratry frequency and adequacy f pulmnary ventilatin, the mnitring f bld pressure at regular intervals, and cardiac mnitring (by EKG r use f cntinuus cardiac mnitring device) in patients/clients/residents with significant cardivascular disease r when dysrhythmias are anticipated r detected Dcumentatin f care Mnitring f utcmes Definitins f fur levels f sedatin and anesthesia include the fllwing: [Nte, nly the definitin f ne level is prvided here as changes are nly applicable t that definitin.] Mderate sedatin/analgesia ( cnscius sedatin ) A drug-induced depressin f cnsciusness during which patients/clients/residents respnd purpsefully t verbal cmmands (nte, reflex withdrawal frm a painful stimulus is nt cnsidered a purpseful respnse) either alne r accmpanied by light tactile stimulatin. N interventins are required t maintain a patent airway, and spntaneus ventilatin is adequate. Cardivascular functin is usually maintained. Standard PC Operative r ther prcedures and/r the administratin f mderate r deep sedatin r anesthesia are planned. Elements f Perfrmance fr PC Sufficient numbers f qualified staff (in additin t the LIP perfrming the prcedure) are present t evaluate the patient, assist with the prcedure, prvide the sedatin and/r anesthesia, mnitr, and recver the patient. 2. Individuals administering mderate r deep sedatin and anesthesia are qualified and have the apprpriate credentials t manage patients at whatever level f sedatin r anesthesia is achieved, either intentinally r unintentinally. Page 5 f 33

6 Fr hspitals prviding bstetric r emergency perative services, this means they can prvide anesthesia services as required by law and regulatin. JCAHO Standard PC : Patients are mnitred during the prcedure and/r administratin f mderate r deep sedatin r anesthesia. Elements f Perfrmance fr PC Apprpriate methds are used t cntinuusly mnitr xygenatin, ventilatin, and circulatin during prcedures that may affect the patient's physilgical status. 2. The prcedure and/r the administratin f mderate r deep sedatin r anesthesia fr each are dcumented in the medical recrd JCAHO Standard PC : Patients are mnitred immediately after the prcedure and/r administratin f mderate r deep sedatin r anesthesia. Elements f Perfrmance fr PC The patient's status is assessed n arrival in the recvery area. 2. Each patient's physilgical status, mental status, and pain level are mnitred. 3. Mnitring is at a level cnsistent with the ptential effect f the prcedure and/r sedatin r anesthesia. 4. Patients are discharged frm the recvery area and the hspital by a qualified LIP r accrding t rigrusly applied criteria apprved by the clinical leaders. 5. Patients wh have received anesthesia in the utpatient setting are discharged in the cmpany f a respnsible, designated adult Page 6 f 33

7 AUTHORITY: This plicy prmulgated and disseminated by the Department f Anesthesia has been reviewed and ratified by the Medical Bard and the Bard f Trustees via the Jint Cnference and Prfessinal Affairs Cmmittee t ensure cmpliance with standards established by the New Yrk State Department f Health and the Jint Cmmissin (JCAHO). ROLE OF THE DEPARTMENT OF ANESTHESIA: Develpment f guidelines fr the training, supervisin, credentialing and recredentialing f all individuals invlved in the care f patients sedated fr prcedures underging intravenus sedatin/analgesia (IVSA). Assist in the apprpriate Department and/r Divisin where sedatin is t ccur thrughut the hspital. Establish methds f patient evaluatin and risk assessment including: ASA physical status classificatin Airway assessment Fasting interval Aspiratin risk Criteria fr anesthesia cnsultatin Establish designated Sedating Lcatins with mandatry staffing, equipment, mnitring, dcumentatin, intake and discharge criteria and cntinuum f care. Apprpriate drug dses, titratin and techniques used during IVSA. Peridic inservice educatin and updates regarding medicatins - including prblem recgnitin and respnse. Assist in develpment f mnitring and evaluatin tls, adverse event reprting and prcess imprvement via the Perfrmance Imprvement Crdinating Grup. Page 7 f 33

8 ANESTHESIA CONSULTATION: Frmal cnsultatin with the Department f Anesthesia shuld be requested when the physicians and nurses caring fr the patient are uncertain abut the patient's ability t underg the planned prcedure and sedatin safely. 1. A significant risk f: Fr patients with: Airway cmprmise Lss f prtective reflexes r lss f cnsciusness Cardipulmnary r neurlgic decmpensatin Gastric cntent aspiratin 2. A histry f cmplicatins r failure f prir sedatin: Inability f patient t cperate Generally pr patient cnditin Histry f sleep apnea. 3. Any questins related t apprpriateness f the methd f sedatin. Page 8 f 33

9 EQUIPMENT: The Sedating Lcatin must prvide: PSI xygen surce. Supplemental xygen is recmmended fr mst patients being sedated. 2. Variable pwer vacuum suctin apparatus. N.B: Wall xygen and suctin surces are mst reliable and preferred. Where tank xygen and/r prtable suctin machines are used, the attending physician must ascertain that the xygen supply is sufficient and the suctin apparatus is functining prperly befre beginning the prcedure. 3. Standard fully equipped cardiac arrest cart with equipment apprpriate fr the age f the patient being sedated including a self-inflating psitive pressure xygen delivery resuscitatin bag, airways, laryngscpes and endtracheal tubes. A full supply f resuscitatin drugs must be available including narctic and benzdiazepine antagnist drugs - nalxne and flumazenil. The Pharmacy Department is respnsible fr maintenance f the resuscitatin drugs. 4. Pulse ximeter with alarm. 5. Nninvasive bld pressure measuring device. 6. An EKG mnitr with alarm. 7. A patent intravenus infusin fr the duratin f the prcedure and during recvery as deemed necessary. 8. Nitrus xide: When inhalatin sedatin is prvided with nitrus xide (N20) it must be delivered with equipment that: cannt prvide a cncentratin f N20 in excess f 70% inspired; will prvide a maximum f 100% and never less than 21% xygen; is fitted with an xygen analyzer t mnitr the accuracy f delivered gases. 9. All equipment must be prepared and maintained accrding t existing Hspital prtcl develped by the Department f Bimedical Engineering and the Cardiac Arrest Cmmittee. Page 9 f 33

10 PERSONNEL: There must be a minimum f tw peple invlved in the care f a patient sedated fr a prcedure. 1. The Physician. The sedative medicatin must be rdered by a physician and its administratin, including additinal dses, must be supervised by a physician. Careful titratin f drugs is mandatry. The physician may be directly invlved in the prcedure, r may delegate aspects f the prcedure t ther practitiners (i.e. Specifically trained technicians.) 2. The Mnitr. The patient's vital signs, level f cnsciusness and cnditin must be cntinually mnitred by a dedicated bserver. The dedicated bserver has the primary duty t mnitr the patient and may be used fr minr interruptible tasks and nly if abslutely necessary. A mnitr will be available t the patient frm the time f administratin f sedatin/analgesia medicatin until recvery is judged adequate r the care f the patient is transferred t apprpriate persnnel perfrming recvery care. Credentialing Practitiners qualified t sedate and mnitr patients fr prcedures will be credentialed by their respective departments with the assistance f the Department f Anesthesia. The credentials fr each physician sedating patients fr prcedures will be maintained by the Departments. The credentials fr nurses caring fr and mnitring sedated patients will be maintained by the Department f Nursing. The credentialing prcess will fcus n the practitiner's relevant training and experience; the ability t assess the patient prir t the prcedure; t knw the apprpriate dses and effect f drugs, t perate and dcument mnitring, t recgnize airway cmprmise, lss f cnsciusness, cardipulmnary decmpensatin and t be able t intervene in a timely fashin t rescue and begin resuscitatin f the patient as needed. All persns invlved in the care f patients sedated fr prcedures: physicians, nurses, allied health prfessinals, physicians' assistants will be prvided with: Current hspital Sedatin Plicy Adjunct general infrmatin n sedatin/analgesia Bibligraphy Cmpact disc Unit specific infrmatin frm Divisin Head and/r Unit Crdinatr Infrmatin re: a BLS / ACLS Certificatin Cmpetency test with answer sheet Inservice training in airway management Bi-annual medical staff recredentialing Yearly nging cmpetency evaluatins fr nursing staff Page 10 f 33

11 PATHWAY - SEDATED PROCEDURE: Prir t Prcedure: Patient Preparatin Prir t the prcedure the patient must have a pre-sedatin evaluatin cmpleted by an MD; NP within 7 days prir t the prcedure t include the fllwing as apprpriate: 1. Indicatin fr the prcedure 2. The patient's histry including: imprtant medical cnditins especially cardipulmnary status; allergies r adverse drug reactins; prir sedative r anesthesia experiences; ptential fr pregnancy 3. Physical assessment including: ASA physical status; baseline vital signs with baseline xygen saturatin; weight; airway status; apprpriate fasting interval fr the elective case (NPO at least 6 hurs) (see appendix #3); aspiratin risk factrs;cardiac and pulmnary status general neurlgic status; mental status; level f cnsciusness 4. Apprpriate labratry tests 5. Infrmed cnsent by respnsible adult 6. Fr children and adult ut-patients - a respnsible adult escrt 7. An assessment f the need fr bld and bld cmpnent transfusin when relevant 8. A plan fr sedatin 9. A plan fr nursing care 10. Determinatin that the patient is suitable candidate fr the prcedure and sedatin. The fllwing is required: During the Prcedure: Mnitring and Dcumentatin 1. Physician rder fr all sedative medicatins 2. The time, rute, dse and effect f all medicatins including xygen therapy in liters/min. and by means delivered (e.g. nasal prngs) Page 11 f 33

12 3. All dses f drugs must be titrated t the desired effect, allwing sufficient time fr circulatin and bservatin f variable respnses 4. Mnitred cntinuusly and recrded every five minutes as apprpriate: heart rate; respiratry rate and adequacy f pulmnary ventilatin; SpO2 by pulse ximetry; nninvasive bld pressure; level f cnsciusness; EKG mnitring shuld be available and utilized fr patients with significant cardipulmnary disease r when dysrhythmias are anticipated r detected. Dcumentatin n a specific "sedatin recrd" is required. When the prcedure is dne in an ICU, use f the "sedatin recrd" supersedes ICU, flwsheet dcumentatin. During recvery frm sedatin: Recvery and Dispsitin: 1. An Aldrete scring system must be used; 2. Vital signs must be taken every ten minutes x3 then every hur x2 (r until fully recvered); 3. The patient must be bserved fr a minimum f thirty minutes after the prcedure; 4. If antagnist drugs (nalxne, flumazenil) have been used, the patient must be bserved fr a minimum f 2 hurs after the prcedure watching fr resedatin. The patient may be transferred frm the prcedure area t a recvery area when: 1. Able t maintain a patent airway with intact reflexes (swallw, cugh, gag); 2. Respnsive t verbal and tactile stimuli as apprpriate; 3. Vital signs are stable with satisfactry SpO2. If the recvery area is remte frm the prcedure area, the patient must be mnitred in transit by the mnitring persn with a pulse ximeter. If the patient is sedated in an area remte frm the prcedure area, the patient must be transprted t the prcedure area by a mnitring persn with a pulse ximeter. The patient may be discharged frm the hspital when: 1. Fully awake with an Aldrete scre f 8 r better; 2. Hydratin is adequate; 3. Able t walk unassisted - where apprpriate; 4. Accmpanied by a respnsible adult escrt; 5. Advised regarding aftercare with written and verbal instructins; Page 12 f 33

13 6. The respnsible attending physician must write the discharge rder and write a discharge nte including patient status; 7. An RN may discharge the patient utilizing the abve criteria; 8. Standard institutinal Ambulatry Care prtcls must be emplyed regarding fllw-up and care f pst discharge cmplicatins. QUALITY MANAGEMENT & PROCESS IMPROVEMENT: Every department and discipline sedating patients fr prcedures must submit quarterly reprts f their experience t the Operative and Invasive Prcedures Cmmittee fr review. The reprt must include the number and types f prcedures dne, cmplicatins and results f quarterly Perfrmance Imprvement mnitring and activities. Critical adverse events will be reprted and reviewed in a timely manner. Page 13 f 33

14 AMERICAN SOCIETY OF ANESTHESIOLOGISTS Physical Status Classificatin: CLASS I: N rganic, physilgical, bichemical r psychiatric disturbance. The pathlgic prcess fr which peratin is t be perfrmed is lcalized and is nt a systemic disturbance. CLASS II: Mild t mderate systemic disturbance caused either by the cnditin t be treated r by ther pathphysilgical prcesses. CLASS III: Severe systemic disturbance r disease frm whatever cause, even thugh it may nt be pssible t define the degree f disability with finality. CLASS IV: Severe systemic disrder already life-threatening, nt always crrectable by the prcedure. CLASS V: Mribund patient wh has little chance f survival, but is submitted t the prcedure in desperatin. CLASS VI: Organ dnr. Page 14 f 33

15 AIRWAY ASSESSMENT PROCEDURES FOR SEDATION: Psitive pressure ventilatin, withut endtracheal intubatin, may be necessary if respiratry cmprmise develps during sedatin / analgesia. This may be mre difficult in patients with atypical airway anatmy. Sme airway abnrmalities may increase the likelihd f airway bstructin during spntaneus ventilatin. Factrs that may be assciated with difficulty in airway management are: HISTORY Previus prblems with anesthesia r sedatin; Stridr, snring r sleep apnea; Dysmrphic facial features; Tumr in airway; Trauma t airway; Radiatin therapy t head, neck; Advanced rheumatid arthritis. PHYSICAL EXAMINATION Habitus: Significant besity (especially invlving the face, neck and thrax) Head and Neck: Shrt neck, limited neck extensin, decreased distance frm the tp f the mandible t the tp f the thyrid cartilage (<3 cm in an adult); neck mass, cervical spine disease r trauma, tracheal deviatin, decreased tissue cmpliance Muth: Small pening (<3 cm in an adult); edentulus r prtruding incisrs; lse r capped teeth; high arched palate; macrglssia; tnsillar hypertrphy; nnvisible uvula Jaw: Micrgnathia, retrgnathia, trismus, significant malcclusin Page 15 f 33

16 FASTING PROTOCOL FOR SEDATION AND ANALGESIA FOR ELECTIVE PROCEDURES: The fllwing guidelines are intended fr patients with nrmal airway and gastresphageal anatmy. Several factrs are assciated with delayed gastric emptying and/r increased risk f aspiratin (see Appendix 4: Factrs Assciated with Increased Risk f Aspiratin). When risk f aspiratin is increased, a lnger fasting interval is warranted and antacid prphylaxis r intubatin may be indicated. Adults: Slids & Nnclear Liquids*: 8 hrs r NPO after midnight Clear Liquids: 2-4 hrs Children lder than 36 mnths: Slids & Nnclear Liquids*: 6-8 hrs Clear Liquids: 2-4 hrs Children aged 6-36 mnths: Slids & Nnclear Liquids*: 6 hrs Clear Liquids: 2-4 hrs Children yunger than 6 mnths: Slids & Nnclear Liquids*: 4 hrs (breast milk) 2 hrs Clear Liquids: 6 hrs (frmula) 2 hrs * This includes milk, frmula and breast milk (high fat cntent may delay gastric emptying). There are n data t establish whether a 6-8 hr fast is equivalent t an vernight fast befre sedatin / anesthesia. Page 16 f 33

17 FACTORS ASSOCIATED WITH INCREASED RISK OF ASPIRATION : Abnrmal Airway; Mrbid Obesity; Hiatus Hernia with Reflux; Abnrmal Autnmic Functin; Prir Gastric Surgery; Pregnancy; "Full Stmach" r Delayed Gastric Emptying; Altered Mental State; Spinal Crd Injury with Paraplegia r Quadraplegia; Narctics; Pain. Page 17 f 33

18 SUGGESTED DRUGS & DOSES FOR SEDATION: SEDATIVES: Midazlam (Versed) Adult Dse: mg/kg IV Adult Max: 5-10 mg Peds Dse: mg/kg IV, mg/kg p Peds Max: 20 mg p Cmments: Additive depressin with narctics Lrazepam (Ativan) Adult Dse:.05 mg/kg Adult Max: 4 mg Cmments: Lng acting Beware cumulative effect Diazepam (Valium) Adult Dse:.05 - l mg/kg IV Adult Max: 10 mg Cmments: Pain n injectin Half as ptent as Versed Page 18 f 33

19 Chlral hydrate Peds Dse: mg/kg p/pr Peds Max: 1 gm / dse ttal 2 gm Cmments: Must be given under supervisin Pentbarbital (Nembutal) Adult Dse: 2-4 mg/kg IV Secbarbital (Secnal) Cmments: Deep sedatin Lng acting N reversal agent ANALGESICS: Fentanyl (Sublimaze) Adult / Peds: 1-3 mcg/kg IV Cmments: Mrphine Ptent synthetic Depressed CO2 respnse May utlast Narcan Reevaluate reversal Adult / Peds:.1 mg/kg IV Cmments: Prttype narctic Histamine release Lng acting Page 19 f 33

20 Meperidine (Demerl) Adult / Peds: 1 mg/kg IV Cmments: Less ften used Dangerus interactin with MAO inhibitrs Nalxne (Narcan) (fr Narctics) ANTAGONISTS: Adult: mg IV, q 2-3 min t desired effect Peds: mg/kg IV, q 2-3 min Cmments: Brief duratin f actin min Ptential fr residual resedatin Flumazenil (Rmazicn) (fr Benzdiazepines) Adult Dse: mg IV t desired effect Adult Max: 3 mg Peds Dse: 0.01 mg/kg Peds Max:.2 mg/dse.05 mg/kg Cmments: May precipitate seizures Residual resedatin Page 20 f 33

21 ANESTHETICS: 1. Sdium Thipental (Penthal) 2. Methhexital (Brevital) 3. Prpfl (Diprivan) 4. Ketamine 5. Etmidate (Amidate) These medicatins are cmmnly used t induce and / r maintain general anesthesia where lss f prtective airway reflexes is anticipated. Therefre, these medicatins are nt suitable fr cnscius sedatin/analgesia. Their use is restricted t specifically credentialed practitiners. Page 21 f 33

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32 BIBLIOGRAPHY: 1. American Academy f Pediatrics, Cmmittee n Drugs; Guidelines fr the elective use f cnscius sedatin, deep sedatin, and general anesthesia in pediatric patients. Pediatrics 76: , American Academy f Pediatrics, Cmmittee n Drugs; Guidelines fr mnitring and management f pediatric patients during and after sedatin fr diagnstic and therapeutic prcedures. Pediatrics 90: , l Hltz, J.A. Cnscius Sedatin: Pediatric and Adult, Advances in Anesthesia. Vl 13, pgs , Vitkun, SA. A Methd fr Credentialing Nn-Anesthesilgists t Prvide Sedatin and Analgesia (Cnscius Sedatin), NY State Sciety f Anesthesilgists, Sphere, Vl 49, N. 4, pgs , Oct. Dec Cte, CJ: Sedatin fr the Pediatric Patient. Pediatric Anesthesia 1:31-58, Cuncil n Scientific Affairs, American Medical Assciatin: The use f pulse ximetry during cnscius sedatin. JAMA 270: , American Nursing Assciatin: Psitin statement n the rle f the registered nurse in the management f patients receiving IV cnscius sedatin fr shrt-termtherapeutic, diagnstic r surgical prcedures. AORN J 55: , JCAHO, The Jint Cmmissin: Accreditatin Manual fr Hspitals, Vl I: Standards; Vl II: Scring Guidelines. Oakbrk Terrace, IL, JCAHO, Rss, AF, Tinker, JH: Anesthesia risk, in Miller RD (ed): Anesthesia, ed 3, New Yrk, Churchill Livingstne, p. 723, Nahata, MC, Cltz, MA, Krgg, EA: Adverse effects f meperidine, prmethazine and chlrprmazine fr sedatin in pediatric patients. Clin Pediatrics 24: , Jacbs, JR, Reves, JG, Marty, J, et al: Aging increases pharmacdynamic sensitivity t the hypntic effects f midazlam. Anesthesia Analg 80: , Jastak, JT, Peskin, RM: Majr mrbidity r mrtality frm ffice anesthetic prcedures: A clsed-claim analysis f 13 cases. Anesth Prg 38:39-44, Page 32 f 33

33 13. Arrwsmith, JR, Gerstman, BB, Fleischer, DE, et al: Results frm the AmericanSciety fr Gastrintestinal Endscpy / US Fd and Drug Administratin cllabrative study n cmplicatin rates and drug use during gastrintestinal endscpy. Gastrintestinal Endscpy 37: , A reprt by the American Sciety f Anesthesilgists Task Frce n Sedatin and Analgesia by Nn- Anesthesilgists, Practice Guidelines fr Sedatin and Analgesia by Nn-Anesthesilgists. Anesthesilgy, 84: , Bailey, P.L., Pace, N.L.., Ashburn, M.A., Mll, J.W.B., Kast, K.A., Stanley, T.H. Frequent hypxemia and apnea after sedatin with midazlam and fentanyl. Anesthesilgy. 73: , Stlzfus, D.P. Advantages and disadvantages f cmbining sedative agents. Critical Care Clinics, 11 (4): , Pher, J.C., Pharmaclgic management f pain, anxiety and behavir: sedatin and analgesia, deep sedatin and general anesthesia, Pediatric Dentistry, 15: , Prudft, J. Analgesia, anesthesia and cnscius sedatin. Emergency Medicine Clinics f Nrth America, 13: , Striker, T.W., Cte, C.J., Perspectives n guidelines fr mnitring the sedated pediatric patient. American Jurnal f Anesthesilgy, 23: , Smersn, S.J., Husted, C.W., Sicilia, M.R. Insights int Cnscius Sedatin. American Jurnal f Nursing. 6:26-33, Smith, D.F., Cnscius Sedatin and the JCAHO (Opus Cmmunicatins) Kst, M., Manual f Cnscius Sedatin. W.B. Saunders, Page 33 f 33