Moderate Sedation

1
Moderate Sedation
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3
Description of Course

• This course is designed to provide the health
  care professional with information needed to
  manage a patient receiving moderate sedation
  during a procedure at Tulare Regional Medical
  Center.
• Information for both Adult and Pediatric Sedation
  will be included.

4
Objectives

• Identify the purpose of procedural sedation.
• Explain the criteria for the proper level of
  sedation on the sedation continuum.
• Differentiate between the different levels of
  sedation (example procedural vs. deep).
• Discuss common medications used for sedation,
  including the desired effect, side effects and
  reversal agents.
• Articulate the elements of respiratory depression
  and airway compromise including techniques to
  rescue.
• Explain TRMC policy for Procedural Sedation.

5
Introduction

• Moderate sedation (often referred to as conscious
  sedation or procedural sedation) is a drug
  induced depression of consciousness during which
  a patient is able to respond purposefully to
  verbal commands or light tactile stimulation. No
  interventions are required to maintain a patent
  airway and spontaneous ventilation is adequate.
  Cardiovascular function is usually maintained
  (Cote et al, 2006).

6
Introduction continued

• A growing number of outpatient procedures,
  advances in medical technology, and increasing
  population has lead to an increasing number of
  procedures being performed under moderate
  sedation.
• Basic life support equipment and trained
  personnel should always be immediately available
  when procedural sedation is performed (ASA,
  2002).

7
Definitions

• Local Anesthesia
• Elimination of pain and other sensations in one
  body location utilizing the topical application
  or regional injection of a drug.
• No modification of memory or affect and no
  alteration or loss of consciousness occurs.

8
Definitions cont

• Minimal Sedation (Anxiolysis)
• A drug induced state during which patients
  respond normally to verbal commands.
• Cognitive function and coordination may be
  impaired ventilation and cardiovascular
  functions are unaffected.
• Light sedation occurs following the
  administration of medication for reduction of
  anxiety or pain and allows the patient to
  maintain normal respiration, eye movements, and
  protective reflexes.
• NOTE Medication used for this purpose and for
  sedation of mechanically ventilated patients or
  for urgent/emergent endotracheal intubation is
  not considered moderated sedation therefore not
  part of this module.

9
Definitions cont

• Procedural/Moderate Sedation
• A state of altered consciousness resulting in
  relaxation, euphoria, and amnesia.
• Procedural/Moderate sedation/analgesia is a state
  of depressed consciousness, controlled by drugs,
  allowing protection reflexes to be maintained.
• Patient independently maintains a patient airway
  and appropriately responds to physical
  stimulation and/or verbal commands. The patients
  cardiovascular system is not usually impaired.
• Procedural/Moderate sedation is not the use of IV
  analgesics for pain control when no procedure is
  being conducted.
• NOTE Procedural sedation is not eh use of IM
  sedatives with or with IM analgesics even if an
  invasive procedure is performed.

10
Definitions cont

• Deep Sedation/Analgesia
• A state of depressed consciousness or
  unconsciousness controlled by drugs which may
  result in the partial or complete loss of
  protective reflexes.
• Patients ability to independently maintain a
  patient airway frequently requires airway and
  ventilatory support while cardiovascular function
  is usually maintained.
• The patient ability to respond purposefully to
  physical stimulation or verbal commands is
  compromised.

11
Definitions cont

• Analgesia
• Consists of general anesthesia, as well as spinal
  or major regional anesthesia but no local
  anesthesia.
• General anesthesia is a state of unconsciousness,
  controlled by drugs, resulting in the complete
  loss of protective reflexes.
• Patients ability to maintain an airway
  independently and respond purposefully to
  physical stimulation or verbal command is absent.
• Cardiovascular function may be affected.
• Loss of Protective Reflexes
• Absence of gag reflex and/or ability to maintain
  a patient airway

12
Informed Consent

• Informed consent from the patient (or parent or
  guardian for pediatric patients) must be obtained
  prior to the onset of moderate sedation. Usually
  it is obtained in conjunction with the consent
  for the planned procedure. The pediatric patient
  can be informed with age appropriate expectations
  and directions, but, informed consent can only be
  obtained from a parent or guardian. Important
  elements of informed consent included
• Objectives of Moderate Sedation
• Anticipated Changes in Behavior before and after
  sedation
• Name of anticipated medication to be used and
  side effects
• Post Moderate Sedation limitation of activity

13

• Moderate Sedation Consent form used at TRMC

14
Sedation Continuum

• The American Society of Anesthesiologists (ASA)
  has adopted a continuum for the levels of
  sedation and analgesia from minimal sedation
  (anxiolysis) through general anesthesia. The
  American Academy of Pediatrics (AAP) has adopted
  the continuum and the ASAs recommendations into
  their practice guidelines. This continuum
  provides an easy to follow guide. It is important
  for the clinician to realize the sedation course
  is sometimes unpredictable. It should be noted
  not all patients will follow the continuum in
  exactly the same way and sedation/analgesia must
  be customized for each patient. The clinician
  must take into account each patients age, body
  habitus, developmental status, co-morbidities,
  medications, allergies, and fasting status to
  determine if moderate sedation is the best plan
  of care for that patient. Staging on the
  continuum is based upon the patients
  responsiveness, airway self preservation,
  spontaneous ventilation and cardiovascular
  function. It is important to point out that any
  practitioner should have the capabilities to
  rescue a patient from one level deeper than the
  intended level of sedation (ASA, 2002).

15
ASA Sedation Continuum
16
ASA Sedation Continuum
17
TRMC Policy

• Tulare Regional Medical Center recommends
  procedural/moderate sedation be limited to the
  following areas
• ED, ICU, PICU, OR, Endoscopy, MI, Cath Lab
  (CCVL), Bronchoscopy and Pediatrics.

18
Physician Requirements

• Physician credentialed for administration of
  sedation according to the guidelines established
  and approved by medical staff.
• Must be able to manage complications that may
  occur including rescue from deep sedation.
• Successful completion of TRMC sedation module.
• ACLS certification for adult sedation
• PALS certification for pediatric sedation
  (exception to ACLS/PALS requirement - Certified
  Emergency Medicine Physician and/or Cardiologist
  with documentation of ACLS equivalent of airway
  management skills)
• Other specific criteria available with the
  Medical Staff Office for credentialing
  requirements.

19
Registered Nurse Requirements

• RNs assisting with a procedure requiring moderate
  sedation will be ACLS certified for adult
  sedation and/or PALS certified for pediatric
  sedation and have appropriate competency
  documentation including completion of TRMC
  sedation module.
• Note an RN does not have the authority to
  administer medications which would result in deep
  sedation and/or loss of consciousness.

20
Respiratory Therapist Requirements

• Respiratory Therapists assisting with a
• procedure requiring
• moderate sedation will be
• ACLS certified for adult
• sedation and/or PALS
• certified for pediatric sedation and have
• appropriate competency documentation including
  completion of TRMC sedation module.
• 
  
  

21
TRMC Policy cont.

• An anesthesiologist will be available 24 hours a
  day, 7 days a week as consultants for the
  implementation of sedation.
• Anesthesia will respond to calls requesting
  consultation or resuscitation efforts, should
  they become necessary.
• Anesthesiology can be reached through the
  Operating Room (OR), the Nursing Supervisor, or
  via their pagers.

22
Pharmacology

• The goal of moderate sedation is to allow the
  practitioner to perform the procedure with
  minimal pain and discomfort to the patient.
  Previously sleep deprivation was encouraged as a
  synergistic technique to help with pediatric
  sedation. Recent evidence suggests routine use of
  sleep deprivation may not be beneficial (Shields
  et al, 2004).

23
Pharmacology

• The goal for the pediatric patient receiving
  sedation at TRMC is to maintain safety/ comfort,
  control anxiety/stress, modify behavior/movement,
  minimize psychological trauma, and maximize the
• potiential for amnesia.

24
Pharmacology

• There is no standard recipe for moderate
  sedation, however, a combination of
  benzodiazepines and opioids is used most often.
• TRMC policy 12-1054 Policy and Procedure for
  Procedural/Moderate Sedation-Analgesia has a
  table of recommended medications for Moderate
  Sedation (see following 2 slides)

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Medications for Moderate Sedation
26
Medications for Moderate Sedation
27
Medications for Moderate Sedation
28
Medications for Moderate Sedation
29
Pharmacology

• Medications for pediatric sedation should be
  based upon their effects, duration of action,
  ease of reversal, and relative safety.
• It is important to keep in mind the widely varied
  individual patient response to medications and
  the synergistic effect they have when used
  together.
• Regardless of the choice of medications they
  should be carefully titrated with adequate time
  to exert their maximal effect (AAP, 2006)

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Benzodiazepines

• Diazepam can also be used but is longer lasting
  and may lengthen the recovery time.
• Benzodiazepines are synergistic with opioids and
  IV sedatives. In the pediatric patient, the
  combination of fentanyl and midazolam appear to
  result in a greater risk of respiratory
  depression.

• Benzodiazepines are the most commonly used class
  of drugs in sedation.
• Midazolam is preferred due to its quick onset,
  short duration and lack of residual metabolites.
  Midazolam also provides better amnesic properties
  than other benzodiazepines.

31
Opioids

• Opioids are commonly used as an adjunct in
  moderate sedation in order to provide analgesia
  in combination with benzodiazepines or IV
  sedatives. Fentanyl and meperidine are the most
  commonly used opioids during moderate sedation.
• Meperidine has a greater synergistic effect with
  midazolam, while fentanyl carries a greater risk
  of respiratory depression than the analgesic
  effect it provides. Meperidine also produces
  more nausea and may cause the accumulation of
  metabolites in those with renal insufficiency.
• Side effects of Opioids include respiratory
  depression, pruritis, nausea/vomiting,
  bradycardia, hypotension, muscle rigidity,
  urinary retention, and biliary spasms.
• Contraindications and precautions include use in
  patients with increased intracranial pressure,
  decreased respiratory capacity, allergy, and it
  may impair a persons mental judgment.

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Chloral Hydrate

• Chloral hydrate is a sedative hypnotic agent
  first introduced into clinical practice in the
  middle 1800s. The drug may be administered orally
  or rectally and was first described as an
  anxiolytic adjunct for dental procedures or as a
  single or combined sedative agent for painless
  diagnostic studies. It is not indicated as a
  first-line sedative for ages greater than 2 years
  (decreased efficacy rated).

33
Other Agents

• IV sedative agents such as
  propofol, etomidate, and ketamine are not
  commonly used in moderate sedation, and are
  generally considered beyond the scope of
  procedural sedation.
• Use of these anesthetics are usually associated
  with deep sedation or general anesthesia.

34
Propofol

• There has been significant controversy over the
  use of propofol for nurse administered sedation.
  Many states have laws preventing nurses from
  administering propofol outside an intensive care
  sedation setting. It is the position of the ASA
  and the manufacturers of propofol that the
  medication not be used by anyone other than
  properly trained and credentialed anesthesia
  providers (ASA, 2009) (FDA 2006).

35
Reversal Agents

• An important aspect in the selection of
  pharmacological agents in moderate sedation is
  the ability to reverse the agents if the patient
  needs to be rescued from a deeper level of
  sedation.

This is one of the reasons agents such as
ketamine, propofol and etomidate are not used
with moderate sedation.
36
Reversal Agents

• Opiates can be reversed using an opioid
  antagonist such as naloxone (Narcan).
• Benzodiazepines can be reversed using flumazenil
  (Romazicon).
• Important Antagonists may have shorter half
  lives than the agonists being reversed.
  Additional doses may be needed to prevent
  re-sedation.

37
Evaluation

• Appropriate patient selection criteria are
  important factors in moderate sedation.
• The patient must be evaluated and the assessment
  of the risk must be performed.
• The ASA has devised a patient categorization
  system based upon patient co-morbidities and risk
  of adverse events.

38
ASA physical Status

• As the ASA physical status increases, the risk of
  complication from anesthesia increases.
• Moderate sedation is not recommended for
  patients with an ASA
  status class greater than 3.

39
ASA Classification

• Class I Normal healthy patient
• Class II Mild systemic disease (e.g. controlled
  reactive airway disease, essential hypertension
  medication)
• Class III Severe systemic disease (e.g. active
  wheezing, stable coronary artery disease)
• Class IV Severe systemic disease that is
  constant threat to life (e.g. active myocarditis)
  NOTE No class 4 will be performed on an
  outpatient basis.
• Class V Moribund patient not expected to
  survive 24 hours.
• Class VI patient declared brain dead whose
  organs are being removed for donation.
• E (suffix) Emergency (e.g. otherwise healthy
  patient presenting for fracture reduction)

40
Airway evaluation

• Special attention must be given to the patients
  airway. A difficult airway is an airway where
  mask ventilation or orotracheal intubation is
  difficult to establish by a trained airway expert
  (anesthesiologist). In a closed claims review
  respiratory compromise accounted for the single
  largest class of adverse outcomes (Cheney FW et
  al, 1991).
• At TRMC if the patient is found to be ASA class
  4, the physician will contact the
  anesthesiologist and the patient will only be
  sedated as an inpatient (no class 4 shall be
  sedated on an outpatient basis).

41
Pediatric Airway

• The pediatric airway differs from the adult
  airway in many ways. The pediatric airway is
• Smaller
• Proportionally larger head relative to body size
• Relatively larger tongue
• Shorter, narrower, softer, floppier, and
  horizontally placed epiglottis
• Cephalad larynx (C2-3 versus C4-5 in adult)
• Shorter, narrower trachea
• Funnel shaped versus cylindrical shaped airway
• Cricoid cartilage is the narrowest part

42
Difficult Airway

• There is no one evaluation which will determine
  whether a patient will have a difficult airway.
  Any of the following conditions may be considered
  a potential difficult airway
• Macroglossia
• -Downs Syndrome (Trisomy 21)
• -Children have larger tongue compared to adults
• -Mucopolysaccharidosis
• Mandibular Hypoplasia
• -Pierre-Robin Syndrome
• -Crouzon Disease
• -Goldenhar Syndrome
• -Treacher-Collins Syndrome

43
Difficult Airway continued

• Limited Alanto-occipital motion
• -Goldenhar Syndrome
• -Klippel-Feil Syndrome
• -Juvenile Rheumatoid Arthritis
• -Scoliosis
• External/Internal compression
• -Hemangiomas
• -Tumors
• -Abscesses
• -Vascular Rings
• -Cysts

• Unstable Alanto-occipital motion
• -Downs Syndrome
• Tonsillar and Adenoid
• Hypertrophy
• Obesity
• Facial Trauma

44
Difficult Airway continued

• Adult patients who have difficulty extending
  their necks, have lt 3 finger breadths of
  distance between upper and lower incisors, or lt 3
  finger breadths distance between their hyoid bone
  and mental process, may all be potiential
  difficult airways.
• The Mallampati airway classification system (used
  at TRMC) is an important tool in evaluating the
  patients airway.
• To classify the patient have the patient extend
  their neck, fully open their mouth and stick out
  their tongue to observe the hard palate, soft
  palate, uvula, faucial pillars and pharynx.
  Depending upon what is visualized, the patient is
  classified according to the chart on the next
  slide.

45
Difficult Airway continued

• Class I soft palate, uvula, faucial pillars
  visualizedClass II soft palate, faucial pillars
  visualized, portion of uvula Class III soft
  palate, base of uvulaClass IV hard palate only,
  soft palate not visualized

46
Paperwork

• Prior to the procedure requiring Moderate
  Sedation, the physician will complete a
  Pre-Procedure Patient Evaluation of the airway.
• Those involved in bedside sedation procedures
  will complete the Universal Protocol and Fire
  Risk Assessment for Bedside Procedure form.
• During the procedure a Moderate Sedation Record
  will be completed.
• Samples of forms used at TRMC are on the
  following slides

47

• Pre-Procedure
• Patient Evaluation/
• Sedation Record used at TRMC
• (completed by physicians)

48

• Universal Protocol Fire Assess-ment for
  Bedside Procedure Record

49

• Universal Protocol Fire Assess-ment for
  Bedside Procedure (back side)

50

• Procedural Sedation Record (with sedation scale)
  used at TRMC form 1023.

51
NPO Guidelines

• Aspiration pneumonia is a risk anytime a patient
  is to undergo a procedure with moderate sedation.
  As the patient is sedated he or she may lose the
  reflexes that protect their airway allowing
  gastric contents to flow up the esophagus and
  down into the lings. This can lead to aspiration
  pneumonitits, respiratory failure, and even
  death.
• Factors that have shown to increase risk of
  aspiration are increasing ASA physical status,
  emergency procedures, parturients, obesity, and
  those with gastric esophageal reflux disease.
• Guidelines for fasting periods should generally
  follow those created by the ASA for general
  anesthesia (Cote et al, 2006)

52
NPO Recommendations

• Ingested Material Minimum NPO Time Description
• Clear liquids 2 hours water, fruit juice,
  carbonated beverages,
  clear tea, black coffee
• Breast Milk 4 hours
• Infant Formula 6 hours
• Non-Human Milk 6 hours
• Light Meal 6 hours toast, clear liquids, no
  meats or fatty foods (prolong gastric
  emptying time)

53
Rescue

• The concept of rescue is essential to safe
  sedation. Practioners must have the skills to
  rescue the patient from a deeper level than
  intended for the procedure (Cote et al, 2006).
  The ability to manage an airway in this
  circumstance should not be overlooked and
  appropriately sized emergency airway equipment
  such as an oral airway and bag valve mask should
  be immediately available anytime moderate
  sedation is being performed (ASA, 2002).

54
Monitoring
Monitoring will include ECG, BP, EKG (HR), RR,
Pulse Oximetry, LOC.

• The purpose of monitoring is to provide a trend
  and early warning system for treatment of the
  patient to avoid complication from sedation. The
  patient should be observed continuously with
  recording of vital signs and other indicated
  parameters on an intermittent basis. The period
  of vital sign monitoring should be adjusted for
  the condition of the patient and the procedure
  being performed. It is suggested the frequency of
  the vitals not be more than 5 minutes.

55
Monitoring continued

• Cote et al, recommends adding EtCO2 monitoring
  when respirations cannot be visualized, when
  sedation becomes deep, or with pediatric
  sedation.
• The person monitoring the patient status should
  not be the same person performing the procedure
  (ASA, 2002).

56
Monitoring continued

• Consciousness is a major monitoring parameter.
  Patients undergoing moderate sedation should
  maintain the ability to respond to simple verbal
  or tactile stimulation. If the patient fails to
  respond or it takes repeated stimuli in order to
  elicit a response the patient has moved into deep

sedation criteria and should be rescued back
into moderate sedation (ASA, 2002).
57
Monitoring continued

• End Tidal Carbon Dioxide monitoring (EtCO2) or
  capnography will detect the concentration of
  carbon dioxide in the patients exhaled breath by
  drawing a sample of the breath into the monitor
  and using an infrared beam or gas chromatography
  to measure the concentration.

58
Monitoring continued

• The results are then displayed as either a
  numerical value or more usefully as a graph
  plotted against time. Careful monitoring of this
  waveform can lead to the detection of respiratory
  insufficiency, apnea, or airway obstruction often
  before desaturation is detected in pulse
  oximetry.
• Disadvantages of this technology are the cost of
  the monitor and possible distorted reading when
  using high flow oxygen.

59
Monitoring continued

• According to Vargo et al, the use of EtCO2
  monitoring was more successful in detecting apnea
  and hypoventilation, more than both pulse
  oximetry and visual observation during procedural
  sedation.
• Miner et al, found EtCO2 monitoring during
  procedural sedation in the emergency room may add
  to the safety of the sedation by detecting
  episodes of hypoventilation.
• The use of expired carbon dioxide monitoring
  devices is encouraged for sedated children,
  particularly in situations where other means of
  assessing the adequacy of ventilation are limited
  (Cote et al, 2006).

60
Capnography

• Normal EtCO2
• Asthma EtCO2
• Obstructive EtCO2

61
Capnography continued

• The previous images show a normal, small airway
  obstruction (asthma), and large airway
  obstruction.
• A normal airway pattern has a gentle but sharp
  upstroke, a gentle increasing top and a gentle
  but sharp down stroke.
• The slope of the top and higher number indicate
  an asthmatic or small airway obstruction.
• Irregular patterns or the absence of a pattern
  indicates and obstructed airway.
• Capnography is an early detector of inadequate
  respiratory function. Respiratory events leading
  to death occurred twice as often when patients
  were sedated outside the operating room (Cravero
  JP, et al 2004).

62
Capnography continued

• In October 2010 the American Society of
  Anesthesiologists (ASA) committee on Standards
  and Practice Parameters updated the anesthetic
  standards of monitoring to include exhaled carbon
  dioxide monitoring not just for endotracheal tube
  or laryngeal mask general anesthetics (3.2.2) but
  expanded for moderate and deep sedation cases.
• During moderate or deep sedation the adequacy of
  ventilation shall be evaluated by continual
  observation of qualitative clinical signs and
  monitoring for the presence of exhaled carbon
  dioxide unless precluded or invalidated by the
  nature of the patient, procedure or equipment
  (3.2.4). This became effective July 1, 2011.

63
Discharge Criteria

• Patients receiving procedural/moderate sedation
  are to be monitored by a Registered Nurse until
  discharge criteria are satisfied.
• Patients are to be monitored for a minimum of 30
  minutes from the last dose of medication or until
  the Aldrete score is 8 or greater or until the
  patient reaches his/her pre-procedure baseline
  score.
• If a reversal agent is given to the patient the
  RN must monitor the patient for 90 minutes from
  the time the reversing agent is given.
• Post procedural documentation shall include
  minimally
• Vital signs within 5 minutes and reassessment
  every 5-15 minutes
• Assessment of patients level of comfort
• LOC / mental status
• Intact protective reflexes
• Aldrete Score
• Discharge education

64
Discharge Criteria continued

• The patient must meet all discharge criteria
  (Physician order)
• Aldrete Score gt or 8, or at pre-procedure level
  
• Documented BP is within 20mm/Hg of the admitting
  BP
• Respirations unlabored and patient able to deep
  breathe and cough freely or at pre-procedure
  levels
• Absence of respiratory distress
• Alert and oriented or LOC returned to
  pre-procedure level
• Tolerates fluids with minimal nausea and vomiting
  (notify the physician if the patient is actively
  vomiting)
• Pain is adequately managed, and pain is
  appropriate for procedure
• Swallow, cough and gag reflex present, protective
  reflexes intact.
• Dressing (if applicable) dry/intact or with
  minimal drainage appropriate for procedure
• Reference Policy 20-20,002 Standardized
  Procedure Discharge of Patients from Ambulatory
  Care Unit by an RN

65
Pediatric Discharge Criteria

• After a procedure, adequate time must be allowed
  for the patient to recover from the effects of
  moderate sedation. Recommended guidelines for how
  long a pediatric patient should be monitored is
  as follows
• 2 hours for infants lt 5.5 kg
• 4 hours for infants lt 4.5 kg
• 2 hours for infants lt 6-12 months
• 4 hours and overnight admission for
• ex-premature infants lt50 52 weeks
• post-conception age

66
Pediatric Discharge Criteria

• With outpatient sedation, the American Academy of
  Pediatrics has developed the following discharge
  criteria
• Cardiovascular function and airway patency are
  satisfactory and stable
• Patient is easily arousable and protective
  reflexes are intact
• Patient can talk (if age appropriate)
• Patient can sit up unaided (if age appropriate)
• The state of hydration is adequate
• For a very young or handicapped child incapable
  of the usual expected responses, the pre-sedation
  level of responsiveness or a level as close a
  possible to the normal level for that child
  should be achieved.

67

• TRMC Recovery (Phase II and Phase III with
  Aldrete Score) Record
• form 1019.

68
TRMC Pediatric Sedation

• Policy 12-1054 contains additional information
  concerning Pediatric Sedation at TRMC. In
  conjunction with previous standards, keep the
  following in mind
• Age criteria for Pediatric patients at TRMC is
  2-3 days old through 13 years of age (Pediatric
  Scope of Service).
• Continuous (Blood Pressure) BP monitoring may be
  altered or suspended if BP interferes with the
  completion of the procedure. The reason for
  omission must be documented in the patient
  record. In this circumstance continuous heart
  rate, respiratory rate, and pulse oximetry will
  not be interrupted. BP monitoring will resume
  post procedure.

69
TRMC Pediatric Sedation cont.

• Pediatric patients receiving oral medication for
  sedation purposes and have no prior cardiac
  history, may be monitored with continuous pulse
  oximetry and heart rate only. EKG monitoring may
  or may not be used according to patient tolerance
  and risk of procedure.
• The physician/pediatrician must be present for
  pediatric oral sedation procedures (TJC 2010).

70
TRMC Pediatric Sedation cont.

• Orally sedated out-patients in the Pediatric Unit
  may or may not have IV access dependent on
  physician orders, assessment risk, and risk of
  procedure.
• Emergency Department pediatric patients receiving
  moderate sedation will have IV assess
  established.

71
Quality Improvement at TRMC

• Outcomes of patients undergoing moderate and deep
  sedation are collected and analyzed in order to
  identify opportunities to improve care throughout
  the institution.
• Data will be reported as a component of the
  organization-wide performance improvement
  program.
• The following data are gathered following the
  administration of sedation in any site within the
  facility
• Unplanned admission or transfer to a higher level
  of care
• Administration of reversal agent
• Drop in O2 saturation lt92 for 5-7 minutes
• Failure to conform to documentation requirements

72
Summary

• As the demand for sedation in hospital areas
  increase, the need for non-anesthesia trained
  sedation will continue to increase. Patients
  scheduled to undergo moderate sedation will be
  given a basic thorough health history and
  physical. Special attention should be given to
  any conditions which may interfere with
  respiratory or cardiovascular function. If
  concerns arise, some conditions may warrant
  consultation with an anesthesia professional.
• The patients NPO status and preoperative
  medication regimen should also be reviewed.
• Proper monitoring by trained personnel not
  performing the procedure will be provided with
  baseline values recorded. Monitoring will be
  continued until the patient returns to his or her
  baseline status.

73
Summary Continued

• Proper sedation agents should be used and
  titrated slowly, to effect, and in small doses
  (especially with pediatric sedation) paying
  careful attention to established ranges and
  maximums of dosing.
• If deep sedation is encountered ventilatory
  and/or cardiovascular assistance will be rendered
  by trained personnel and correct reversal agents
  should be administered to return the patient to
  moderate sedation level.
• As new technologies and evidence based practice
  continue to emerge the provider should continue
  his or her education into moderate sedation
  trends.

74
References

• American Society of Anesthesiologists (2002).
  Practice guidelines for sedation and analgesia by
  non-anesthesiologists. Anesthesiology,
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• American Society of Anesthesiologists (2009).
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• American Academy of Pediatrics (2006). Dedicated
  to the Health of all Children.
• Cheney FW, Posner KL, Caplan RA. (1991). Adverse
  respiratory events infrequently leading to
  malpractice suits A closed claims analysis.
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• Colson, J. (2005). The Pharmacology of sedation.
  Pain Physician, 8, 297-308.
• Cote C, Wilson S. (2006). Guidelines for
  monitoring and management of pediatric patients
  during and after sedation for diagnostic and
  therapeutic procedures an update. Pediatrics,
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• Cravero J, Blike G. (2004). Review of pediatric
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75
References continued

• Hata K, Andoh A, Klyoyuki H, Ogawa A, Nakahara T,
  Tsujikawa T, Fujiyama Y, Saito Y. (2009)
  Usefulness of Bispectoral Monitoring of Conscious
  Sedation during Endoscopic Mucosal Dissection.
  World Journal of Gastroenterology. 15(5)595-598.
• Shields C, Johnson S, Knoll J, Chess C,
  Goldberg D.(2004). Sleep deprivation for
  pediatric sedated procedures not worth the
  effort. Pediatrics, 113(5), 1204-1208.
• TRMC Policy 12-1054, Policy and Procedure for
  Procedural/Moderate Sedation-Analgesia.
• TRMC Policy 20-20,002, Standardized Procedure -
  Discharge of Patients from Ambulatory Care Unit
  by an RN.
• TRMC Procedural Moderate Sedation Record 1023
  Phase II and Phase III Procedure Recovery Record
  1019 Pre-Procedure Patient Evaluation/Sedation
  Plan Universal Protocol Fire Assessment for
  Bedside Procedure Record 1781.

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