CONTINUING EDUCATION Effectiveness of Transmucosal Sedation for Special Needs Populations in the Ambulatory Care Setting

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1 CONTINUING EDUCATION Effectiveess of Trasmucosal Sedatio for Special Needs Populatios i the Ambulatory Care Settig SUE TETEF, MSN, RN, CPAN Cotiuig Educatio Cotact Hours idicates that cotiuig educatio (CE) cotact hours are available for this activity. Ear the CE cotact hours by readig this article, reviewig the purpose/goal ad objectives, ad completig the olie Examiatio ad Learer Evaluatio at A score of 70% correct o the examiatio is required for credit. Participats receive feedback o icorrect aswers. Each applicat who successfully completes this program ca immediately prit a certificate of completio. Evet: #14547 Sessio: #0001 Fee: Members $28, Nomembers $56 The cotact hours for this article expire December 31, Pricig is subject to chage. Purpose/Goal To provide the learer with kowledge specific to providig perioperative care for patiets receivig sedatio medicatios via the trasmucosal route of admiistratio. Objectives 1. Discuss the use of procedural sedatio medicatios. 2. Discuss the perioperative urse s role i procedural sedatio. 3. Describe the use of trasmucosal dexmedetomidie for procedural sedatio. 4. Discuss the use of trasmucosal midazolam for procedural sedatio. 5. Idetify medicatios used to couteract the effects of overdose after admiistratio of sedatio medicatios. Accreditatio AORN is accredited as a provider of cotiuig ursig educatio by the America Nurses Credetialig Ceter s Commissio o Accreditatio. Approvals This program meets criteria for CNOR ad CRNFA recertificatio, as well as other CE requiremets. AORN is provider-approved by the Califoria Board of Registered Nursig, Provider Number CEP Check with your state board of ursig for acceptace of this activity for relicesure. Coflict of Iterest Disclosures Ms Tetef has o declared affiliatio that could be perceived as posig a potetial coflict of iterest i the publicatio of this article. The behavioral objectives for this program were created by Rebecca Holm, MSN, RN, CNOR, cliical editor, with cosultatio from Susa Bakewell, MS, RN-BC, director, Perioperative Educatio. Ms Holm ad Ms Bakewell have o declared affiliatios that could be perceived as posig potetial coflicts of iterest i the publicatio of this article. Sposorship or Commercial Support No sposorship or commercial support was received for this article. Disclaimer AORN recogizes these activities as CE for RNs. This recogitio does ot imply that AORN or the America Nurses Credetialig Ceter approves or edorses products metioed i the activity. Ó AORN, Ic, 2014 December 2014 Vol 100 No 6 AORN Joural j 651

2 Effectiveess of Trasmucosal Sedatio for Special Needs Populatios i the Ambulatory Care Settig SUE TETEF, MSN, RN, CPAN 3.5 ABSTRACT Trasmucosal is a alterative route for admiisterig medicatios (ie, dexmedetomidie, midazolam, aloxoe) that ca be effective for procedural or moderate sedatio i patiets with special eeds whe other routes are ot practical or are cotraidicated. Special eeds populatios iclude childre, older adults, pregat ad breast-feedig wome, ad people with disabilities or coditios that limit their ability to fuctio ad cope. Uderstadig the perioperative urse s role i the care of patiets receivig medicatios via the trasmucosal route ca lead to better cliical outcomes. Successful use of the trasmucosal route requires kowledge of whe to admiister a medicatio, how ofte ad how much of a medicatio should be admiistered, the oset ad duratio of actio, the adverse effects or cotraidicatios, ad the key beefits. I additio, a case study approach suggests that trasmucosal sedatio ca decrease patiet stress ad axiety related to udergoig medical procedures or surgery i the ambulatory care settig. AORN J 100 (December 2014) Ó AORN, Ic, Key words: trasmucosal, itraasal, dexmedetomidie, midazolam, aloxoe, pediatric, moderate sedatio, procedural sedatio, case studies, special eeds populatios, patiets with special eeds, ambulatory care settig. The umber of oivasive ad miimally ivasive procedures performed outside the OR has grow expoetially durig the past decades. 1 Sedatio may be eeded preoperatively ad for itervetioal or diagostic procedures. Maagig the care of patiets with special eeds who require sedatio for a medical procedure or surgery cotiues to be a challege for health care providers. Special eeds populatios iclude childre, older adults, pregat ad breast-feedig wome, ad people with disabilities or coditios that limit their ability to fuctio ad cope. Cliicias eed to cotiually idetify ad maage barriers to providig care whe a patiet with special eeds requires sedatio. Patiets with special eeds may require additioal emotioal j AORN Joural December 2014 Vol 100 No 6 Ó AORN, Ic, 2014

3 EFFECTIVENESS OF TRANSMUCOSAL SEDATION support ad specialized care. Performig ivasive procedures i a ambulatory settig may decrease patiet stress ad axiety. The ambulatory settig ca offer flexibility because it is ot limited to the ipatiet settig, provide less ivasive ad effective sedatio for patiets with special eeds, ad facilitate positive patiet outcomes ad positive patiet experieces. The admiistratio of procedural sedatio medicatios results i a depressed level of cosciousess that allows the patiet to idepedetly maitai oxygeatio ad airway cotrol. 1 Trasmucosal is a alterative route to itramuscular (IM), IV, ad oral admiistratio to achieve sedatio ad ca be admiistered to a variety of age groups ad patiet populatios. Admiisterig medicatios via the trasmucosal route provides the patiet with sedatio without icurrig the pai of a IM ijectio, allows medicatio admiistratio to occur without a IV, ad allows medicatio admiistratio to occur whe the patiet is required to remai NPO. Therefore, trasmucosal medicatios decrease patiet axiety ad discomfort ad allow patiets to receive ecessary care. Uderstadig the efficacy ad safety of trasmucosally admiistered medicatios is essetial to the cliicia beig able to perform procedures requirig procedural or moderate sedatio. Trasmucosal medicatios are effective for procedural sedatio. However, trasmucosal admiistratio of medicatios for sedatio has decreased effects i a patiet with epistaxis (ie, osebleed), 2 with high mucous productio i the asal cavity, 2 or who forcefully expels (ie, sorts out) the medicatio. As with other medicatios, special cosideratios are required for trasmucosal sedatio i youg childre, older adults, ad wome who are pregat or breast-feedig. Special cosideratios for patiets with special eeds iclude lower medicatio doses, fewer doses, decreased or delayed medicatio metabolism, ad differig oset of actio. Although trasmucosal medicatios have similar side effects whe admiistered via the IV or IM routes, the efficacy depeds o the patiet s compliace whe siffig ad the coditio of the asal cavity. Medicatios delivered trasmucosally are ot diluted ad are admiistered by usig a syrige with a itraasal mucosal atomizatio device (MAD Nasal TM ). The oset of actio ad duratio of medicatios admiistered trasmucosally are similar to IV ad IM medicatio admiistratio. Cliicias should follow trasmucosal medicatio delivery guidelies: Admiister doses ragig from 0.25 ml to 0.3 ml per ostril to reduce ruoff. Divide doses equally betwee each ostril, with a maximum of 0.5 ml i each ostril at oe time. 2 Allow 5 to 10 miutes betwee doses if more tha 1 ml is eeded to icrease absorptio. Use the most cocetrated ad lowest volume of the medicatio available. 2 CARING FOR PATIENTS RECEIVING MEDICATIONS FOR SEDATION The urse works i collaboratio with the physicia or aesthesia professioal. I additio, to be qualified to admiister medicatios for sedatio, the urse must have advaced cardiac life support (ACLS) certificatio if workig with adult patiet populatios ad pediatric advaced life support (PALS) certificatio if workig with pediatric populatios, attai ad maitai competecy i moderate or procedural sedatio, be proficiet i airway maagemet ad cardiovascular support, ad possess the skills required to rescue a patiet from uiteded deep sedatio if ecessary. AORN Joural j 653

4 December 2014 Vol 100 No 6 TETEF Perioperative urses should moitor the patiet accordig to facility policies ad procedures, to iclude verifyig that the patiet or guardia ad surgeo have completed the iformed coset process ad siged the coset form; esurig that a curret history ad physical examiatio are i the patiet s medical record; ascertaiig the patiet s NPO status; moitorig the patiet s vital sigs before, durig, ad after the procedure; moitorig the patiet s pulse oximetry cotiuously; applyig oxyge ad suctioig as eeded; moitorig the patiet s airway patecy ad respiratory status; moitorig ad documetig the patiet s sedatio level; esurig that reversal agets are available; ad adherig to ACLS or PALS guidelies for emerget medical treatmet. UNDERSTANDING TRANSMUCOSAL MEDICATION DELIVERY The beefits of usig trasmucosal medicatios for patiets with special eeds are that cliicias ca admiister the medicatios without a IV, if the patiet refuses a IV, ad with a simple siffig actio by the patiet. This decreases stress ad axiety i the patiet ad his or her family members ad allows health care providers to provide care that would otherwise ot be performed or would be ucomfortable or difficult for the patiet. Trasmucosal Dexmedetomidie Dexmedetomidie is a alpha2-adreoceptor agoist ad is idicated for sedatio because it decreases sympathetic ervous system activity 3 ad ca be used for patiets of all ages. However, cliicias should idividualize dosig ad itervals depedig o the idicatio for ad legth of the procedure to be performed ad should titrate the medicatio to the desired cliical effect. The recommeded dose of trasmucosal dexmedetomidie is 4 mcg/kg. 2 Table 1 provides a outlie of recommeded doses based o the patiet s weight ad accoutig for dead space (ie, the small amout of solutio remaiig i the syrige whe the pluger is fully depressed). To determie the volume to be admiistered, multiply the patiet s weight i kilograms by the recommeded dose (4 mcg/kg), divide by the medicatio cocetratio (100 mcg/ml), add 0.1 ml to accout for dead space, ad roud up to the ext highest 0.1 ml. For example, if a patiet weighs 10 kg, the correct volume to admiister would be calculated as follows: 10 kg 4 mcg=kg ¼ 40 mcg O 100 mcg=ml ¼ 0:4mL þ 0:1mL ¼ 0:5 ml total volume Half of the dose should be admiistered i each ostril. Volumes greater tha or equal to 2 ml should be divided ad admiistered 5 to 10 miutes apart to allow for absorptio ad to reduce ruoff. TABLE 1. Trasmucosal Dexmedetomidie 1 Patiet weight Dose (4 mcg/kg) Volume (100 mcg/ml þ 0.1 ml) 3 kg to 5 kg 20 mcg 0.2 ml þ 0.1 ml 6 kg to 10 kg 40 mcg 0.4 ml þ 0.1 ml 11 kg to 15 kg 60 mcg 0.6 ml þ 0.1 ml 16 kg to 20 kg 80 mcg 0.8 ml þ 0.1 ml 21 kg to 25 kg 100 mcg 1.0 ml þ 0.1 ml 26 kg to 30 kg 120 mcg 1.2 ml þ 0.1 ml 31 kg to 35 kg 140 mcg 1.4 ml þ 0.1 ml 36 kg to 40 kg 160 mcg 1.6 ml þ 0.1 ml 41 kg to 45 kg 180 mcg 1.8 ml þ 0.1 ml 46 kg to 50 kg 200 mcg 2.0 ml þ 0.1 ml 51 kg to 55 kg 220 mcg 2.2 ml þ 0.1 ml 56 kg to 60 kg 240 mcg 2.4 ml þ 0.1 ml 61 kg to 70 kg 280 mcg 2.8 ml þ 0.1 ml 71 kg to 80 kg 320 mcg 3.2 ml þ 0.1 ml 81 kg to 90 kg 360 mcg 3.6 ml þ 0.1 ml 91 kg to 100 kg 400 mcg 4.0 ml þ 0.1 ml 1. Itraasal medicatio admiistratio. I: Pharmaceutical Departmet Maual Policy. Valecia, CA: Hery Mayo Newhall Memorial Hospital; j AORN Joural

5 EFFECTIVENESS OF TRANSMUCOSAL SEDATION The patiet should be moitored cotiuously for respiratory depressio. Cautios ad cotraidicatios. Cliicias should exercise cautio whe admiisterig dexmedetomidie to pediatric patiets, older adults, ad pregat ad breast-feedig wome. Because dexmedetomidie decreases sympathetic ervous system activity, hypotesio or bradycardia may be expected to be more proouced i older adult patiets ad patiets with hypovolemia, diabetes, or chroic hypertesio. 3,4 Dexmedetomidie clearace (eg, the rate that the medicatio is excreted from the body) decreases with icreased hepatic impairmet 3 ; therefore, a dose reductio should be cosidered i patiets with impaired hepatic fuctio. 3,4 Cautio should be used whe admiisterig medicatios to older adults because of their delayed medicatio metabolism ad potetial comorbidities. Cautio also should be used i pediatric patiets because they have a lower body mass ad are susceptible to hypotesio. Hypotesio ad bradycardia should be avoided i pregat patiets to prevet a decrease i blood flow to the fetus. Oset ad duratio. The oset of actio of trasmucosal dexmedetomidie is 20 miutes. 3 The duratio of trasmucosal dexmedetomidie is oe hour. Therefore, to avoid oversedatio ad prevet the potetial for a icreased icidece of adverse effects, cliicias should wait at least 20 miutes before determiig the extet of each required dosage modificatio. The cliicia should exercise cautio to prevet oversedatio, particularly because there is o reversal medicatio for dexmedetomidie. Patiets receivig trasmucosal dexmedetomidie are sedated but arousable to tactile stimuli, which is a ormal respose with dexmedetomidie ad does ot mea the medicatio is ieffective. 5 As with other medicatios admiistered trasmucosally, dexmedetomidie is less effective if the patiet asally expels some or all of the medicatio. Adverse effects. Commo adverse effects of trasmucosal delivery of dexmedetomidie are similar to those of IM ad IV routes of admiistratio. These iclude bradycardia, hypotesio, ad dry mouth 3 ; i additio, sius arrests have bee associated with dexmedetomidie admiistratio. 3,4 I cliical studies, adverse effects of dexmedetomidie have icluded a decrease i heart rate (7%); decreases i systolic blood pressure (SBP) ad diastolic blood pressure (DBP) of 10% ad 11%, respectively; ad hypovetilatio. 3 Hypotesio is defied as a SBP of less tha 80 mmhg ad a DBP of less tha 50 mmhg or greater tha or equal to 30% of baselie. Bradycardia is defied as a heart rate of less tha 40 beats per miute or greater tha or equal to 30% of baselie. 3 Cautio should be used whe determiig whether trasmucosal dexmedetomidie is suitable for patiets with advaced heart block ad severe vetricular dysfuctio. 3 Cocurret admiistratio of other aesthetics, sedatives, hypotics, ad opioids with dexmedetomidie, midazolam, ad fetayl are more likely to lead to potetiated effects. 4,6 Hypotesio ad bradycardia occur most commoly whe the preoperative urse admiisters trasmucosal dexmedetomidie i the preoperative uit ad the aesthesia professioal admiisters additioal IV dexmedetomidie durig the surgical procedure. Cliicias ca treat hypotesio ad asymptomatic bradycardia with IV fluids whe trasmucosal ad IV dexmedetomidie are admiistered together; if eeded, they ca admiister atropie to treat symptomatic bradycardia after IV admiistratio of dexmedetomidie. The effects of dexmedetomidie ca be reversed with the alpha2-adreergic atagoist atipamezole. 7 Cliicias should adhere to ACLS ad PALS guidelies for emerget medical treatmet. Beefits. I additio to the beefits of sedatio for a surgical procedure, a extra beefit AORN Joural j 655

6 December 2014 Vol 100 No 6 TETEF of dexmedetomidie is less postoperative opioid use. Dexmedetomidie ca be admiistered trasmucosally durig the preoperative phase, ad the aesthesia professioal ca admiister additioal IV doses itraoperatively if ecessary. Patiets who receive dexmedetomidie preoperatively ad/or itraoperatively have bee show to require less opioids postoperatively. I a cliical study, oly 28% of patiets who received dexmedetomidie required morphie to maage postoperative pai versus 63% of patiets who were give propofol. 8 Patiets who received trasmucosal dexmedetomidie required sigificatly lower doses of fetayl to maitai adequate aalgesia. 8 Trasmucosal Midazolam Midazolam is a bezodiazepie that is effective for sedatio, axiety, ad seizures but ot for aalgesia. 2 Midazolam ca be admiistered trasmucosally or via IM or IV routes. 9 Midazolam ca be admiistered before diagostic, therapeutic, edoscopic, or surgical procedures. As outlied i Table 2, the recommeded doses of midazolam are determied accordig to the patiet s weight ad purpose of the medicatio. The recommeded doses for trasmucosal midazolam may be geeralized as follows: 0.2 mg/kg for seizures i adults weighig more tha 50 kg or i childre (ie, a maximum dose of 10 mg); 0.3 mg/kg for sedatio of patiets before udergoig mior, opaiful procedures (eg, radiographic imagig); ad 0.5 mg/kg for sedatio of patiets before udergoig paiful procedures (eg, laceratio repair). 2 To determie the total volume, add 0.1 ml to accout for dead space. The, roud up to the ext highest 0.1 ml. For example, if a patiet weighs 20 kg ad is udergoig sedatio for a paiful procedure, the correct dosage would be calculated as follows: 20 kg 0:5mg=kg ¼ 10 mg O 5mg=mL ¼ 2mLþ 0:1mL ¼ 2:1 ml total volume TABLE 2. Trasmucosal Midazolam (5 mg/ml) 1 Age (years) Patiet weight Seizures (0.2 mg/kg) Nopaiful procedure (0.3 mg/kg) Paiful procedure (0.5 mg/kg) Dose Volume Dose Volume Dose Volume Neoate 3.0 kg 0.6 mg 0.3 ml 0.9 mg 0.3 ml 1.5 mg 0.4 ml < kg 1.2 mg 0.4 ml 1.8 mg 0.5 ml 3.0 mg 0.7 ml 1 10 kg 2.0 mg 0.5 ml 3.0 mg 0.7 ml 5.0 mg 1.1 ml 2 14 kg 2.8 mg 0.7 ml 4.2 mg 1.0 ml 7.0 mg 1.5 ml 3 16 kg 3.2 mg 0.8 ml 4.8 mg 1.1 ml 8.0 mg 1.7 ml 4 18 kg 3.6 mg 0.9 ml 5.4 mg 1.2 ml 9.0 mg 1.9 ml 5 20 kg 4.0 mg 1.0 ml 6.0 mg 1.3 ml 10.0 mg 2.1 ml 6 22 kg 4.4 mg 1.0 ml 6.6 mg 1.5 ml 11.0 mg 2.3 ml 7 24 kg 4.8 mg 1.1 ml 7.2 mg 1.6 ml 12.0 mg 2.5 ml 8 26 kg 5.2 mg 1.2 ml 7.8 mg 1.7 ml 13.0 mg 2.7 ml 9 28 kg 5.6 mg 1.3 ml 8.4 mg 1.8 ml 14.0 mg 2.9 ml kg 6.0 mg 1.4 ml 9.0 mg 1.9 ml 15.0 mg 3.1 ml kg 6.4 mg 1.4 ml 9.6 mg 2.1 ml 16.0 mg 3.3 ml kg 6.8 mg 1.5 ml 10.2 mg 2.2 ml 17.0 mg 3.5 ml Small teeager 40 kg 8.0 mg 1.8 ml 12.0 mg 2.5 ml 20.0 mg 4.1 ml Adult or full-grow teeager 50 kg 10 mg 2.0 ml 15.0 mg 3.1 ml 25.0 mg 5.1 ml 1. Itraasal medicatio admiistratio. I: Pharmaceutical Departmet Maual Policy. Valecia, CA: Hery Mayo Newhall Memorial Hospital; j AORN Joural

7 EFFECTIVENESS OF TRANSMUCOSAL SEDATION Volumes greater tha or equal to 2 ml should be divided i half ad admiistered 5 to 10 miutes apart to allow for absorptio ad reduce ruoff. Half of the dose should be admiistered i each ostril. The patiet should be moitored cotiuously for respiratory depressio. Cautios ad cotraidicatios. Cliicias should iform patiets ad their family members that trasmucosal midazolam may cause a burig sesatio that lasts for 30 to 45 secods after admiistratio. 2 For example, parets should be iformed that trasmucosal midazolam may cause their child to cry iitially. Oset ad duratio. The oset of actio of trasmucosal midazolam is less tha 10 miutes. Cliicias should wait after each dose to determie the extet of each dosage modificatio, avoid oversedatio, ad prevet the potetial for a icreased icidece of adverse reactios. I healthy voluteers, the elimiatio half-life of midazolam is betwee 1.5 to 2.5 hours. 10 Adverse effects. The adverse effects of trasmucosal midazolam are similar to those of bezodiazepies admiistered via other routes, ad primarily iclude cardiorespiratory depressio. 1,6 Respiratory depressio or hypotesio also may occur with trasmucosal midazolam, particularly whe admiistered with opioids; therefore, a decreased dose of trasmucosal midazolam is required whe admiisterig midazolam with opioids. Flumazeil should be admiistered by IV if eeded to reverse excessive sedatio after trasmucosal admiistratio of midazolam. Cliicias should adhere to ACLS ad PALS guidelies for emerget medical treatmet. Beefits. The beefits of givig trasmucosal medicatios are the same for midazolam as for dexmedetimodie. The primary differece is that midazolam causes a short, burig sesatio after admiistratio. I additio to the beefits of sedatio for a surgical procedure, a extra beefit of midazolam is amesia. The patiet does ot remember eterig the OR suite, the procedure, ay postoperative discomfort, or other evets, which helps icrease patiet satisfactio. Trasmucosal Naloxoe Opioids are commoly admiistered i additio to other aesthetics for sedatio. Naloxoe is a opioid atagoist that is used to treat opiate overdose or oversedatio; it is ot a reversal medicatio for dexmedetomidie. Naloxoe reverses the effects of opioids, icludig respiratory depressio, sedatio, ad hypotesio. Naloxoe ca be admiistered via IV or trasmucosal routes (Table 3). The recommeded trasmucosal dose of aloxoe is 2 mg (2 ml) for all patiets because dosig is ot TABLE 3. Use of Naloxoe (1 mg/ml) to Treat Opiate Overdose Procedure 1. Assess the patiet s ABCs: airway, breathig, ad circulatio. 2. For patiets who are pulseless, proceed to advaced cardiac life support (ACLS) guidelies. 3. For patiets who are apeic but have a pulse, establish a oral airway ad begi bag vetilatio with 100% oxyge. 4. Load a syrige with 2 mg (2 ml) of aloxoe ad attach to the asal mucosal atomizatio device (MAD Nasal TM ). 5. Place the atomizer i the patiet s ostril. 6. Briskly compress the pluger ito the syrige to admiister 1 ml of atomized spray. 7. Remove ad repeat i the other ostril for full admiistratio of 2 ml (2 mg) of the medicatio. 8. Cotiue vetilatig the patiet as eeded. 9. If o arousal occurs after 5 to 10 miutes, proceed with the stadard ucoscious protocol, icludig ijectable aloxoe, ad secure the airway if ecessary. MAD Nasal is a trademark of Teleflex Icorporated or its affiliates, Philadelphia, PA. AORN Joural j 657

8 December 2014 Vol 100 No 6 TETEF based o weight. 2 The cliicia s goal is to maitai the patiet s airway ad spotaeous breathig but ot to achieve full arousal. 2 It is importat that cliicias be patiet. Most failures of ihaled aloxoe are because cliicias expect the patiet to istatly arouse. Ihaled aloxoe results i breathig but ot full arousal i every case. Oset ad duratio. The oset of actio of trasmucosal aloxoe is three to five miutes to become effective, which is similar to that of IV aloxoe. 2 The half-life of aloxoe is 30 to 81 miutes. 11 To avoid oversedatio, cliicias should assess the patiet s airway, breathig, ad circulatio ad should cotiue to observe the patiet for resedatio for two hours because the half-life of aloxoe is less tha that of most opioids. Adverse effects. Adverse effects iclude agitatio, ausea, vomitig, pulmoary edema, hypotesio, cardiac arrhythmias, ad seizures. 11 Cliicias should adhere to ACLS ad PALS guidelies for emerget medical treatmet as well as the facility s policy ad procedure for admiistratio of aloxoe. TRANSMUCOSAL SEDATION: FOUR CASE SCENARIOS The followig case scearios occurred i a ambulatory care settig. The patiets were selected for trasmucosal admiistratio of medicatios for sedatio because they had special eeds that preseted barriers to providig ecessary preoperative care. The RNs i the case scearios have ACLS ad PALS certificatios, have extesive traiig i the preoperative ad postaesthesia care uit (PACU) settigs, ad have demostrated competecy with moderate or procedural sedatio. After performig the preoperative ursig assessmet, the perioperative urse writes a ursig care pla specific to the patiet receivig trasmucosal medicatios for sedatio before surgery or a procedure (Table 4). The urses cotiuously moitor the patiets whe admiisterig medicatios trasmucosally ad provide oe-o-oe ursig care util released to OR persoel or util the patiets have met discharge criteria. The perioperative urses follow the facility s policy ad procedures (Figure 1) as well as the America Society of PeriAesthesia Nurses (ASPAN) stadards of care. As outlied i Table 5, each case sceario icludes the age, sex, ad cliical or special eeds of the patiet; the trasmucosal medicatios admiistered; ad the effect of the medicatios o the patiet s vital sigs ad legth of stay. Case 1 Sam, a four-year-old boy, is admitted for surgical removal of tosils ad adeoids. He weighs 13 kg. Sam is a cadidate for trasmucosal medicatios because of his age ad axiety level. The patiet s parets ad gradparets are preset. The preoperative urse cofirms that Sam has remaied NPO for the recommeded time ad gives the parets writte iformatio regardig the pla for sedatio. Sam is sittig i a reclier i his mother s lap ad is cryig. The preoperative urse is uable to attai accurate preoperative vital sigs. The urse admiisters 50 mcg of trasmucosal dexmedetomidie via a MAD Nasal device. Despite the fact that Sam is ucooperative, all the medicatio is admiistered trasmucosally without ruoff or the patiet asally expellig the medicatio. After 25 miutes, the patiet is asleep ad the preoperative urse is able to obtai vital sigs ad istitute cotiuous moitorig. Sam remais asleep while the urse applies moitors; however, he starts cryig whe the IV is started. The urse documets these observatios but uderstads that Sam s respose does ot mea that the dexmedetomidie is ieffective. After the IV isertio procedure is complete, Sam returs to sleep. Sam s SBP goes from 128 mmhg while he is cryig o admissio to 73 mmhg while he is asleep after the admiistratio of dexmedetomidie; however, while asleep, he remais arousable to tactile stimuli. The urse starts a IV of lactated Riger solutio ad admiisters a 100-mL bolus. Sam s SBP icreases to 100 mmhg after the 658 j AORN Joural

9 EFFECTIVENESS OF TRANSMUCOSAL SEDATION TABLE 4. Nursig Care Pla for a Patiet Receivig Trasmucosal Medicatios for Sedatio Before Surgery or Other Procedure Diagosis Nursig itervetios Iterim outcome statemet Outcome statemet Ieffective family therapeutic regime maagemet Verifies allergies. Idetifies psychosocial status. Assesses psychosocial issues specific to the patiet s medicatio maagemet. Icludes patiet or desigated support perso i perioperative teachig. Provides istructio about prescribed medicatios. Evaluates respose to istructios. The patiet, family members, desigated support perso, or legal guardia verbalizes realistic expectatios regardig the effect of medicatios o postoperative recovery before discharge. The patiet or desigated support perso demostrates kowledge of medicatio maagemet. Axiety Idetifies psychosocial status. Assesses baselie eurological status. Idetifies sesory impairmets. Idetifies barriers to commuicatio. Assesses copig mechaisms. Assesses psychosocial issues specific to the patiet s medicatio maagemet. Idetifies the patiet s ad desigated support perso s educatioal eeds. Implemets measures to provide psychological support. Icludes the patiet or desigated support perso i perioperative teachig. Explais the expected sequece of evets. Provides status reports to the desigated support perso. Evaluates psychosocial respose to pla of care. Evaluates respose to istructios. The patiet or desigated support perso verbalizes the sequece of evets to expect before ad immediately after surgery. The patiet or desigated support perso demostrates kowledge of the expected psychosocial resposes to the procedure. Risk of ijury Provides care i a odiscrimiatory, oprejudicial maer regardless of the settig i which care is give. Provides care without prejudicial behavior. Provides care with respect for worth ad digity regardless of diagosis, disease process, procedure, or projected outcome. Maitais patiet cofidetiality. Shares patiet iformatio oly with those directly ivolved i care. Acts as a patiet advocate by protectig the patiet from icompetet, uethical, or illegal practices. The patiet voices satisfactio with delivered care. The patiet is the recipiet of competet ad ethical care withi legal stadards of practice. AORN Joural j 659

10 December 2014 Vol 100 No 6 TETEF Figure 1. A sample policy ad procedure to guide practitioers i itraasal (ie, trasmucosal) admiistratio of suitable medicatios. Published with permissio from the Hery Mayo Newhall Memorial Hospital, Valecia, CA. 660 j AORN Joural

11 EFFECTIVENESS OF TRANSMUCOSAL SEDATION ifusio is completed. Sam s heart rate does ot drop ad he does ot require additioal medicatios to achieve desired effects. Naloxoe is ot admiistered, but the urses make sure that it is readily available. Sam remais asleep while the RN circulator ad aesthesia professioal trasfer him to the OR. Sam does ot require additioal dexmedetomidie itraoperatively. Postoperatively, Sam requires a sigle IV dose of hydromorphoe ad is the set home alert, awake, ad without ausea. Case 2 Claire is a seve-year-old girl admitted for the surgical isertio of percutaeous pressure equalizatio tubes (PE tubes). She weighs 22 kg. Claire has a history of attetio-deficit/hyperactivity disorder, which requires daily medicatio therapy. The preoperative urse verifies that Claire has remaied NPO for the required time ad obtais Claire s preoperative vital sigs without difficulty. Claire the becomes icosolable ad axious. Both parets are preset. Claire is sittig i her father s lap i a reclier. The preoperative urse gives the parets writte iformatio regardig the pla for sedatio, icludig Claire i the discussio of the pla of care. The preoperative urse admiisters 5 mg of midazolam orally, but Claire spits out most of the dose because it tastes bad. The preoperative urse iforms the aesthesia professioal of the situatio, who the decides that the patiet is a cadidate for trasmucosal admiistratio of sedatio medicatios. To miimize ruoff of the medicatio, the preoperative urse gives Claire a coservative dose of 60 mcg of trasmucosal dexmedetomidie via a MAD Nasal device. Claire asally expels a portio of the medicatio; however, after 25 miutes, she is calm. The RN circulator carries Claire to the gurey ad the helps the preoperative urse apply moitors, without Claire wakig up. Claire s blood pressure ad heart rate are stable ad uchaged after beig medicated. The patiet wakes while the urse attempts to start the IV. The urse is uable to place the IV catheter successfully ad Claire does ot retur to sleep. The RN circulator trasports Claire to the OR awake ad with her mother at her side. Claire does ot receive additioal dexmedetomidie itraoperatively. Postoperatively, Claire is cooperative ad requires two doses of hydromorphoe for pai; she is discharged home alert, awake, ad without ausea. Case 3 Tim is a 17-year-old boy admitted to the outpatiet uit to have laboratory tests ad preoperative medicatio levels draw. Tim has autism ad seizures ad is takig medicatios for both coditios. The last time Tim had allowed ay blood to be draw was five years earlier. The patiet s shoulder surgery had bee cacelled a week before because of the patiet s axiety over havig a IV iserted ad a erve block placed; Tim s father had bee preset at that time. For the curret procedure, the preoperative urse is able to commuicate with Tim, ad Tim is able to sig coset forms; he allows the preoperative urse to obtai vital sigs without difficulty. Tim weighs 91 kg. The patiet s mother is at the bedside. After the urse cofirms that Tim remaied NPO for the required time, the urse discusses the sedatio procedure ad the required medicatios with Tim ad his mother ad aswers all of their questios. The preoperative urse moitors Tim s vital sigs ad admiisters 100 mg of dexmedetomidie trasmucosally with a MAD Nasal device with o results after 25 miutes. The preoperative urse repeats the medicatio after 30 miutes. Tim is miimally sedated after the secod dose of dexmedetomidie. The urse the admiisters 2.5 mg of midazolam trasmucosally with a MAD Nasal device. After 10 miutes, Tim is sleepig. The patiet wakes whe the IV is started to obtai blood samples but returs to light sleep. Two additioal urses assist with holdig the patiet s arms still ad are successful i verbally calmig the patiet dow to eable the AORN Joural j 661

12 December 2014 Vol 100 No 6 TETEF TABLE 5. Trasmucosal Sedatio: Four Case Scearios Case umber/ patiet Age ad sex Cliical or special eeds Medicatio admiistered Stable BP Stable HR Effective Required additioal legth of stay Case 1: Sam 4-year-old boy Youg age Trasmucosal dexmedetomidie No: required fluid bolus Case 2: Claire 7-year-old girl Attetio-deficit/hyperactivity disorder Youg age Axiety Case 3: Tim 17-year-old boy Autism Case 4: Tim 17-year-old boy (same patiet as i case 3) Previous surgery cacelled because of eedle phobia Has refused blood draw for 5 years Autism Needle phobia Preoperative axiety Oral midazolam; trasmucosal dexmedetomidie Two doses of trasmucosal dexmedetomidie followed by two doses of trasmucosal midazolam Two doses of trasmucosal dexmedetomidie followed by two doses of trasmucosal midazolam Yes Yes No Yes Yes No: asally expelled the medicatio Yes Yes No: required repeat doses of medicatio Yes: preoperatively No: required fluid bolus postoperatively Yes Yes: same dose as prior admissio to achieve sedatio No Yes: a additioal hour because of sedatio Yes: a additioal hour because of oset of hypotesio BP ¼ blood pressure; HR ¼ heart rate. 662 j AORN Joural

13 EFFECTIVENESS OF TRANSMUCOSAL SEDATION blood to be draw. The preoperative urse repeats the trasmucosal dose of 2.5 mg of midazolam. After eight miutes, Tim returs to sleep but is easily arousable after the blood draw procedure is completed. The RN circulator otes these observatios ad uderstads that a ormal respose with dexmedetomidie results i patiets wakig up easily with tactile stimuli ad the returig to sleep. Tim remais asleep for aother hour, after which he wakes, driks water, ad is set home two hours after the blood draw procedure is completed. The duratio of time that Tim was admitted, give medicatios, ad observed postoperatively was four hours, durig which he received oe-ooe ursig care. Tim s mother expressed her appreciatio for havig the blood draw procedure performed for the first time i years. Case 4 Tim is the same patiet as i case 3. He is a 17- year-old boy with autism; he weighs 91 kg. Tim is admitted for shoulder surgery, with his father at the bedside. The pla is to sedate Tim preoperatively, start a IV, ad admiister a peripheral erve block i the preoperative uit. The surgeo discusses the pla of care with Tim ad his father. The preoperative urse discusses the laboratory draw procedure ad sedatio that the patiet received a few days earlier. Tim states that he is happy with the results ad does ot remember the blood draw procedure. The father expresses his appreciatio for havig his so s laboratory tests performed for the first time i five years. Tim is cooperative while the preoperative urse obtais preoperative vital sigs, after which the urse admiisters 100 mg of trasmucosal dexmedetomidie. The urse repeats the dose 30 miutes later, as was doe for the blood draw a few days earlier. Iitially, Tim s heart rate before admiistratio of dexmedetomidie was aroud 70 beats per miute ad remais cosistetly aroud 50 beats per miute after receivig the medicatio. The patiet s blood pressure does ot sigificatly decrease. The aesthesia professioal is at the bedside ad attempts to start a IV, but the patiet refuses. The aesthesia professioal admiisters 2.5 mg of trasmucosal midazolam. After five miutes, Tim is drowsy but still verbally refuses a IV. The aesthesia professioal admiisters a additioal dose of 2.5 mg of trasmucosal midazolam, after which the preoperative urse starts a IV with miimal resistace from Tim. Immediately after the IV isertio, the aesthesia professioal applies a oxyge mask ad admiisters propofol. The aesthesia professioal the performs a erve block with ropivacaie without complicatios. The patiet s blood pressure ad heart rate remai stable throughout the erve block procedure. The RN circulator trasfers Tim to the OR. The aesthesia professioal admiisters geeral aesthesia, ad Tim does ot require additioal doses of dexmedetomidie itraoperatively. I the PACU, Tim is comfortable ad cooperative, does ot have ay episodes of ausea, remais pai-free, ad has o sigificat hypotesio or bradycardia. After oe ad a half hours, Tim experieces a episode of orthostatic hypotesio. His SBP drops 20 mmhg to 80/42 mmhg. The PACU urse returs Tim to the supie positio ad admiisters 200 ml of lactated Riger solutio. After a hour, Tim s blood pressure remais stable. Naloxoe was ot admiistered, but the urses made sure that it was readily available. The PACU urse discharges him home with his parets. DISCUSSION OF CASE SCENARIOS I the precedig case studies, medicatios were admiistered trasmucosally to patiets ragig from four to 17 years of age. Trasmucosal medicatios have a cosistet, expected time of oset if ot asally expelled. Some trasmucosal medicatio doses were decreased because of the restricted quatities of medicatio to be admiistered trasmucosally. I oe case sceario, the patiet reported a bad taste with midazolam ad expelled some of the dexmedetomidie dose. Sam ad Tim AORN Joural j 663

14 December 2014 Vol 100 No 6 TETEF PATIENT EDUCATION Trasmucosal Admiistratio of Medicatios for Sedatio Overview Whe a patiet who has special eedsdsuch as a child or a perso who has a disability that affects their ability to copedmust udergo surgery or other care that may be paiful, the cliicia will first give the patiet medicie to make him or her sleepy ad decrease axiety. Sometimes patiets with special eeds caot tolerate havig a shot or IV. To keep the patiet as pai-free as possible durig the procedure, a cliicia may use trasmucosal sedatio istead, which is give i the ose. What is the beefit of usig medicie that is give i the ose? Ihalig medicie may taste fuy or be a little ucomfortable (bur for a few secods), but it avoids the eed for a shot, is less paiful, ad helps the patiet relax. What are possible complicatios of receivig medicatio for sedatio? The medicie may cause the patiet to feel drowsy, tired, or weak for oe or two days. It also may cause problems with the patiet s coordiatio ad ability to thik; the patiet should ot drive, use machies, or ride a bike util he or she has retured to a ormal state of alertess. The patiet should ot drik alcoholic beverages or take medicies that slow dow reactio time or cause drowsiess for about 24 hours. Examples of these medicies are medicie for hay fever, other allergies, or colds; sedatives; traquilizers; sleepig medicie; prescriptio pai medicie or arcotics; ad muscle relaxats. Remember to talk to the patiet s doctor before chagig ay medicatios. What will the preoperative care iclude? The patiet should ot eat or drik aythig before the procedure for the amout of time specified by the patiet s doctor. Ask the doctor whether the patiet should take ay curret medicies the morig of surgery. I the preoperative holdig area, a urse will measure the patiet s vital sigs ad ask questios about allergies ad the patiet s medical ad surgical history. A aesthesia professioal will talk to you about the aesthesia the patiet will receive. What happes whe the preoperative sedatio is give? You may be allowed to hold the patiet i the sittig or recliig positio durig the sedatio. The cliicia will put a small asal ihaler ito oe side of the patiet s ose ad the push the pluger to give a spray of medicie. The cliicia will the repeat this i the other ostril. Although the medicie may taste bad or bur for about 30 secods, it is importat that the patiet ot sort the medicie out because it caot work if it does ot stay i the ose. Does the medicie work right away? It ca take 5 to 20 miutes for the medicie to take effect, ad the patiet may eed two or more doses of the medicie depedig o his or her size. Although the patiet may be sleepy, he or she may awake if touched or moved. This is ormal ad does ot mea that the medicie is ot workig. After the patiet is sleepy eough, cliicias will carry the patiet or use a stretcher to take him or her to the surgery or procedure room. What happes after we go home? Make sure the patiet gets eough rest. Give the patiet the prescribed pai medicie as istructed to cotrol pai. Call the patiet s doctor immediately if he or she experieces ay of the followig postoperative complicatios: weakess, dizziess, or light-headedess; ervousess, agitatio, irritability, or headaches; cofusio; excessive sweatig; abdomial pai; or diarrhea or costipatio. Resources Midazolam. Mayo Cliic. -supplemets/midazolam-oral-route/descriptio/drg Accessed September 4, Precedex [dexmedetomidie] e patiet iformatio. RxList. Accessed September 4, What will postoperative care iclude? After the procedure, the patiet is take to the recovery area, where urses will moitor him or her very closely. If possible, the urse will let you be with the patiet while he or she is wakig up. The urse will give the patiet additioal medicie if eeded for pai. The patiet may seem tired or sleepy durig recovery; this is ormal. 664 j AORN Joural

15 EFFECTIVENESS OF TRANSMUCOSAL SEDATION exhibited mild hypotesio, which the urses treated with IV fluids. Noe of the patiets exhibited sigificat bradycardia with trasmucosal medicatio admiistratio. Postoperatively, the patiets required less pai medicatio tha is typical for patiets after udergoig a medical procedure ad did ot exhibit additioal cardiorespiratory problems. The barrier to use of trasmucosal medicatios is the risk of the patiet asally expellig it. Sam did ot actively ihale the medicatio because of his youg age, yet sedatio still occurred. I additio, patiets are still arousable to tactile stimulatio, such as startig a IV, which sometimes makes it difficult to attai IV access or admiister additioal IV medicatios. The time allotted for sedatio ad the blood draw procedure time were extesive with Tim; however, perioperative persoel were successful because he allowed blood samples to be draw for the first time i five years. Tim required subsequet trasmucosal medicatios so that the plaed procedure could be completed. Tim was o seizure medicatios ad medicatios for autism, which may ihibit the effectiveess of trasmucosal medicatios. Although aloxoe was ot admiistered, the urses made sure that it was readily available. CONCLUSION Providig patiet care to special eeds populatios has iheret barriers ad requires idividual cosideratios. Special traiig ad certificatio are required for cliicias i the trasmucosal admiistratio of medicatios for sedatio. The precautios, cotraidicatios, ad adverse reactios associated with trasmucosal sedatio are similar to IV, IM, ad oral routes but require additioal kowledge ad competecy. I additio, the oset ad duratio of trasmucosal dexmedetomidie ad midazolam are similar to the IV route. Perioperative persoel have observed that patiets receivig dexmedetomidie are arousable ad alert whe stimulated, but this aloe should ot be cosidered as evidece of lack of efficacy i the absece of other cliical sigs ad symptoms. The oset of sedatio for dexmedetomidie is 20 to 30 miutes ad midazolam is 10 miutes. Cocurret admiistratio of other aesthetics, sedatives, hypotics, ad opioids with dexmedetomidie, midazolam, ad fetayl is more likely to lead to potetiated effects. 4,6 I coclusio, my cliical experieces with trasmucosal medicatio admiistratio suggest that it is as effective as IM or IV routes. Usig trasmucosal medicatios i the ambulatory care settig also improves patiet outcomes ad flexibility because it is ot limited to the ipatiet settig. Trasmucosal is a effective alterative route for medicatio admiistratio that ca decrease patiet axiety ad stress ad also decrease the disparity of health care i special eeds populatios, thereby allowig cliicias to provide ecessary care that would otherwise be ieffective or uobtaiable ad to cotribute to positive patiet outcomes. Editor s otes: The evets ad observatios of trasmucosally admiistered medicatios for sedatio were made by the author while providig care at the bedside ad were ot attaied from other research results. The cliical case scearios of procedures performed i a ambulatory surgery settig are based o real patiet experieces but are compilatios ad ot specific patiets. I additio, patiet idetifiers have bee modified. MAD Nasal is a trademark of Teleflex Icorporated or its affiliates, Philadelphia, PA. Refereces 1. Orlewicz MS, Colema AE, Dudley RM, Widle ML, Bailey RA. Procedural sedatio. Medscape. emedicie.medscape.com/article/ overview. Updated May 28, Accessed September 4, Itraasal medicatio admiistratio. I: Pharmaceutical Departmet Maual Policy. Hery Valecia, CA: Mayo Newhall Memorial Hospital; Dosig guidelies for PrecedexÒ. Precedex.com. Guide.pdf. Accessed September 4, AORN Joural j 665

16 December 2014 Vol 100 No 6 TETEF 4. Warigs & precautios. Precedex.com. Accessed September 4, Safety iformatio. Precedex.com. Accessed September 4, Midazolam ijectio: drug descriptio. RxList. Accessed September 4, Emergig techologies ad agets: dexmedetomidie. Updates/EmergigAgets.aspx. Accessed September 4, Cocomitat medicatios. Precedex reduces the eed for opioids without compromisig patiet comfort i the ICU. Precedex.com. cocomitat-meds. Accessed September 4, Midazolam ijectio: idicatios, dosage, ad admiistratio. RxList. -ijectio-drug/idicatios-dosage.htm. Accessed September 4, Midazolam 5 mg/ml, solutio for ijectio: 4.9 overdose. SPC. Accessed September 4, Narca: metabolism ad elimiatio. RxList. Accessed September 4, Sue Tetef, MSN, RN, CPAN, is a cliical coordiator for the preoperative uit ad postaesthesia care uit at Hery Mayo Newhall Memorial Hospital, Valecia, CA. Ms Tetef has o declared affiliatio that could be perceived as posig a potetial coflict of iterest i the publicatio of this article. 666 j AORN Joural

17 EXAMINATION CONTINUING EDUCATION Effectiveess of Trasmucosal Sedatio for Special Needs Populatios i the Ambulatory Care Settig PURPOSE/GOAL To provide the learer with kowledge specific to providig perioperative care for patiets receivig sedatio medicatios via the trasmucosal route of admiistratio. OBJECTIVES 1. Discuss the use of procedural sedatio medicatios. 2. Discuss the perioperative urse s role i procedural sedatio. 3. Describe the use of trasmucosal dexmedetomidie for procedural sedatio. 4. Discuss the use of trasmucosal midazolam for procedural sedatio. 5. Idetify medicatios used to couteract the effects of overdose after admiistratio of sedatio medicatios. The Examiatio ad Learer Evaluatio are prited here for your coveiece. To receive cotiuig educatio credit, you must complete the olie Examiatio ad Learer Evaluatio at QUESTIONS 1. The admiistratio of procedural sedatio medicatios 1. results i a depressed level of cosciousess. 2. allows the patiet to maitai oxygeatio idepedetly. 3. allows the patiet to maitai airway cotrol idepedetly. 4. requires itubatio i the secod stage of aesthesia. a. 1 ad 3 b. 2 ad 4 c. 1, 2, ad 3 d. 1, 2, 3, ad 4 2. Sedatio ca be admiistered via routes icludig 1. itramuscular. 2. IV. 3. oral. 4. trasmucosal. a. 1 ad 2 b. 3 ad 4 c. 2, 3, ad 4 d. 1, 2, 3, ad 4 3. Trasmucosal admiistratio of medicatios for sedatio has a decreased effect i a patiet 1. with epistaxis (ie, osebleed). 2. with high mucous productio i the asal cavity. 3. who forcefully expels (ie, sort outs) the medicatio. a. 1 ad 2 b. 1 ad 3 c. 2 ad 3 d. 1, 2, ad 3 Ó AORN, Ic, 2014 December 2014 Vol 100 No 6 AORN Joural j 667

18 December 2014 Vol 100 No 6 CE EXAMINATION 4. To be qualified to admiister trasmucosal medicatios for sedatio, the urse must 1. attai ad maitai competecy i moderate or procedural sedatio. 2. be proficiet i airway maagemet ad cardiovascular support. 3. have advaced cardiac life support (ACLS) certificatio if workig with adult patiet populatios. 4. have pediatric advaced life support (PALS) certificatio if workig with pediatric populatios. 5. possess the skills required to rescue a patiet from uiteded deep sedatio if ecessary. a. 4 ad 5 b. 1, 2, ad 3 c. 1, 2, 3, ad 4 d. 1, 2, 3, 4, ad 5 5. The correct volume of dexmedetomidie to admiister to a child weighig 10 kg is a. 0.5 ml. b. 0.6 ml. c. 0.8 ml. d. 1 ml. 6. I additio to the beefits of sedatio for a surgical procedure, a extra beefit of dexmedetomidie is less postoperative opioid use. a. true b. false 7. Midazolam is a bezodiazepie that 1. ca be admiistered trasmucosally or via IM or IV routes. 2. is effective for sedatio, axiety, ad seizures. 3. is effective as a aalgesic. 4. ca be admiistered before diagostic, therapeutic, edoscopic, or surgical procedures. a. 1 ad 2 b. 3 ad 4 c. 1, 2, ad 4 d. 1, 2, 3, ad 4 8. The correct volume of midazolam to admiister to a child weighig 20 kg who is udergoig a paiful procedure is a. 1.3 ml. b. 2.1 ml. c. 3.5 ml. d. 4.1 ml. 9. If the patiet experieces excessive sedatio after trasmucosal admiistratio of midazolam, cliicias should admiister a. IV flumazeil. b. IV aloxoe. c. trasmucosal flumazeil. d. trasmucosal aloxoe. 10. Naloxoe 1. maitais the patiet s airway ad spotaeous breathig but does ot achieve full arousal. 2. ca oly be admiistered trasmucosally. 3. is used to treat opiate overdose. 4. is a reversal aget for dexmedetomidie. a. 1 ad 3 b. 2 ad 4 c. 1, 2, ad 3 d. 1, 2, 3, ad j AORN Joural

19 LEARNER EVALUATION CONTINUING EDUCATION PROGRAM Effectiveess of Trasmucosal Sedatio for Special Needs Populatios i the Ambulatory Care Settig This evaluatio is used to determie the extet to which this cotiuig educatio program met your learig eeds. The evaluatio is prited here for your coveiece. To receive cotiuig educatio credit, you must complete the olie Examiatio ad Learer Evaluatio at Rate the items as described below. OBJECTIVES To what extet were the followig objectives of this cotiuig educatio program achieved? 1. Discuss the use of procedural sedatio medicatios. Low High 2. Discuss the perioperative urse s role i procedural sedatio. Low High 3. Describe the use of trasmucosal dexmedetomidie for procedural sedatio. Low High 4. Discuss the use of trasmucosal midazolam for procedural sedatio. Low High 5. Idetify medicatios used to couteract the effects of overdose after admiistratio of sedatio medicatios. Low High CONTENT 6. To what extet did this article icrease your kowledge of the subject matter? Low High 7. To what extet were your idividual objectives met? Low High 8. Will you be able to use the iformatio from this article i your work settig? 1. Yes 2. No 9. Will you chage your practice as a result of readig this article? (If yes, aswer questio #9A. If o, aswer questio #9B.) 9A. How will you chage your practice? (Select all that apply) 1. I will provide educatio to my team regardig why chage is eeded. 2. I will work with maagemet to chage/ implemet a policy ad procedure. 3. I will pla a iformatioal meetig with physicias to seek their iput ad acceptace of the eed for chage. 4. I will implemet chage ad evaluate the effect of the chage at regular itervals util the chage is icorporated as best practice. 5. Other: 9B. If you will ot chage your practice as a result of readig this article, why? (Select all that apply) 1. The cotet of the article is ot relevat to my practice. 2. I do ot have eough time to teach others about the purpose of the eeded chage. 3. I do ot have maagemet support to make a chage. 4. Other: 10. Our accreditig body requires that we verify the time you eeded to complete the 3.5 cotiuig educatio cotact hour (210-miute) program: Ó AORN, Ic, 2014 December 2014 Vol 100 No 6 AORN Joural j 669