Conscious Sedation

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Conscious Sedation

• Carol Elliott

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Conscious Sedation

• Being awake and aware but yet being free of
  anxiety

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Analgesia

• State of being without pain
• (Tabers Dictionary)

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What We Really Want

• Free of anxiety
• Free of pain
• Arousable
• Ventilating
• In control of airway reflexes
• Amnesia

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Sedation and Analgesia

• New term for conscious sedation
• Relief of anxiety and pain
• Stops short of general anesthesia

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General Anesthesia

• Complete loss of sensation with loss of
  consciousness
• Respiratory drive and airway reflexes may be lost

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National Federation of Specialty Nurse
Organizations (NFSNO)
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NFSNO

• Addressed the question of who may sedate
• Privilege to sedate should be based on
  qualifications, not title
• Person sedating and monitoring should not have
  any other duties

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Sedation and analgesia may be administered by any
health care worker who
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Administration of Anesthesia

• Is licensed to administer drugs
• Knows pharmacology considerations
• Knows how to monitor the patient
• Is able to intervene to prevent harm to the
  patient

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Patient Selection

• Patient selection is critical
• Minor surgical or diagnostic procedures
• Relatively healthy patients
• Consider limitations of your environment
• Patient safety must be the priority

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Indications

• Oral surgery / dentistry
• Supplement local / regional anesthesia
• Orthopedic procedures
• Removal of skeletal fixation
• Knee arthroscopy
• Minor peripheral procedures

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Indications (cont)

• Minor GYN procedures
• D C
• Laser procedures
• Plastic surgery
• Face lift
• Scar revisions

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Indications (cont)

• ENT
• Rhinoplasty
• Myringotomy
• General surgery
• Biopsies
• Line placement

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Indications (cont)

• Eye
• Cataract
• Blepharoplasty
• Gastroenterology
• Diagnostic X-Ray

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Pharmacologic Intervention

• Sedatives
• Narcotics
• Cardiovascular drugs

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Sedative Drugs

• Benzodiazepines
• Barbiturates
• Chloral hydrate

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Benzodiazepines

• Sedation
• Hypnosis
• Decreased anxiety
• Muscle relaxation
• Antegrade amnesia
• Anticonvulsant

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Benzodiazepines (con't.)

• Act within the CNS
• GABA inhibits neurotransmission
• Glycine inhibits neuronal pathways in the brain
  stem

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Diazepam (Valium)

• Dose 5 - 10 mg
• May be given p.o. 30-60 minutes preop
• Painful if injected
• May cause phlebitis
• Has active metabolites

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Lorazepam

• Dose 2 - 4 mg
• Prolonged sedation
• Profound amnesia

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Midazolam (Versed)

• Dose 1 - 5 mg
• Short duration
• Good sedation
• Dose dependent amnesia
• No pain on injection

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Barbiturates

• Time-honored sedatives
• Less safe than benzodiazepines
• No analgesic effect
• Used to induce general anesthesia

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Barbiturates (cont)

• Secobarbital
• Dose 50 - 200 mg p.o.
• Sedation lasts 4 hours
• May impair performance 10-22 hours

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Butyrophenones

• Droperidol
• Dose 2.5 - 7.5 mg IV
• Do NOT give alone
• Produces sedation
• Good anti-emetic

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Narcotics

• Dose-dependent analgesia
• Produce respiratory depression
• Cause orthostatic hypertension

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Narcotics (cont)

• Cause nausea
• NOT good for
• Relief of anxiety
• Sedation
• Amnesia
• Cause itching

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Narcotics (cont)

• Morphine
• Dose 5 - 10 mg IV
• Side effects are dose dependent
• Longer duration than other narcotics

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Narcotics (cont)

• Meperidine (Demerol)
• Dose 50 - 100 mg
• May be given p.o.
• Not commonly used in the OR
• May be good choice for outpatients

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Narcotics (cont)

• Fentanyl
• Dose 1 - 3 mcg/kg (50 - 200 mg)
• Potent and fast acting
• May depress respirations
• May cause truncal rigidity
• Give slowly

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Propofol

• Milk of Amnesia
• Anesthesia induction agent
• Use low dose for sedation
• .5 - .75 mcg / kg bolus
• .5 - 1 mcg / kg / min infusion

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Propofol (cont)

• Use with extreme caution
• Good anti-emetic
• Ultra short action - rapid recovery

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Ketamine

• Produces dissociative state
• Respirations maintained
• Airway reflexes hyperactive
• Blood pressure maintained
• May cause hallucinations

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Monitoring

• Standards for monitoring
• Professional organization
• Institutional protocol

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Observation

• Direct observation by trained HCW
• Level of consciousness
• Rate and depth of respiration
• Vital signs

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Communication

• Establish rapport
• Maintain verbal contact
• Reassure as needed

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Oxygenation

• Skin color is not reliable
• Pulse oximetry is the standard
• Non-invasive
• Provides real time O2 saturation
• Confirms capillary circulation
• Single most important monitor

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ECG

• Documents rate and rhythm
• Indicates cardiac ischemia
• ST segment analysis

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Capnography

• Measures end-tidal CO2
• Documents ventilation
• May be connected to nasal prongs
• Identifies placement of endotracheal tube in
  trachea
• Not commonly available outside the OR

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Management of Emergencies

• Follow ACLS protocols
• Use a calm, graded response
• Respiratory depression
• Arouse the patient
• Chin lift
• Oral airway

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Emergency Management (cont)

• Respiratory depression (cont)
• Mask ventilation
• Endotracheal intubation
• Hyper / hypotension
• Make sure monitors are functioning correctly
• Vasopressors / dilators as needed

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Pharmacologic Reversal

• Speeds recovery from narcotic or benzodiazepine
• Use only as a rescue drug
• Careful titration eliminates need for reversal
• Reversal is not without danger

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Benzodiazepines

• Use flumazenil (0.1 mg / ml)
• Give incremental doses of 0.2 mg up to 1 mg
  total
• May precipitate seizures
• May precipitate withdrawal

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Narcotics

• Use naloxone (0.4 mg / ml)
• Dilute to 10 ccs ( 0.4 mg / ml)
• Titrate to effect
• Will reverse analgesia
• May cause withdrawal

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Narcotics (cont)

• May cause pulmonary edema
• Caution Naloxone may have a shorter duration
  than the narcotic