Conscious Sedation: What You Need to Know

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Conscious SedationWhat You Need to Know

• Michael Sugarman, MD
• Visiting Professor of Anesthesiology
• Montefiore Medical Center
• Albert Einstein College of Medicine

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Conscious Sedation

• Introduction
• New JCAHO Standards are here!
• How to...
• Continuum of Sedation
• Medications
• Quality/Risk Management

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Conscious SeaDation
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JCAHO

• JCAHO (Joint Commission on Accreditation of
  Healthcare Organizations) directs institutions to
  develop individual policies, protocols and
  procedures and provides direction for the content.

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JCAHO Standards

• Pre-procedure Medical Evaluation
• Informed Consent
• Credentials of Personnel
• Qualified Staff Present
• Necessary Equipment
• Required Documentation
• Recovery
• Quality Management System

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JCAHO Scoring of Institutions

• Has the patient received proper informed consent?
• Has the patient received a proper pre-procedure
  medical evaluation?
• Is moderate or deep sedation provided by
  qualified individuals?
• Are sufficient numbers of qualified personnel
  available to perform the procedure and monitor
  the patient?

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JCAHO Scoring(Continued)

• Is appropriate equipment available to monitor the
  patients heart rate, respiratory rate, and
  oxygenation?
• Is each patients status monitored while
  undergoing moderate or deep sedation and
  documented in the medical record?
• Are outcomes of patients undergoing moderate or
  deep sedation collected and analyzed?

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How to...

• Logistics
• Patient Evaluation
• Equipment Monitoring
• Managing Complications
• Recovery

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Credentials

• Procedural sedation must be administered by or
  under supervision of a credentialed member of the
  staff
• Appropriate supporting personnel in attendance.
• The protocol should describe
• Training Requirements
• Experience Requirements
• Demonstration of capability in resuscitation and
  emergency airway management.

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Staffing

• The minimum number of staff required to conduct
  procedural sedation is two, the operator and a
  qualified assistant to monitor and provide
  supportive care of the patient.

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Equipment

• Oxygen
• Airway rescue equipment
• Suction
• Defibrillator
• Blood pressure
• EKG
• Pulse oxymetry

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Monitoring

• Record at intervals ? 15 minutes
• Time of day
• Pulse and respiratory rates
• Oxygen saturation
• Level of consciousness
• Dose of each medication administered
• These will be recorded minimally at pre- and
  post-procedure.

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Patient Evaluation

• Patient interview to review
• Medical history
• Anesthesia history
• Medication history
• NPO Status
• Appropriate physical examination
• Review of objective diagnostic data (e.g.,
  laboratory, ECG, X-ray)
• Formulation and discussion of a plan with the
  patient and/or responsible adult

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Informed Consent

• Informed consent is to be obtained by a physician
  or his/her designee and the record will reflect
  that the patient was informed of the indications
  for and accepted the risks associated with
  procedural sedation
• The plan of care must be discussed with and
  approved by an Attending physician.

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Recovery and Outcomes

• Post-procedure and sedation monitoring and
  evaluation should indicate the elements of
  decision-making leading to return to routine
  nursing care, transfer or discharge of each
  patient.
• Outcomes should be collected and analyzed for
  quality of care.

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Continuum of Sedation

• Minimal Sedation (Anxiolysis)
• Light Sedation/Analgesia (Conscious Sedation)
• Deep Sedation/Analgesia
• General Anesthesia

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Managing the Continuum

• Not always possible to predict how an individual
  will respond
• Practitioners intending to produce a given level
  of sedation should be able to rescue patients
  whose level of sedation becomes deeper than
  initially intended

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Minimal Sedation (Anxiolysis)

• Drug-induced state
• Normal response to verbal commands
• Cognitive function may be impaired
• Coordination may be impaired
• Cardiovascular function unaffected
• Respiratory function unaffected

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Moderate Sedation/Analgesia(Conscious Sedation)

• Drug-induced depression of consciousness
• Purposeful response to verbal commands
• Reflex withdrawal from pain persists
• Impairment of independent ventilatory function
• Cardiovascular function is usually maintained

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Deep Sedation/Analgesia

• Drug-induced depression of consciousness
• Difficult to arouse
• Respond purposefully following repeated or
  painful stimulation
• Ability to maintain ventilatory function
  independently may be compromised
• Cardiovascular function is usually maintained

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General Anesthesia

• Drug-induced loss of consciousness
• Cannot be aroused following repeated or painful
  stimulation
• Ventilatory function is often impaired with
  patients often requiring assistance in
  maintaining a patent airway

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General Anesthesia (Continued)

• Positive pressure ventilation may be necessary
  because neuromuscular function may be depressed
• Cardiovascular function may be impaired

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Continuum of Depth of Sedation
reflex withdrawal from a painful stimulus is
NOT a purposeful response
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Rescue

• Individuals administering Moderate
  Sedation/Analgesia should be able to rescue
  patients who enter a state of Deep
  Sedation/Analgesia
• Individuals administering Deep Sedation/Analgesia
  should be able to rescue patients who enter a
  state of General Anesthesia

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Managing Complications

• Light Sedation vs. Deep Sedation
• Hypotension - NPO effects
• Hypertension
• Anxiety
• Pain
• Bladder Distention
• Cardiac Dysrhythmias

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Managing Complications (Continued)

• Respiratory Compromise
• Narcotic Induced
• Benzodiazepine Induced
• Upper Airway Obstruction
• Bronchospasm
• Laryngospasm
• Nausea and Vomiting

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Recovery

• Loss of procedural stimulation
• Oxygen therapy immediately available
• Urinary Retention
• Ability to take PO

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Discharge Criteria

• Adequate respiratory function
• Level of consciousness
• Intact protective reflexes
• Vital signs stable
• Mobility consistent with pre-procedural level
• Satisfactory skin color and condition/peripheral
  circulation

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Discharge Criteria (Continued)

• Acceptable nausea/vomiting status
• Acceptable pain management
• Stable operative area
• Understanding by patient and/or significant other
  of Discharge Instructions

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Medications

• Sedatives
• Narcotics
• Reversal Agents

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Sedatives
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Sedatives (Continued)
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Other Sedatives (Induction Agents)

• Propofol
• Achieve deep sedation quickly
• Apnea occurs frequently
• Rapid passage to general anesthesia
• Ketamine
• Produces a dissociative state with profound
  analgesia
• Copious secretions
• Emergence delerium

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Narcotics
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Narcotics (Continued)
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Reversal Agents
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Reversal Agents (Continued)
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Quality Management

• Risk Management
• Quality Management
• Reporting
• Sample Indicators

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Risk Management

• Mechanisms to Reduce Medical Malpractice Related
  to the Administration of Conscious Sedation
• Education, Preparation Requirements for the
  Conscious Sedation Providers
• Quality Management Database
• Data Driven Continuous Quality Improvement

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Quality Improvement Monitoring and Reporting

• The clinical department must regularly reviews
• Quality indicator thresholds should be
  specifically established
• Clear corrective processes should be established
  when these thresholds have been exceeded
• Quality Reports will be completed and forwarded
  to the Quality Office when any of the
  pre-determined adverse outcome criteria are met

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Sample Components of a Conscious Sedation Database

• ANY use of a Reversal Agent
• ANY patient requiring Assisted Ventilation (Bag
  Breathing)
• ANY new cardiac arrhythmia
• ANY desaturation of O2 below 90 sustained for 5
  minutes

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More Sample Components of a Conscious Sedation
Database

• ANY decrease of VS by 30
• ANY failure to return to baseline
• ANY case with unplanned admission resulting from
  sedation
• ANY case wherein review is thought to be
  beneficial

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