Who can provide Conscious Sedation? Any Licensed Independent Practitioner (LIP) with privileges at the ASC. Registered Nurse s (RN) with documented competency and current ACLS. Any procedure for which increased discomfort, pain or anxiety may increase stress or risk to the patient. Examples include: Reduction of a dislocation Setting of a fracture Drainage of an abscess Cardioversion Endoscopic procedures Standard The perioperative registered nurse administering moderate sedation/analgesia must practice within the scope of nursing practice as defined by his or her state and should be compliant with state advisory opinions, declaratory rules, and other regulations that direct the practice of the registered nurse. Four Levels of Sedation Sedation occurs along a continuum but is generally broken into four levels 1. Minimal sedation (anxiolysis) 2. Moderate sedation (Conscious) 3. Deep sedation 4. General anesthesia 1. Minimal Sedation (anxiolysis) A drug-induced state during which patients respond normally to verbal commands. Cognitive function and coordination may be impaired Ventilatory and cardiovascular functions are unaffected 2. Moderate Sedation (Conscious) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation Spontaneous ventilation is adequate and no interventions are required to maintain a patent airway Cardiovascular function is usually maintained 2011 ASC Compliance, LLC Page 1
3. Deep Sedation A drug-induced depression of consciousness during which patients: Cannot be easily aroused Respond purposefully to repeated or painful stimulation Respiratory effort may be impaired Spontaneous ventilation may be inadequate and patients may require assistance to maintain an open airway. Cardiovascular function is usually maintained. 4. General Anesthesia (Local Anesthesia not included) A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. Independent ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway. Depressed spontaneous ventilation or drug induced depression of neuromuscular function may require the use of positive pressure ventilation. Cardiovascular function may be impaired Requires Anesthesiologist or CRNA Most complications are a result of the effects medications have on the respiratory and/or central nervous system. Pre-existing conditions or medications already on board may also potentiate complications. 2011 ASC Compliance, LLC Page 2
Respiratory System Review How it Works Increases in Carbon Dioxide levels (CO 2 ) trigger the body to take a breath The diaphragm contracts, pulling down towards the abdomen increasing the negative pressure in the chest and allowing room for the lungs to expand. Higher pressures outside the body force the air through the mouth and nasal cavity (warming, moistening and slightly filtering the air) into the trachea, down the bronchi and into the alveoli where oxygen exchange occurs. Oxygen is taken into the cells and CO 2 and other byproducts are given up. As the diaphragm relaxes and begins to rise, the accessory muscles of the chest walls contract further squeezing the chest and assisting in CO 2 expulsion, lowering the body s CO 2 level. This constitutes a breath. The number of breaths your body takes in a minute (Respiratory Rate) is controlled by your CO 2 level and your autonomic nervous system. 2011 ASC Compliance, LLC Page 3
Upper Respiratory Tract Oral cavity Nasal cavity Nasopharynx Oropharynx Epiglottis Laryngopharynx Esophagus Vocal cords Even partial obstruction of any of these airways can lead to hypoventilation, hypoxia and further complications. Obstruction can be from a foreign body (aspirate) or the body part itself (congenital anomaly, edema, infection). Lower Respiratory Tract Trachea Bronchus Bronchi Alveoli Accessory muscles Diaphragm Obstruction may occur due to mucous production or allergic reaction (edema and bronchoconstriction). Decreased use of accessory muscles or the diaphragm may also lead to hypoventilation and hypoxia. 2011 ASC Compliance, LLC Page 4
Central Nervous System Review 2011 ASC Compliance, LLC Page 5
Brain Cerebellum- controls the actions of the muscular system needed for movement, balance, and posture. Cerebrum- areas of higher function. Right hemisphere Imagination Art Symbols Spatial relations Left hemisphere Speech Logic Writing Arithmetic Diencephalon- consists of Thalamus and Hypothalamus Thalamus Relay station for sensory information Interprets sensations of pain, pressure, temperature, and touch Some influence on emotions and memory Receives information regarding sound, smell and taste Hypothalamus Control of the autonomic nervous system Controls normal body temperature Regulates the endocrine system Regulates hunger, satiation, thirst, sleep and wakefulness Involved in anger and aggression 2011 ASC Compliance, LLC Page 6
Brain stem Medulla oblongata Messages arriving from the spinal cord to the brain cross at the medulla causing the opposite side of the brain to control each side of the body. Controls heartbeat, respiratory rate, and diameter of the blood vessels. Helps coordinate swallowing, vomiting, hiccupping, coughing, sneezing, and other basic life functions. Helps maintain the conscious state. Pons (Latin for bridge) Conducts messages between the spinal cord and the brain and between the different parts of the brain. Midbrain Conveys impulses from the hypothalamus to the pons and spinal cord. Contains visual and audio reflex centers involving the movement of the eyeballs and head. Twelve pair of cranial nerves originate in the underside of the brain and brain stem. These provide information from the face, head and neck. The vagus nerve (latin for wandering) is the only cranial nerve that also serves other areas. It branches to the larynx, heart, lungs, stomach, and intestines (helping to promote digestive activity and regulate heart activity). Spinal Cord Transmits sensory impulses to the brain along ascending tracts and transmits motor commands from the brain to the muscles via descending tracts. Thirty one sets of sensory neurons and motor neurons come together before they exit the vertebral column. 2011 ASC Compliance, LLC Page 7
The Nervous System The cells of the nervous system are comprised of three types of neurons. 1. Sensory neurons- carry impulses or sensations from receptors (located in the skin, skeletal muscles, joints, and internal organs) to the brain or spinal cord. 2. Motor neurons- carry impulses from the brain or spinal cord to muscles and glands, causing muscles to contract and glands to secrete. 3. Interneurons- located in the CNS and conduct impulses from sensory to motor neurons Each neuron carries impulses in only one direction to prevent impulses canceling each other. Impulses are transmitted via electrochemical reactions that occur at the synapses (tiny space between the dendrite of one cell and the axon of another cell) Sodium/Potassium gates as well as neurotransmitters cause this electrochemical reaction. The effectiveness of many drugs/medications are based on their ability to mimic or block secretion/uptake of certain neurotransmitters 2011 ASC Compliance, LLC Page 8
Contraindications for Sedation There are many contraindications to the use of sedation for procedures, and each patient must be assessed on an individual basis by both the RN and the Physician. Contraindications may include: Pre-existing cardiac condition Pre-existing pulmonary condition Medication allergies Medications currently on board Unstable vital signs (to include cardiac arrhythmia) Unstable airway To minimize the risk to the patient specific safety guidelines MUST be adhered to: Prior to sedation the physician must: Physically assess the patient Verify the H&P and perform presurgical assessment Review any pertinent labs Assess the patient for risk (assign an ASA Classification) Assess the patient s airway (assign a Mallampati Airway Assessment Score) American Society of Anesthesiologist s (ASA) Classification I. Normal healthy patient II. Mild systemic disease, no limitation of activity III. Severe systemic disease, limitation of activity IV. Severe systemic disease that is constant threat for life V. Moribund, patient is not expected to survive 24 hours, with or without procedure Mallampati Airway Assessment 2011 ASC Compliance, LLC Page 9
Prior to sedation the RN must: Obtain consent. Review medical history and physical examination Review labs (pregnancy, etc., as applicable) Review substance use (alcohol, tobacco, etc.) Review current medication list and those taken the day of the procedure Verify allergies and sensitivities, as well as NPO status Verify responsible adult to escort patient home Make sure that patient/family received Conscious Sedation education prior to procedure. Ensure that all the required safety equipment is immediately available Continuous cardiac monitor NIBP cuff Continuous pulse oximeter Oxygen Suction Code Cart Patent IV access Reversal agents Two patient identifiers and Universal Protocol (Time Out) apply to all sedation procedures with reassessment immediately prior to the procedure. The administering RN should: Auscultate heart and lung sounds prior to procedure Confirm NPO status Confirm medication already present for possible interactions Obtain baseline vital signs Assign a baseline Modified Aldrete Score Modified Aldrete Score 2011 ASC Compliance, LLC Page 10
Aldrete Score Intra-procedure The Physician must be in the immediate area from the initiation of sedation until 30 minutes after last dose The Physician must be available in the facility for the duration of the recovery time The RN may not leave the patient or engage in activities that interfere with the monitoring of the patient once sedation has begun. VS and level of consciousness should be documented at least every 5 minutes during the procedure and for 30 minutes after final medication If reversal agents are given the recovery time is extended and includes VS every 15 minutes for an additional 60 minutes Aldrete scores must be noted before the procedure, immediately after the procedure and at the time of discharge or transfer. Be sure to add a strip from the cardiac monitor. Use of reversal agents or unusual responses should be noted on an Occurrence Report and given to the Quality Assessment and Performance Improvement Committee for follow up. 2011 ASC Compliance, LLC Page 11
Intent and Goals for Moderate Sedation The procedure is completed safely while the patient remains: Anxiety and pain free Arousable, but relaxed Cooperative on demand Intact protective reflexes The perioperative registered nurse should know the recommended dose, recommended dilution, onset, duration, effects, potential adverse reactions, drug compatibility, and contraindications for each medication used during moderate sedation/analgesia. Sedation Medication Guidelines that Must be Known: Dosage limits Onset Duration of action Interactions Precautions To Safely Administer Sedation Start with lower dosage Titrate slowly Use caution when combining two classes of drugs Individualize doses Know the drug to drug interactions Alert! Check to see if the patient has recently received opiods or sedation Opiate Agonists Often given pre-procedural or in combination with sedatives, alters perception of pain, analgesic Fentanyl (Sublimaze ) Meperidine (Demerol ) Morphine Adverse Effects of Opiate Agonists Hypotension Nausea and vomiting Over-sedation Respiratory depression Respiratory arrest 2011 ASC Compliance, LLC Page 12
Use caution if patient has a history of Acute asthma COPD Elderly or debilitated Obesity or short neck Hepatic or Renal disease Hypothyroidism Head injury Drug to Drug Interactions with Opiates Contraindicated with MAO inhibitors Do not mix Demerol with Aminophylline Heparin Barbiturates Phenytoin Methicillin Patients under the influence of alcohol may have an additive effect when given narcotics Reversal Agent for Opioids Naloxone (Narcan ) Displaces opioid analgesics from their receptor sites Reverses respiratory suppression due to over sedation Observe for tachypnea, pain and agitation Has no pharmacologic activity of its own. Alert! Medication peaks in 15 minutes and the remaining opioid may cause patient to re-sedate with a return of respiratory insufficiency. Benzodiazepines (Sedatives) Pre-procedural sedation, to induce sleepiness and reduce anxiety Midazolam (Versed ) Diazepam (Valium ) Lorazepam (Ativan ) Side Effects of Benzodiazepines Slurred speech Nystagmus Amnesia- 3 minutes antegrade Altered judgment 2011 ASC Compliance, LLC Page 13
Adverse Effects of Benzodiazepines Respiratory depression Over-sedation Paradoxical behavior Vein irritation/phlebitis (Valium ) Alert! Patients receiving Benzodiazepines and sedation are at higher risk for fall and should be reassessed for Fall Risk Status. Use caution and/or reduce the dose if patient has a history of Being elderly or debilitated Acute alcohol intoxication Acute angle glaucoma- Midazolam (Versed ) COPD Reversal Agent for Benzodiazepines Flumazenil (Romazicon ) Competitively inhibits the action of Benzodiazepines at the receptor sites May not correct respiratory depression Does not reverse amnesic effect Peak time within 10 minutes- monitor for re-sedation Observe for dizziness, nausea, vomiting Use caution in patients at high risk for seizure or arrhythmia (increased risk) Drug-drug interaction includes anti-depressants Alert! May repeat dosage- not to exceed 3mg/hr Other Agents Used for Sedation Ketamine (Ketalar ) - anesthetic adjunct Chloral hydrate- sedative hypnotic, half life >10 hours Diphenhydramine (Benadryl ) - aids sleep Pentobarbital (Nembutal ) - pre-procedural sedation Droperidol (Inapsine ) - tranquilize/sedation use with extreme caution, FDA warning Alert! There are no reversal agents for these medications 2011 ASC Compliance, LLC Page 14
Most Common Complications and Treatments Respiratory Depression Hypotension Nausea and Vomiting Respiratory Depression Stimulate the patient Verbal Tactile Open the airway Chin lift Jaw thrust Oxygen as indicated Nasal prongs (up to 6L/min-adjust flow meter) Venti mask (variable up to 60% FiO2- use insert and adjust flow meter accordingly up to 10L/min) Non-rebreather (up to 100% FiO2- must run at 15L/min to clear CO2 build-up) Support the patient s ventilation (Ambu bag, CPAP) Initiate Rapid Response to stabilize airway if necessary Initiate CPR if necessary Hypotension Leg elevation Fluid challenge with Dr.'s order Reversal agents with Dr. s order Nausea and Vomiting Side-lying position Modified trendelenberg Suction Medicate with Dr. s order Cardiac Arrhythmia (Not Common) May be a result of: drug interactions hypoxia over-sedation Hypotension Treat the Reason! 2011 ASC Compliance, LLC Page 15
Typical Arrhythmias 2011 ASC Compliance, LLC Page 16
Recovery and Discharge The recovery phase of sedation begins immediately after the administration of the final dose of medication (sedative or reversal agent) The RN should determine the patients Aldrete score at the end of the procedure and at the end of the recovery phase The patient must have an Aldrete score of 8 or a return to baseline before patient can be considered recovered. Discharge teaching must occur with the responsible party (whether receiving staff or family/friend). Discharge instructions must include a reminder not to perform any function which requires concentration or coordination for the next 24 hours, due to possible residual drug levels. Documentation It is the RN's responsibility to complete the required documentation Moderate Sedation/Analgesia Report Occurrence Report (if appropriate) 2011 ASC Compliance, LLC Page 17
Goal: To provide safe patient care Sedation is a continuum Know how to define your role in moderate sedation (pre, intra and post procedure) Provide safe administration of medications Provide ongoing monitoring until discharged from sedation Be prepared to rescue the patient Complete all documentation for sedation care To receive credit for this training, complete the following page and return by fax to: 918-517-3338 2011 ASC Compliance, LLC Page 18
Request for Continuing Education Post Test & Certificate PLEASE PRINT LEGIBLY!!! Name: Name of ASC: Learning Module Title: Date Completed: Email Address to send Post Test & Certificate to: PLEASE PRINT LEGIBLY!!! If you would like us to email this to your Director of Nursing/Administrator for inclusion in your file, please provide their name and email address: Name: EMAIL: 1. Did this course meet the stated objectives? Yes No 2. Will this information be useful to you in your job? Yes No 3. Was the course content presented in an understandable way? Yes No Suggestions for future learning modules: Comments / Suggestions: Signature of Participant Please fax to completed form to: 918-517-3338. Upon receipt of this form, you will be emailed your post test. After receipt of post test, you will be emailed your Certificate of Completion. 2011 ASC Compliance, LLC Page 19