Procedural Sedation for the Non-Intubated Patient

Transcription

1 Procedural Sedation for the Non-Intubated Patient Self Learning Module Presented by The Procedural Sedation Committee and The Center for Learning & Development 2007

2 Program Goals and Objectives Discuss the Procedural Sedation Policy and Protocols as directed by the Department of Anesthesiology. Explain the roles and responsibilities of the Registered Nurse, in the implementation of the Procedural Sedation Protocol (including monitoring, equipment management, drug knowledge, assessment, complication management and documentation).

3 Target Audience and Course Description This Self Learning Module is designed for Registered Professional Nurses seeking initial competency for Procedural Sedation. This certification provides the opportunity for the Registered Nurse to develop the knowledge and skills required by Albany Medical Center to serve as the monitor in moderate or deep procedural sedation; and to familiarize the learner with the regulatory requirements, as guided by the American Society of Anesthesiology (ASA) and the Joint Commission for Accreditation of Healthcare Organizations (JCAHO).

4 Table of Contents References/Links to Pertinent Articles AMCH Policy & Protocol Important Definitions Actions Taken Prior to Procedure Pre-procedural Sedation Checklist & Assessment Universal Protocol Drug Administration Post-Procedure Potential Complications Patient and Family Education Recovery Criteria and Discharge/Transfer Documentation Medication Guidelines: Moderate Sedation Reversal Agents

5 Steps to Credentialing for Procedural Sedation Sign In Read Contents of Module, including referenced articles Complete the Post Test Complete Evaluation Form Correct Post Test (if score <93% re-read the module and re-take test) Documentation of Competency on Competency Checklists You will Receive a Certificate of Completion

6 References/Links to Pertinent Articles

7 References Baltes-Messner, J., VanDenLangenberg, B., Koberstein, H., & Hollman, G. (1999). Pediatric Sedation: The Art and Science. Orothopaedic Nursing, September/October, Bryan, R.J. (1997). Administering Conscious Sedation, Operational Guidelines. Critical Care Nursing Clinics of North America, 9(3), Dachs, R.J. & Innes, G.M. (1996). Intravenous Ketamine Sedation of Pediatric Patients in the Emergency Department. Annals of Emergency Medicine, 29(1), Darling, E. (1997). Practical Considerations in Sedating the Elderly. Critical Care Nursing Clinics of North America, 9(3), Dursteler, B.B. & Wightman, J.M. (2000). Etomidate-facilitated Hip Reduction in the Emergency Department. American Journal of Emergency Medicine, 18(2), Hata, T., Nickel, E., Hindman, B. and Morgan, D. Anatomy and Physiology Related to Pediatric Sedation., from The University of Iowa Hospitals Procedural Sedation Committee. scsa_p.html\

8 References Landrum, L. (1997) A Nursing Guide to Conscious Sedation: Clarification of Current Practice Issues. Critical Care Nursing Clinics of North America, 9(3), Zempsky, W.T. & Cravero, J.P. (2004). Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems. Pediatrics,114(5), Sedation and Monitoring of Patients Undergoing Gastrointestinal Endoscopic Procedures. A Sedation and Monitoring of Patients Undergoing Gastrointestinal Endoscopic Procedures (SAGES) Co-Endorsed ASGE Guideline.

9 Policies and Protocols AMCH Procedural Sedation: Moderate (Conscious Sedation) Protocol AMCH Protocols

10 Important Definitions

11 Important Definitions Pre-medication Procedural Sedation Deep Sedation Modified Ramsay Score Mallampatti Classification ASA Risk Status Score Credentialed Sedation Prescriber Qualified Monitor Post Anesthesia Score (Aldrete)

12 Pre-medication A limited use of an individual anxiolytic, sedative, or analgesic medication for the purpose of preparing patients that are anxious, agitated or claustrophobic for a non/minimally painful or invasive procedure (e.g. MRI or dressing change). Desired response for patients to remain at Ramsay level 2 (cooperative, oriented and tranquil). Smallest initial dose is used and may be repeated once if the patient remains at Ramsey level 1 (anxious, agitated or restless). The Procedural Sedation: Moderate (Conscious Sedation) Protocol does not pertain to Premedication.

13 Procedural Sedation Delivery of medication for sedation and analgesia to non-intubated patients by non anesthesiologists during diagnostic and therapeutic procedures. 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. Modified Ramsay Score (MRS) = 3-4

14 Procedural Sedation (cont.) The credentialed sedation provider and RPN administering moderate sedation must meet institutional requirements for procedural sedation as defined in AMC Policy. The Anesthesia Department is available for consult or collaboration with high-risk patients. The minimum number of available personnel shall be two: the credentialed sedation provider and the qualified monitor. Each procedure/sedation area will have the means for activating code blue/911 and/or additional support staff.

15 Deep Sedation/Analgesia Drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug induced depression of neuromuscular function. Cardiovascular function may be impaired. RPNs MAY NOT administer deep sedation.

16 Sedation on a Continuum Procedural sedation is not a one time administration of an analgesic or sedative agent. It is a process by which these agents are titrated to reach a specific effect. Patients have the potential to become more sedated than planned. (i.e. patient receiving procedural sedation may enter a state of deep sedation) Practitioners must be prepared to rescue patients whose level of sedation becomes deeper than initially planned.

17 Modified Ramsay Score (MRS) A tool used to objectively determine a patient s degree of sedation. The MRS is the basis for frequency of vital sign monitoring and for determination of when a patient has recovered to baseline.

18 Modified Ramsay Score (MRS) 1. Patient anxious, agitated or restless 2. Patient cooperative, oriented and tranquil 3. Patient responds to voice and commands 4. Patient responds to shaking 5. Patient responds to noxious stimulus 6. Patient has no response to firm nailbed pressure or other noxious stimuli

19 Mallampatti Classification An airway assessment tool used to determine ease of intubation. Class I: visualization of soft palate, fauces, uvula, anterior and posterior pillars. Class II: visualization of soft palate, fauces and uvula. Class III: visualization of soft palate and base of uvula. Class IV: soft palate not visible.

20 Mallampatti Classification

21 American Society of Anesthesiologists (ASA) Patient Classification ASA 1 A normal, healthy patient. The pathological process for which surgery is to be performed is localized and does not entail a systemic disease. Example: An otherwise healthy patient scheduled for a cosmetic procedure.

22 American Society of Anesthesiologists (ASA) Patient Classification ASA 2 A patient with mild systemic disease, caused either by the condition to be treated or other pathophysiological process, but which does not result in limitation of activity. Example: A patient with asthma, diabetes or hypertension that is well controlled with medical therapy, and has no systemic sequelae.

23 American Society of Anesthesiologists (ASA) Patient Classification ASA 3 A patient with moderate or severe systemic disease caused either by the condition to be treated surgically or other pathophysiological processes, which does limit activity. Example: A patient with uncontrolled asthma that limits activity, or diabetes that has systemic sequelae such as retinopathy.

24 American Society of Anesthesiologists (ASA) Patient Classification ASA 4 A patient with severe systemic disease that is a constant potential threat to life. Example: A patient with heart failure, a patient with renal failure requiring dialysis.

25 American Society of Anesthesiologists (ASA) Patient Classification ASA 5 A patient who is at substantial risk of death within 24 hours, and is submitted to the procedure in desperation. Example: A patient with fixed and dilated pupils status post a head injury.

26 American Society of Anesthesiologists (ASA) Patient Classification E Emergency status This is added to the ASA designation only if the patient is undergoing an emergency procedure. Example: A healthy patient undergoing sedation for reduction of a displaced fracture would be an ASA 1E. NOTE: ASA Classification is completed by the Credentialed Practitioner.

27 Roles in Procedural Sedation Provider Physician or licensed independent practitioner Administrator Credentialed RPN Monitor Credentialed RPN

28 Credentialed Sedation Provider A Physician or licensed independent practitioner who prescribes the sedation plan is PRESENT during the procedure. May also perform surgical or diagnostic procedure. Must be immediately available throughout the procedure to diagnose, treat and otherwise attend to any and all complications. Must be physically in the hospital until recovery from sedation-analgesia is assured. Is personally responsible for competency in prescribing procedural sedation.

29 Qualified Monitor An RN trained to monitor appropriate physiologic variables and to assist in any supportive or resuscitation measures required. In all instances of procedural sedation, patients must be monitored and assessed by such an individual whose principal role is patient safety and monitoring. Each monitor is personally responsible for competency in monitoring patients receiving procedural sedation.

30 Qualified Monitor The monitor must be in continuous physical proximity with the patient at all times during the procedure, with unrestricted visual and/or physical access. Is a DEDICATED nurse during the procedure. The monitor will inform the patient to verbally communicate increasing pain or discomfort. If verbal communication is not possible, then an alternative method of communication will be established based on age specific/developmental criteria. Pain will be measured using a 0-10 Pain Scale.

31 Post Anesthesia Score (Aldrete) Activity Able to move 4 extremities=2 Able to move 2 extremities=1 Able to move 0 extremities=0 Respiratory Able to breathe deeply/cough effectively=2 Dyspnea or limited breathing=1 Apnea=0 Circulation BP+/-20% of Pre-Anesthesia Level=2 BP+/ % of Pre-Anesthesia Level=1 BP+/- 50% of Pre-Anesthesia Level=0 Awareness Fully awake=2 Arousable on calling=1 Not responding=0 Color Pink=2 Pale/dusky/blotchy/jaundiced=1 Cyanotic=0

32 Actions Taken Prior to Procedure

33 Actions Taken Prior to Procedure: NPO Status Establish NPO status using the following recommendations: Children: No non-breast milk, formula or food within 6 hours pre procedure No breast milk within 4 hours pre procedure Water, or clear liquids (apple or grape juice) are acceptable up to 2 hours pre procedure. Adults ( 18 years and older): Water is acceptable up to 3 hours prior to the procedure No food ( includes chewing gum, candy, cough drops, or antacids) or liquids other than water after midnight the night before the procedure. For all patients: Medications may be taken on morning of the procedure with a sip of water. Emergency procedure: precaution for airway protection may include cricoid pressure

34 Actions Taken Prior to Procedure: Equipment Validate the following items are prepared, operational and immediately available: Continuous pulse oximetry Airway equipment Cardiac monitoring-continuous monitoring Supplemental oxygen and delivery systems Bag-valve-mask ambu Suction equipment (age appropriate) Automated blood pressure monitor Emergency cart and age appropriate defibrillator Reversal agents for sedation planned Appropriate equipment to administer intravenous fluids and drugs, including blood and blood components Means for activating Code Blue and/or additional support staff

35 Preprocedural Sedation Checklist & Assessment

36 Preprocedural Sedation Checklist & Assessment Written consent completed by the credentialed practitioner which includes: Potential risks and benefits Potential problems after procedure Potential for failure Consequences of not providing sedation/ analgesia Alternatives to sedation

37 Preprocedural Sedation Checklist & Assessment Baseline health evaluation completed within last 30 days Including a brief health history and physical examination Completed preprocedural H&P only if History & Physical is not available Re-evaluation of patient s current health status immediately before planned sedation

38 Preprocedural Sedation Checklist & Assessment ASA Score Mallampatti Airway Score Sedation Plan Completed by the credentialed practitioner

39 Preprocedural Sedation Checklist & Assessment by the RPN Last oral intake Vital signs (BP, P, R) Cardiac rhythm Weight Allergies Reactions to previous anesthesia and/or sedation agents Oxygen saturation If baseline O2<92%, administer supplemental oxygen

40 Preprocedural Sedation Checklist & Assessment Comfort/anxiety level according to: Pain Scale 0-10 (Faces Pain Rating Scale-Pediatrics) Modified Ramsay Score (MRS) Pregnancy status If positive, or unknown, collaborate with provider, avoid category D drugs, consider rescheduling If unknown, urine testing Universal protocol to include preprocedural check, site marking and time out verification Exposure to infectious disease and the need for isolation procedures

41 Preprocedural Sedation Checklist & Assessment Delay procedure if any items on checklist are not completed. All items must be reviewed and documented on the Preprocedural Checklist and Assessment prior to start of procedure involving procedural sedation.

42 Universal Protocol

43 Universal Protocol Immediately prior to start of procedure, all practitioners involved in the procedure must take a timeout and stop to verify: Correct patient Correct procedure Correct site Correct equipment Correct positioning

44 Drug Administration

45 Drug Administration Prior to administration, initiate or verify IV access. Administer the prescribed drug according to guidelines. Maintain side rails up.

46 Drug Administration: Monitoring by the RPN Continuously monitor airway, respiratory status, head position, color, and pain. document deviations Continuously monitor EKG rhythm, O2 saturation. document with vital sign intervals Repeat vital signs and MRS as follows: MRS 2: monitor BP,P,R q5 min x 2, then q 15 min until procedure is complete. MRS 3-4: monitor BP,P,R q5 min until procedure is complete and patient and patient achieves a MRS or 2 (or baseline).

47 Post-Procedure

48 Post-Procedure Monitor the following once MRS 2 or baseline: Vital signs q15 min until recovery criteria met. The post anesthesia score (Aldrete) and pain scale at end of procedure, then in 15 min. Repeat Aldrete score at discharge. Reassess as condition/procedure warrants or for a deteriorating LOC/VS.

49 Potential Complications

50 Potential Complications Monitor for the following complications and notify credentialed practitioner: O2 saturation<92% Respiratory Depression/Apnea Symptomatic Bradycardia Particularly with Fentanyl Hypotension Cardiac Arrest/ Hemodynamic Instability/ Dysrhythmia

51 Potential Complications: Interventions O2 saturation<92% Stimulate patient and instruct to take deep breaths. If no response, administer or increase supplemental O2 as indicated.

52 Potential Complications: Interventions Respiratory Depression/Apnea Instruct/coach patient to breathe frequently. Administer O2 via face mask. Consider assisted ventilations. Administer reversal agents: For narcotics: naloxone- titrate until desired result achieved (see guidelines) For benzodiazepines: flumazenil (see guidelines) Call anesthesia stat (911). Specify if pediatric patient. Prepare for intubation.

53 Potential Complications: Interventions Symptomatic Bradycardia Administer atropine as follows: Adults: 0.5mg IVP q 5 min, not to exceed 3 mg or 0.04 mg/kg Neonate: 0.01 mg/kg, may repeat x 1 Children: 0.02 mg/kg or minimum 0.1 mg up to 0.5 mg Adolescent: 0.02 mg/kg up to 1 mg

54 Potential Complications: Interventions Hypotension Administer fluid challenge per credentialed practitioner.

55 Potential Complications: Interventions Cardiac Arrest/ Hemodynamic Instability/ Dysrhythmia Activate Code Blue (911) Initiate CPR

56 Patient and Family Education

57 Patient and Family Education Instruct patient and SO of the following: Purpose of sedation/analgesic therapy Short-term effects and precautions of specific drugs Restrictions on driving/operating machinery Pediatric restrictions (see pediatric procedural sedation information tool) No alcohol for 24 hours Discharge home under supervision of a responsible adult who will provide transportation Notify primary physician/ed if patient becomes drowsy/lethargic or change in mental status after 2h post recovery (provide 24 hour emergency contact) Medications received and effect on breastmilk, if applicable

58 Recovery Criteria and Discharge/ Transfer

59 Recovery Criteria Patient is considered recovered when returned to presedation state including: Airway management Stable vital signs MRS/ Pain score Post Anesthesia Score (Aldrete) >/= 9 All patients who receive reversal agents must be monitored for at least 2 hours after final administration of any reversal agent.

60 Discharge/ Transfer to Another Nursing Unit Patient may be transferred when recovery criteria have been met. If recovery criteria are not met, the accepting nursing unit must provide the same level of care as outlined by this protocol. This requires RN transport Collaborate with accepting RN regarding transfer and report including hand-off communication.

61 Discharge to Home Evaluate for discharge to home when patient achieves the recovery criteria and is able to: Ambulate with minimal assistance Tolerate po fluids (adults >/= ml/ children >/=25-50ml) Be accompanied by a responsible adult Patient/SO can validate knowledge of written instructions and prescriptions Aldrete=10 or pre-procedural baseline

62 Documentation

63 Documentation: Preprocedural Checklist and Assessment Completed by sedation monitor (RN) Validate H&P available Validate reassessment of pt s current health status Written informed consent Plan for sedation Allergies and/or reaction to previous anesthesia or sedation NPO status Pregnancy status VS, MRS score, pain score, O2 saturation Universal protocol including preprocedural check, site marking

64 Documentation: Procedural Sedation Prescribing Evaluation Completed by sedation prescriber Review of current H&P or completion of Procedural Sedation H&P Reevaluation of the patient s current physical status Mallampatti/ ASA Sedation orders

65 Documentation: Procedural Sedation Record Time Out-verification of correct patient, procedure site/side, equipment and positioning Assessment data, including VS, EKG rhythm, MRS score, pain scale, O2 sat, and Aldrete score Medications (including route, site, time, drug and dose) and oxygen therapy Changes in airway, EKG or pain in narrative note Evaluation of effectiveness of care in relation to presence of adverse reaction, and patient comfort Procedure site bleeding and dressing status Discharge criteria met/discharge time, or transfer time, transfer location and plan (name of responsible party)

66 Medication Guidelines: Moderate Sedation

67 Opioids

68 Opioids Central nervous system agents that work as agonists at opioid receptors Include: Morphine Hydromorphone (Dilaudid) Meperidine (Demerol) Fentanyl

69 Opioids Beneficial Effects: Analgesia Sedation Euphoria Cough suppression (except meperidine)

70 Opioids Adverse Effects: Decreased respiratory rate, apnea Potential increase in CO2, potential decrease in O2 Bradycardia (with morphine and fentanyl) Vasodilation Hypotension or orthostatic changes Nausea & vomiting Decreased GI motility Spasm of sphincter of Oddi & increased bile duct pressure Dizziness Pruritis Urticaria & skin rashes True allergic reactions are uncommon

71 Opioids Potency: Meperidine is approximately 1/10 as potent as morphine. Hydromorphone is approximately 10 times as potent as morphine. Fentanyl is approximately 100 times as potent as morphine.

72 Opioids Drug Interactions: Increased risk for respiratory depression and apnea when combined with other sedatives. Phenothiazines, tricyclic antidepressants, and CNS depressants may potentiate therapeutic and adverse effects of opiods. Consider dose reduction in these cases.

73 Opioids Special considerations: Elderly patients May be more sensitive & may require lower doses. Decreased renal & hepatic elimination. Increased volume of distribution for fat-soluble drugs leading to longer duration of action. Pediatric patients Very young children have immature blood-brain barrier and altered pharmacokinetics (use with caution <6 mos).

74 Opioids Special considerations (cont): Fentanyl At equianalgesic doses, ventilatory depression, nausea, sedation, and pruritis are equivalent to morphine. Chest wall and glottic rigidity (more likely with higher doses and/or rapid IV administration) may make manual ventilation difficult or impossible is unconsciousness ensues. Meperidine Use cautiously in pts with renal or hepatic impairment. Minimize doses in pts at risk for neurotoxic effects of metabolite normeperidine (pt with sickle cell anemia, burns, or cancer). CNS manifestations. Avoid in pts with little cardiac reserve. DO NOT administer in patients taking MAO Inhibitors or who have taken one within previous two weeks.

75 Fentanyl (Sublimaze) Opiate for sedation In pediatric pts, only used for deep sedation Onset of action 1 ½ min Duration min Preparation: Dilute each ml of Fentanyl with 4 ml of saline to equal 10 mcg/ml Dose: Adults: 0.5 to 1 mcg/kg slow IVP Pediatrics: only for deep sedation Rate of infusion: Slow over at least 3-5 min Titration: Every 4 min, titrate to desired effect with doses of 1 mcg/kg or half the initial dose Reversal: Adults: Naloxone (Narcan) 0.1 mg IV q 2 min up to 2mg Pediatrics: Naloxone (Narcan) 0.1 mg/kg IV, may repeat q 2-3 min (max dose of 2 mg)

76 Morphine Opiate for sedation Onset of action: IV rapid 1-3 min Duration: 3-4 hours Preparation: May dilute in at least 5 ml of sterile water or saline, but not necessary Dose: Adults: 1-4 mg IV Pediatrics: mg/kg IVP (max of 4 mg) Rate of infusion: Slow over 3-5 minutes Titration: Every 5 min, titrate to desired effect with doses of 0.05 mg/kg (peds), 1-2 mg (adults) Reversal: Adults: Naloxone (Narcan) 0.1 mg IVP q 2 min to max of 2 mg Pediatrics: Naloxone (Narcan) 0.1 mg/kg IV, may repeat q 2-3 min. Max dose 2 mg

77 Meperidine (Demerol) Opiate for sedation Onset of action: IV rapid 1-3 min Duration: 1-3 hours Preparation: Dilute to concentration of 10 mg/ml with saline Dose: Adults: mg IV Pediatrics: 1-2 mg/kg IVP (max of 25 mg) Rate of infusion: slow over 3-5 min Titration: every 5 min, titrate to desired effect with doses of 1 mg/kg (Peds), 12.5 mg (adults) Reversal: Adults: Naloxone (Narcan) 0.1 mg IVP q 2 min to max of 2 mg Pediatrics: Naloxone (Narcan) 0.1 mg/kg IV, may repeat q 2-3 min. Max dose 2 mg

78 Benzodiazepines

79 Benzodiazepines Provide sedation and amnesia but no analgesia. Work at the GABA receptor. Include: Midazolam (Versed) Diazepam (Valium) Lorazepam (Ativan) Alprazolam (Xanax)

80 Benzodiazepines Beneficial Effects: Anxiolysis Sedation Amnesia Anticonvulsant

81 Benzodiazepines Adverse Effects: Dose-related central respiratory system depression and apnea. Hypotension & tachycardia (more often in elderly, severely ill pts, pt with unstable CV status). Drug Interactions: Effects are synergistic when administered with opioids or other CNS depressants.

82 Benzodiazepines Potency: Midazolam is approximately 3-4 times as potent as diazepam (10 mg diazepam=2.5 or 3 mg midazolam). Lorazepam is approximately 5 times as potent as diazepam (10 mg diazepam=2 mg lorazepam).

83 Benzodiazepines Special Considerations: Elderly Patients May have an age-related increase in potency. Onset of full therapeutic effect may be delayed. Duration of action may be prolonged. Pregnancy Contraindicated due to risk of congenital malformations.

84 Benzodiazepines Special considerations (cont): Midazolam (Versed) Must be given slowly as rapid infusion may cause hypotension and respiratory depression. Diazepam injection Contains propylene glycol which is irritating to veins. Can cause pain, swelling, and thrombophlebitis, especially when administered in small veins. Lorazepam Can cause venous irritation and thrombophlebitis. Dilute with an equal volume of diluent (sterile water, D5W, or saline) for IV administration.

85 Midazolan Hcl (Versed) Benzodiazepine useful as hypnotic or amnesic (Not an analgesic) Onset of action: 1-2 min (dose/route dependent) Duration: min Preparation: can mix with morphine; undiluted intranasal route peds; 10 mg oral syringe available from pharmacy Dose: Adults: mg IV q 3-5 min Pediatrics: mg/kg po or mg/kg IV Intranasal: 0.2 mg/kg Rate of infusion: slow over 2-5 min Titration: titrate to desired effect Adults: mg IV q 3-5 min Pediatrics: mg IV q 3-5 min Reversal: Adults: Flumazenil (Romazicon) 0.2 mg IV q 1 min as needed to max dose of 1 mg Pediatrics: Flumazenil (Romazicon) 0.01 mg/kg IV q 1 min up to 1 mg Pt must be monitored for 2 hours after receiving flumazenil; flumazenil alone may not adequately reverse respiratory depression.

86 Barbiturates

87 Barbiturates Provide sedation but no analgesia. Depress the sensory cortex, decrease motor activity, alter cerebellar function, and produce dose dependant drowsiness, sedation and hypnosis. Thought to enhance action of GABA. Include: Pentobarbital (Nembutal) Methohexital (Brevital)

88 Barbiturates Beneficial Effects: Drowsiness Amnesia Adverse Effects: Respiratory depression, apnea Laryngospasm, bronchospasm Arrhythmias, compensatory tachycardia, occasional bradycardia Hypotension secondary to myocardial depression and peripheral vasodilatation Lethargy, CNS excitation or depression Twitching or myoclonus Methohexital may lower seizure threshold

89 Barbiturates Precautions: Use with caution in pts with hepatic or renal impairment, heart failure, or hypovolemia. Contraindicated in pts with porphyria. Do not infuse at greater than 50mg/min. Solutions are very alkaline and can damage tissue if extravasation occurs. Methohexital is contraindicated in epilepsy (lowers seizure threshold).

90 Other Agents

91 Chloral Hydrate Exact mechanism is unknown. Both chloral hydrate and active metabolite, trichlorethanol, have CNS depressant effects. Does not have any analgesic properties. Beneficial effect is sedation.

92 Chloral Hydrate Adverse effects: Increased risk of airway obstruction with enlarged tonsils or adenoids. Respiratory depression more likely with repeated or high doses, or when used in combination with opiods or benzodiazepines (may be delayed for 4 or more hours). Cardiac dysrhythmias may occur with underlying CV disease (risk is dose related). Ataxia, vertigo, dizziness. Confusion, disorientation, delirium, hallucinations, nightmares. Paradoxical agitation (more likely in children with developmental delays or neurological disorder). Vomiting, diarrhea.

93 Chloral Hydrate Special considerations: Efficacy reduced in children > 5 years old. Primary reason for failure of successful sedation is inadequate initial dose. Liquid form may irritate skin and mucous membranes. Oral form used with caution in pts with recent hx of gastritis, esophagitis, ulcer. Use with caution in pt with large tonsils/ adenoids, or other upper airway abnormalities. Use with extreme caution in pts with sleep disorders. Contraindicated in patients with porphyria.

94 Pediatric Uses of Chloral Hydrate Chloral Hydrate is used for procedural sedation of a child under 2 years of age Used for children undergoing MRI and CT Scan imaging who need to be still for a detailed, clear scan

95 As with any Procedural Sedation agent Physicians credentialed in deep sedation may order Chloral Hydrate for procedural sedation purposes Nurses who are credentialed in moderate (procedural sedation) may administer Chloral Hydrate for procedural sedation purposes Both the physician and nurse must have current Basic Life Support (BLS) certification as well as Pediatric Advanced Life Support (PALS)

96 Side Effects The most common side effect to be monitored for is respiratory depression. Assess for decrease in pulse oximetry, decreased respiratory rate and cyanosis. Patient could have an allergic reaction to the medication. Ask about known allergies prior to medication administration.

97 Prior to Medication Administration Patients must be NPO of food or formula 6 hours prior to sedation, NPO of breast milk 4 hours prior to sedation, NPO of Pedialyte 3 hours prior to sedation, and NPO of clear liquids 2 hours prior to sedation. The nurse must confirm the NPO status prior to administering medications. Validate that pulse oximetry, airway equipment, oxygen, ambu bag, suction equipment, blood pressure monitoring, emergency cart with defibrillator, and appropriate intravenous equipment are available, in working order and age appropriate for the patient Emergency procedures precaution for airway protection may include cricoid pressure

98 Prior to Procedure Continued A Licensed Independent Practioner (LIP) must obtain informed consent from the parent or legal guardian to administer the medication and a physician credentialed in deep sedation must complete a brief health history including allergies and conduct a physical exam of the patient. Aldrete Score (ASA) and Mallampati Airway Score must be assessed and documented by the credentialed practioner. Baseline vital signs including blood pressure, heart rate, pulse oximetry, respiratory rate, and weight must be documented prior to administration of any medication. A time out must be conducted prior to medication administration.

99 Administration of Chloral Hydrate Administer Chloral Hydrate per dosing order of 50mg/kg po for first dose followed by ½ the initial dose, or 25mg/kg, 20 minutes later if adequate results were not obtained from the first dose. Continuous monitoring of heart rate, pulse oximetry, and respiratory rate are to be documented every 5 minutes throughout the duration of the time the child is sedated. Childs color and airway patency are to be monitored throughout the sedation.

100 Post Sedation with Chloral Hydrate Patient must be monitored by credentialed nurse until the child wakes up, a parent cannot recover the child. Continuous monitoring of heart rate, pulse oximetry, and respiratory status including child's color until patient wakes up, is able to hold their head erect, open their eyes, and is at an Aldrete Score of 10.

101 Discharge Post Sedation Children should stay a minimum of 30 minutes post procedure or 60 minutes from the last incremental dose of chloral hydrate unless they meet the criteria early. Patient must be able to hold head erect, open eyes and tolerate oral intake prior to discharge. If the child is going home with a parent they are discharged with Procedural Sedation Discharge Instructions and also instructed not to leave the child unattended for the remainder of the day.

102 Key Information Chloral Hydrate can only be ordered by a physician credentialed in deep sedation and administered by a nurse credentialed in procedural sedation, a Licensed Independent Practioner (LIP) may get consent for the procedure. A physician must obtain informed consent for sedation from the parent or legal guardian and complete a brief history and physical prior to administration of the medication. Vital signs must be monitored throughout the sedation and the child must be monitored by the certified procedural sedation nurse until they fully wake up, can hold their head erect, open their eyes, and are at an Aldrete score of 10.

103 Ketamine (Ketalec) Short acting anesthesia agent. Pediatric use only. Onset of action 5-15 minutes. Duration minutes. Can mix with midazolam. Dose (peds only) up to 4 mg/kg IM. No reversal agent.

104 Ketamine (Ketalec) Effects of medication: Bronchodilation Profound sedation Analgesia Transelike/dissociation BP elevation Amnesia Vomiting Hypersalivation (verify Atropine avaliable) Nystagmus Frank deliriums Hallucinations upon awakening

105 Ketamine (Ketalec) Contraindications: Known hypersensitivity Hydrocephalus (r/o shunt failure) Head injury, increased ICP Symptomatic brain tumor Precautions: May need restraints for purposeless movement/ psychic reactions Porphyria

106 Nitrous Oxide (Self-Administered Inhalation) Anesthetic and sedative agent Onset of action 2 min Duration 2-4 min beyond administration Dose: 50% N2O; 50% O2 fixed delivery selfadministered via demand valve (supplemental O2 continued until oxygen saturation returns to baseline or minimum of 5 min) Titration: self-administered and titrated by pt Reversal: quick reversal of sedation (2-4 min) upon interruption of administration

107 Nitrous Oxide (Self-Administered Inhalation) Effects: CNS depression, analgesia Respiratory depression Dizziness, nausea Dysphoria Contraindications: Pneumothorax, air embolism Otitis media, sinusitis Perforated viscus Abdominal distention, bowel obstruction Decompression sickness Pregnancy Head injury, altered LOC, heavy sedation or intoxication

108 Nitrous Oxide (Self-Administered Inhalation) Precautions: Not to be used as a supplement to other procedural sedation agents (synergistic effects can lead to unanticipated length of sedation). Second gas effect shortly following interruption of administration. Patients with COPD may have suppression of hypoxic respiratory drive. Insure that patient s mask can freely fall from face.

109 Reversal Agents

110 Reversal Agents Naloxone (Narcan) An opioid antagonist. Binds to opioid receptors in the CNS and displaces the opioid agonists from the receptor. Dose: Adults: 0.1 mg IV q 2 min up to 2 mg Pediatrics: 0.1 mg/kg IV, may repeat q 2-3 min (max 2 mg) Flumazenil (Romazicon) A benzodiazepine antagonist. Binds to benzodiazepine receptors in the CNS and prohibits the benzodiazepines from exerting an effect. Dose: Adults: 0.2 mg IV q 1 min to max dose 1 mg Pediatrics: 0.01 mg/kg IV q 1 min to max dose 1 mg

111 Naloxone (Narcan) Benefits: Reversal of respiratory depression and sedation. Adverse effects: Will potentially reverse analgesia (can lead to tachycardia and hypertension). Nausea and vomiting. Cardiac irritability, dysrhythmias. Pulmonary edema. Precipitation of withdrawal syndrome in patients who are dependent on opioids.

112 Naloxone (Narcan) Precautions: Repeated dosing may be necessary because the half life of naloxone can be as short as 30 minutes, while the half life of opioids may be 4-6 hours. When initial dose of naloxone dissipates, the patient may again be overnarcotized, requiring another dose of naloxone. This effect can be minimized when the reversal agent is titrated and given in incremental doses.

113 Flumazenil (Romazicon) Beneficial Effects: Reversal of sedation Reversal of amnesia Reversal of respiratory depression Reversal of paradoxical reactions Adverse Effects: Anxiety, tremors, headache Nausea

114 Flumazenil (Romazicon) Precautions: Reversal of benzodiazepines may lead to seizures in high-risk patients Underlying seizure disorder Physically dependent on benzodiazepines Repeated dosing may be necessary because the half life of flumazenil can be as short as 45 minutes, while the half life of benzodiazepines may be greater than 12 hrs. This effect can be minimized when the reversal agent is titrated and given in incremental doses.

115 RN Credentialing Process Complete the post test (93% is required) Clinical competency demonstration