MODERATE SEDATION/ANALGESIA Linda Wilson, PhD, RN, CPAN, CAPA, BC, CNE Christine Price, MSN, RN, CPAN, CAPA H. Lynn Kane, MSN, MBA, RN, CCRN Linda J. Webb, MSN, RN, CPAN
OVERVIEW Purpose: The orientee will: Demonstrate knowledge of the patient population, appropriate setting, and primary goals of moderate sedation/analgesia Demonstrate the requisite skills necessary for the assessment and management of patients receiving moderate sedation/analgesia related to upper respiratory and airway management, patient monitoring, drug administration, managing potential complications and emergency situations, and patient discharge criteria Competency Statement: Monitor and provide care for the patient receiving Moderate Sedation/Analgesia. Criteria: 1. Define Moderate Sedation/Analgesia, previously known as Conscious Sedation, and recognize the indications for the use of moderate sedation/analgesia. Sedation occurs on a continuum and is directly related to the patient s response. The four levels of sedation and anesthesia are: Minimal Sedation: Oral medications administered to reduce anxiety. The patient responds to verbal commands, and although cognitive function and coordination may be impaired, cardiovascular and respiratory functions are not Moderate Sedation/Analgesia: A patient under moderate sedation/analgesia has a depressed level of consciousness but retains the ability to independently and continuously maintain a patent airway and respond appropriately to physical stimulation and/or verbal command. A medically produced depressed level of consciousness can be produced by oral, nasal, rectal, or intravenous pharmacologic agents Deep Sedation: A state of depressed consciousness or unconsciousness, accompanied by a partial or complete loss of protective reflexes, and the inability to independently and continuously maintain a patent airway or elicit a purposeful response to verbal or physical stimuli General Anesthesia: A medication-induced loss of consciousness and protective reflexes. The patient is unable to maintain ventilatory function without assistance, may have impaired cardiovascular function, and does not respond to any stimulus, including pain Monitored Anesthesia Care (MAC): Intravenous sedation and monitoring by an anesthesia provider. The patient is able to maintain ventilatory function without assistance Note: As the level of sedation increases, so does the risk of complications. The indications and primary goals of moderate sedation/analgesia include: Tranquilization/mood alteration to allay the patient s fear and anxiety about undergoing an elective procedure Comfort to provide an adequate level of analgesia by elevating the pain threshold with minimal changes in vital signs Partial amnesia to reduce unpleasant memories of the procedure Safety to provide a rapid, safe return to the ambulatory/pre-procedural state 2. Identify the patient population acceptable for nurse-monitored Moderate Sedation/Analgesia and determine appropriate staffing. Patients acceptable for nurse-monitored moderate sedation/analgesia should be generally healthy. The American Society of Anesthesiology (ASA) Classification may be used in evaluating risk factors in patients receiving moderate sedation/analgesia. If the patient classification is greater than Class II, the registered nurse (RN) and physician should jointly determine whether to proceed with moderate sedation/analgesia, and determine appropriate staffing. MAC may be considered. ASPAN 2009 Edition 203
The RN monitoring the care of the patient shall have no other responsibilities that would leave the patient unattended or compromise continuous monitoring Because sedation to anesthesia is a continuum, it is not always possible to predict how an individual receiving medication with the intent to achieve moderate sedation will respond. The RN providing sedation will be competent in recognizing levels of sedation as described in section 1 The RN will be aware of, and follow, the scope of practice as dictated by Resource 8 in the ASPAN 2008-2010 Standards of Perianesthesia Nursing Practice ( The Role of the Registered Nurse in the Management of Patients Undergoing Sedation for Short-Term Therapeutic, Diagnostic or Surgical Procedures ), the State Board of Nursing, other applicable national guidelines and position statements, and by the facility s policies and procedures regarding moderate sedation/analgesia 3. Verbalize pre-sedation admission procedure including physical and psychological assessment and education. Verify appropriate informed consent Verify that the patient has a responsible party available for transportation home A comprehensive assessment includes pertinent medical/surgical history, current medications, allergies, chief complaint, review of laboratory and diagnostic studies, smoking/alcohol/drug use, and last menstrual cycle to determine possible pregnancy The physical evaluation includes height and weight, cardiovascular and respiratory assessment, baseline pulse, respiration, oxygen saturation, level of consciousness, NPO status, and system evaluation related to the admitting diagnosis Pre-procedure assessment provides baseline data, and identifies patient risk factors as identified by the American Society of Anesthesiologists (ASA) pre-anesthetic score (Exhibit 1), and Mallampati Airway assessment. The pre-procedure assessment is performed by the anesthesiologist / procedural physician prior to the procedure Re-evaluation of the patient s readiness for sedation is done immediately prior to the first administration of moderate sedation Patient education includes orientation to surroundings, discharge criteria and expectations, and information regarding the upcoming procedure and use of moderate sedation /analgesia Thorough preparation contributes to more effective sedation, decreases fear and apprehension, and increases patient and family cooperation Exhibit 1 - ASA Physical Status Classification System P1 P2 P3 P4 P5 P6 Normal healthy patient Patient with mild systemic disease Patient with severe systemic disease Patient with severe systemic disease that is a constant threat to life Moribund patient who is not expected to survive without the operation Declared brain-dead patient whose organs are being removed for donor purposes 4. Verify intravenous access patency. Intravenous access must be continuously maintained in the patient receiving moderate sedation /analgesia. 5. Identify monitoring parameters and appropriate equipment needed. Monitoring parameters include respiratory rate, oxygen saturation, BP, cardiac rate and rhythm, level of consciousness, skin condition and comfort level The nurse must demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmia recognition, and complications related to Moderate Sedation/Analgesia and medications All patients will be monitored throughout the procedure as well as during the recovery phase 204 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
Supplemental oxygen will be immediately available and administered per order An emergency cart with resuscitative medications and a defibrillator will be available Suction, a positive pressure breathing device, and appropriate airways and ventilatory adjuncts must be in each room where moderate sedation/analgesia is administered A telephone or call device, must be immediately available to summon expert emergency support personnel in the event of complications The airway is paramount The ASA suggests that the response of patients to commands during procedures performed with moderate sedation/analgesia serves as a guide to their level of consciousness, with spoken responses providing an indication of breathing patterns Sample monitoring assessment tool: A, B, C, C, D, D A. Airway - position for observation, O2 B. Breathing - regular, quality, need for assistance, oxygen saturation trends C. Circulation - BP trend, pulse quality, ECG rate and rhythm (ectopic activity) C. Consciousness - verbal contact response D. Drugs - dosage, route, response; comfort level D. Documentation - consistency, tools to use The use of a sedation scale, per facility protocol, simplifies documentation of patient response to treatment 6. Demonstrate knowledge of the operation of all monitoring equipment. Knowledge of the functions and proper use of monitoring equipment is essential for providing safe care 7. Verbalize knowledge of medication action, dilution, dosage, interactions, and reversal agents. Nurses administering drugs must be familiar with dosage requirements, onset, and duration of action with special consideration given to interactions and precautions. A practitioner trained to monitor patients under these conditions must be present to assess the patient s cerebral, respiratory, and cardiovascular reaction to these medications and be prepared to intervene to correct any untoward response to them Medications used for moderate sedation/analgesia may cause rapid, adverse physiologic responses in the patient Early detection of such responses allows for rapid intervention and treatment in compliance with orders and facility protocols and guidelines Titration of medications in small incremental doses decreases the chance of adverse responses from the patient Observe and monitor for adverse effects of medications, report changes, and remember to treat the cause, not the symptom Signs and symptoms of adverse effects include: o Restlessness o Cyanosis o Pallor o Flushing o Diaphoresis o Nausea o Bradycardia/tachycardia o Hypotension/hypertension Signs and symptoms of allergic reaction include: ASPAN 2009 Edition 205
o Conjunctivitis o GI disturbances o Hives o Pruritis o Wheezing o Bronchospasm o Syncope Undesirable effects of sedation include: o Nystagmus o Severely slurred speech o Unresponsiveness o Hypo or hypertension o Agitation o Hypoventilation o Respiratory depression o Airway obstruction o Apnea. If adverse effects occur, ensure adequate oxygenation and ventilation. Treat allergic reactions with appropriate interventions and antidotes. Implement appropriate rescue/arrest interventions if patient deteriorates rapidly REMEMBER: The nurse is the most important monitor! Common agents used for moderate sedation/analgesia include: Benzodiazepines: Diazepam, Midazolam o Reversal agent: Flumazenil Opioids: Morphine, Fentanyl, Alfentanil, Meperidine o Reversal agent: Naloxone Anesthetic agents: Propofol, Ketamine, Methohexital (Brevital) Allergic reaction treatment: Benadryl, Corticosteroids, Epinephrine, Aminophylline REMEMBER: The half-life of reversal drugs is often shorter than the sedative producing agents, and rebound sedation can be a significant side effect. *(Refer to Chapter 9 Anesthesia Agents and Adjuncts, Section D Intravenous Agents, for more detailed information). 8. Demonstrate knowledge of the recognition and treatment of cardiac dysrhythmias. Successful completion of a basic dysrhythmia class and/or test, and Advanced Cardiac Life Support (ACLS) certification are recommended for RNs administering Moderate Sedation/Analgesia. For pediatric patients, Pediatric Advanced Life Support (PALS) is recommended. 9. Demonstrate skills needed for airway management and resuscitation to include chin support, insertion of oral and nasal airways, location and use of intubation equipment, and operation of oxygen delivery systems. The nurse monitoring the patient in moderate sedation/analgesia must be capable of initiating appropriate supportive measures in the case of untoward reactions or complications, and must understand the principles of oxygen delivery, respiratory physiology, transport and uptake, and demonstrate the ability to use oxygen delivery devices. 206 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
10. State measures needed to provide safety and support for patients receiving moderate sedation/analgesia. Performance of a time out immediately pre-sedation to assure that the correct patient, correct site, intended procedure, and affirmation by those members of the care team present mirror the consent form Verbal contact and touch assure responsiveness of patient and reinforce continuity of care Assess comfort level and need for opiates, or local anesthesia Maintain side rails up, safety straps in place, locked wheels, and sterile technique precautions If nausea and/or vomiting occur, a side lying position, or a modified trendelenberg, will allow for drainage of secretions Providing a safe environment is the nurse s responsibility 11. Identify post procedure recovery requirements. Recovery post procedure will begin at the completion of the procedure Vital signs will stabilize and oxygen saturation will return to normal or baseline limits on room air Return to an alert level of consciousness with intact protective reflexes and an acceptable comfort level with minimal nausea are necessary prior to discharge Immediately notify the physician who performed the procedure of changes in the patient s condition such as a drop in oxygen saturation, a 20 mm/mercury drop or rise in systolic BP, or a decreased level of consciousness (LOC) Satisfactory surgical site and dressing condition, return of pre-procedural ambulation abilities, and the presence of a responsible adult are required for discharge to home care The maintenance of a patent IV is needed until discharge criteria are met 12. Identify key elements for discharge criteria. Patients and significant others should receive written and verbal discharge instructions Pre-procedural education is encouraged due to the amnesic effects of sedative drugs Post procedural site care, pain control measures, prescriptions, home care needs, and follow up medical care should be reviewed A post-procedure phone call within 72 hours is suggested to ensure continuity of care and for quality assurance reasons Patients who receive moderate sedation/analgesia should not drive themselves home A second person for transportation from the facility should be identified prior to the start of the procedure 13. Communicate and document all pertinent information per facility/unit specific policy/protocol. Documentation should reflect the continuity of patient care and evidence of the assessment, diagnosis, outcome identification, planning, implementation, and evaluation of the patient receiving moderate sedation/analgesia A clearly defined Post Sedation Scoring System is recommended to assure that discharge criteria has been established and met ASPAN 2009 Edition 207
Bibliography American Society of Anesthesiologists. Practice Guidelines for Sedation and Analgesia by Non- Anesthesiologists. Park Ridge, IL: ASA; 2001. American Society of PeriAnesthesia Nurses. The Role of the Registered Nurse in the Management of Patients Undergoing Sedation for Short-Term Therapeutic, Diagnostic or Surgical Procedures. In: 2008-2010 Standards of PeriAnesthesia Nursing Practice. Cherry Hill, NJ: ASPAN; 2008. Bloomquist T. Propofol controversy... Shades of sedation: learning about moderate sedation and analgesia. Nursing 2006. August 2006; 36(8): 10, 12. Deitch K, Chudnofsky C, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with Midazolam and Fentanyl: A randomized, controlled trial. Annals of Emergency Medicine. January 2007; 49(1):1-8. Gan TJ. Pharmacokinetic and pharmacodynamic characteristics of medications used for moderate sedation. Clinical Pharmacokinetics. 2006; 45(9):855-869. Green S. Research advances in procedural sedation and analgesia. Annals of Emergency Medicine. January 2007; 49(1):31-36. Harrington L. Nurse-administered Propofol sedation: A review of current evidence. Gastroenterology Nursing. September/October 2006; 29(5):371-383. Halliday A. Shades of sedation: Learning about moderate sedation and analgesia. Nursing 2006. April 2006; 36(4):36-41. Kaplan RF. Sedation/Analgesia for Diagnostic and Therapeutic Procedures in Children Outside of the Operating Room. ASA Refresher Courses in Anesthesiology. 2006; 34(1):77-83. Lin DM, Wightman MA. Sedation, Anesthesia and the JCAHO. 3 rd ed. 2005. Mallampati RS, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: A prospective study. Can Anaesth Soc J. 1985; 32: 429. Maxwell L, Yaster M. The myth of moderate sedation/analgesia. Archives of Pediatric and Adolescent Medicine. July 1996. Odom-Forren J, Watson D. Practical Guide to Moderate Sedation/Analgesia. St. Louis, MO: Elsevier; 2005. Virtual Disaster Medicine Training Center (VDMTC). Available at: http://www.vdmtc.org/module01/anatomy/anatomy01.htm 2007. Accessed December 18, 2007 208 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
QUESTIONS: MODERATE SEDATION /ANALGESIA COMPETENCY 1. The primary goals of moderate sedation /analgesia are: a. amnesia b. elevate the pain threshold c. maintain protective reflexes d. allay fear and anxiety e. deep sleep f. a, b, c, d 2. For the adult patient, an early sign of hypoventilation which can lead to hypoxia and cardiac arrest is a. bradycardia b. slow capillary refill c. slow, shallow respirations d. diaphoresis 3. Benzodiazepines and narcotics are the classes of drugs most often used in moderate sedation/analgesia. a. True b. False 4. The primary drugs used to reverse sedation and analgesia in moderate sedation are: a. physostigmine b. naloxone c. flumazenil d. prostigmine e. b and c 5. Patients receiving medication to achieve moderate sedation/analgesia must have venous access maintained until discharge criteria are met. a. True b. False 6. In healthy patients, midazolam is recommended to be given: a. 1 mg/minute until patient is completely sedated b. in 500 ml normal saline over 1 hour c. rapid IV push over 5 seconds d. titrated to desired effect with no more than 2.5 mg over 2 minutes 7. When discharge teaching, the nurse should always: a. provide written discharge instruction to patient and care giver b. provide patient with telephone number to call in case of further questions c. review written discharge instructions with patient and care giver both present d. all of the above ASPAN 2009 Edition 209
8. The response of patients to verbal command during procedures performed with moderate sedation/analgesia is not reflective of their LOC. a. True b. False 9. The highest priority of assessment is: a. cardiovascular b. oxygenation c. renal perfusion d. skin integrity 10. Nurses administering moderate sedation/analgesia, should follow the scope of practice as directed by: a. ASPAN Standards b. their State Board of Nursing c. the facility s policies & procedures d. all of the above 210 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
KEY: MODERATE SEDATION /ANALGESIA COMPETENCY QUESTIONS 1. The primary goals of moderate sedation /analgesia are: a. amnesia b. elevate the pain threshold c. maintain protective reflexes d. allay fear and anxiety e. deep sleep f. a, b, c, d 2. For the adult patient, an early sign of hypoventilation which can lead to hypoxia and cardiac arrest is: a. bradycardia b slow capillary refill c. slow, shallow respirations d. diaphoresis 3. Benzodiazepines and narcotics are the classes of drugs most often used in moderate sedation /analgesia. a. True b. False 4. The primary drugs used to reverse sedation and analgesia in moderate sedation are: a. physostigmine b. naloxone c. flumazenil d. prostigmine e. b and c 5. Patients receiving medication to achieve moderate sedation /analgesia must have venous access maintained until discharge criteria are met. a. True b. False 6. In healthy patients, midazolam is recommended to be given: a. 1 mg /minute until patient is completed sedated b. in 500 ml normal saline over 1 hour c. rapid IV push over 5 seconds d. titrated to desired effect with no more than 2.5 mg over 2 minutes 212 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting
7. When discharge teaching, the nurse should always: a. provide written discharge instruction to patient and care giver b. provide patient with telephone number to call in case of further questions c. review written discharge instructions with patient and care giver both present d. all of the above 8. The response of patients to verbal command during procedures performed with moderate sedation /analgesia is not reflective of their LOC. a. True b. False 9. The highest priority of assessment is: a. cardiovascular b. oxygenation c. renal perfusion d. skin integrity 10. Nurses administering moderate sedation / analgesia should follow the scope of practice as directed by: a. ASPAN Standards b. their State Board of Nursing c. the facility s policies & procedures d. all of the above ASPAN 2009 Edition 213
Competency Based Orientation for the Perianesthesia Nurse Name Date Written Competency Test Pass & Date (90%) MODERATE SEDATION/ANALGESIA Competency Criteria can be validated by discussion, or by performance, or both. If an item is not appropriate for each column, please indicate with N/A. Competency Statement Discusses with Preceptor Monitor and provide care for the patient receiving Moderate Sedation/Analgesia. CRITERIA: 1. Define Moderate Sedation/Analgesia, previously known as Conscious Sedation, and recognize the indications for the use of moderate sedation/analgesia. 2. Identify the patient population acceptable for nurse-monitored Moderate Sedation/Analgesia and determine appropriate staffing. 3. Verbalize pre-sedation admission procedure including physical and psychological assessment and education. 4. Verify intravenous access patency. 5. Identify monitoring parameters and appropriate equipment needed. 6. Demonstrate knowledge of the operation of all monitoring equipment. 7. Verbalize knowledge of drug action, dilution, dosage, interactions, and reversal agents. 8. Demonstrate knowledge of the recognition and treatment of cardiac dysrhythmias. Retake & Date Observed Performs with Assistance Independent ASPAN 2009 Edition 215
9. Demonstrate skills needed for airway management and resuscitation to include chin support, insertion of oral and nasal airways, location and use of intubation equipment, and operation of oxygen delivery systems. 10. State measures needed to provide safety and support for patients receiving moderate sedation/analgesia. 11. Identify post-procedure recovery requirements. 12. Identify key elements for discharge criteria. 13. Communicate and document all pertinent information per facility/unit specific policy/protocol. Meets Criteria Does Not Meet Criteria Re-Validate Meets Criteria Employee Signature Date Preceptor Signature Date 216 A Competency Based Orientation and Credentialing Program for the Registered Nurse in the Perianesthesia Setting