SEDATION AND ANALGESIA: non-ventilator



Sedation/Analgesia (Moderate/Deep)

Policy & Procedure

Purpose

To establish guidelines and procedures for administration of sedation/analgesia given by physicians who are not specialists in anesthesiology.

To establish guidelines and procedures for monitoring patients receiving sedation/analgesia as part of diagnostic, therapeutic or invasive procedures.

II. Scope

This policy applies to all patients, in any setting, for any purpose, by any route, that receive sedation/analgesia for a diagnostic, therapeutic or invasive procedure. All patients who are undergoing procedures and receiving sedation/analgesia prior to and during the procedure will receive one standard of care throughout the facility.

This policy DOES NOT:

▪ Include patients who require general anesthesia and have lost protective reflexes and are unable to maintain a patent airway independently

▪ Include patients who require therapeutic pain management

▪ Include patients who require sedation for maintenance on a ventilator

▪ Include patients who require sedation to control seizures

▪ Include patients that undergo monitored anesthesia care (MAC) given by anesthesia providers

III. Definitions

Degrees of Sedation

The American Society of Anesthesiologists (ASA) recognizes the following levels of sedation/analgesia and anesthesia: minimal, moderate (conscious sedation), deep and general anesthesia. The various degrees of sedation occur on a continuum: minimal, moderate, deep, and general anesthesia. The patient may progress from one degree to another, based on the medications administered, route, dosages, age and physical status of the patient. The determination of patient monitoring and staffing requirements will be based on a patient’s acuity and the potential response of the patient to the procedure. Only qualified individuals will administer pharmacological agents to predictably achieve desired levels of sedation and monitor patients in order to maintain them at the desired level of sedation.

Anesthesia – Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Sedation - represents a continuum of consciousness to unconsciousness with three levels most commonly described: minimal, moderate, and deep sedation.

Minimal sedation (anxiolysis) – A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate sedation/analgesia (formerly conscious sedation) – A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Sedation/analgesia is generally achieved when there is slurred speech, but the patient is arousable, able to respond, and retains the ability to independently maintain a patent airway.

(Note: Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.)

Deep sedation/analgesia – A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

Policy

1. Sedation/analgesia is provided by physicians that have received training in the administration of pharmacological agents for diagnostic or therapeutic procedures. The physician must be trained in and capable of managing airways and have clinical privileges to administer sedation/analgesia.

2. Individuals that provide sedation/analgesia should also be trained on standards and techniques to monitor patients carefully in order to maintain them at the desired level of sedation and to manage complications of sedation techniques.

3. Individuals administering sedation/analgesia will have the appropriate credentials to manage patient at whatever level of sedation is achieved, moderate or deep, either intentionally or unintentionally. Physicians may request clinical privileges for moderate sedation/analgesia (conscious sedation), deep sedation, or both. The chairperson of the Anesthesia Committee will review each request for initial and subsequent clinical privileges for sedation (moderate or deep) and forward the findings to the Credentials Committee.

4. The physician has the ultimate responsibility for the safety and welfare of the patient undergoing sedation. A history and physical evaluation performed by the physician must be obtained prior to administering medication for sedation/analgesia cases.

5. Physicians who provide sedation/analgesia must be re-credentialed every two years. Nursing staff that provide assistance during sedation/analgesia must demonstrate competency on an annual basis.

6. Sedation/analgesia may be administered by the attending Physician, consulting Physician, or RN under the direct supervision of a physician who has been granted sedation/analgesia privileges. (EXCEPTION: Deep sedation agents, such as Methohexital [Brevital] and Fentanyl may only be administered by a physician).

7. The nurse responsible for monitoring the patient should have completed appropriate education and training related to sedation/analgesia, be able to demonstrate a working knowledge of resuscitation equipment, be able to demonstrate the function and use of monitoring equipment, and be able to interpret data obtained.

8. Appropriate medical specialists should be consulted before administration of sedation/analgesia to patients with significant underlying conditions. The choice of specialists depends on the nature of the underlying condition and the urgency of the situation. If it appears likely that sedation to the point of unresponsiveness or general anesthesia will be necessary to obtain adequate conditions, practitioners who are not specifically qualified to provide these modalities should consult an anesthesiologist.

9. The minimum number of available personnel for a procedure involving moderate sedation/analgesia is two: a Physician who performs the procedure, and a registered nurse (RN) who continuously monitors the patient and assists in any supportive or resuscitative measures. Both personnel must be present during the initial and continued administration of sedation/analgesia and remain in attendance until the patient’s vital signs and state of consciousness are at baseline or stable.

10. The minimum number of available personnel for a procedure involving deep sedation/analgesia is three: a physician who performs the procedure, a registered nurse (RN) who continuously monitors the patient and assists in any supportive or resuscitative measures and a second nurse (RN or LVN) or technician (GI Lab tech, Radiology tech, etc). A respiratory therapist is optional at the physician’s request for deep sedation procedures.

11. Emergency resuscitation equipment to monitor the patient’s heart rate and oxygenation will be available and in the patient’s room or procedure area during sedation/analgesia.

12. The physician is responsible for obtaining informed consent for the procedure and for sedation/analgesia prior to a procedure involving sedation/analgesia. Relative to the planned procedure and the sedation/analgesia, information is provided regarding the following:

a. Potential benefits and drawbacks;

b. Potential problems related to recuperation;

c. Likelihood of success;

d. Possible results of non-treatment; and

e. Any significant alternatives.

13. A history and physical examination performed by a physician and a nursing assessment and individualized nursing care plan are required for each patient before any procedure involving moderate or deep sedation/analgesia. The physician must state whether moderate or deep sedation will be used. The physician must determine and document that the patient is an appropriate candidate for the level of sedation selected. The RN should prioritize the patient’s nursing care needs.

14. The physiological status (i.e., BP, HR, RR, O2 sat, EKG, LOC) of each patient undergoing moderate or deep sedation/analgesia is monitored before, during and following the procedure.

15. The nurse will collect, analyze and document each patient’s physiological information during the post-sedation period to establish eligibility for discharge according to approved criteria.

16. Patients are discharged from the post-sedation area by a qualified physician OR according to criteria approved by the Department of Anesthesia.

17. The Department of Anesthesia will oversee sedation/analgesia practices (policies, procedures, credentialing) throughout the hospital to assure optimal patient outcomes. The Department of Anesthesia will follow-up adverse outcomes and report their findings and recommendations to the Medical Executive Committee as needed.

18. The sedation/analgesia policy is employed when the following agents are used in conjunction with a therapeutic, diagnostic or invasive procedure:

▪ IV/IM narcotics employed with IV/IM benzodiazepine, OR

▪ IV/IM diazepam or midazolam employed +/- narcotic, OR use of methohexital (Brevital)

▪ Opioid or mixed agonist/antagonist, OR

▪ PO/PR Chloral Hydrate

The sedation/analgesia policy is NOT employed with the use of:

▪ Pre-operative benzodiazepine for anxiolysis, OR

▪ Oral benzodiazepine is the only medication (e.g., lorazepam dose < 2 mg)

19. The administration of intravenous sedation/analgesia will be limited to medications approved by the Department of Anesthesia at the recommended doses (See Dosing Guidelines for Sedation/Analgesia). The doses may be repeated as indicated to achieve adequate sedation/analgesia.

20. In emergent situations (life or limb), physicians may deviate from the policy and guidelines and use their professional judgment to meet the immediate acute care needs of the patient.

21. Sedation/analgesia may be performed in the following areas:

Critical Care Units Cardiac Catheterization Laboratory

Emergency Department Medical – Telemetry

Radiology, including MRI Labor and Delivery

Outpatient Surgery/ GI Lab / Endoscopy Pediatrics

Attachments

Appendix A – Fasting Guidelines

Appendix B - Dosing Guidelines for Moderate Sedation/analgesia – Adult

Appendix C – Dosing Guidelines for Moderate Sedation/analgesia – Pediatric

Appendix D – Dosing Guidelines for Deep Sedation – Adult, Pediatric

Appendix E – Dosing Guidelines for Reversal Agents – Adult, Pediatric

Appendix F - Comparison of Equipment and Personnel – Moderate and Deep Sedation

Appendix H - Patient Instructions – Pre-Sedation and Post-Sedation

Appendix I - Sedation/Analgesia Workshop

PROCEDURE

A. PHYSICIAN PRIVILEGES AND CREDENTIALING

1. Physicians will be granted privileges to administer sedation/analgesia based on the following criteria:

a) Be knowledgeable of proper dosages, administration, adverse reactions, and interventions for medications used to procedure sedation analgesia – moderate or deep.

b) Be knowledgeable regarding reversal agents.

c) Be knowledgeable regarding medications used to rescue the patient should undesired effects of sedation analgesia occur.

d) Know how to evaluation and recognize airway obstruction and demonstrate skill in airway management and resuscitation. BLS is required or comparable training for moderate and deep sedation.

e) Assess total patient care requirements/parameters, including but not limited to, respiratory rate, oxygen saturation, blood pressure, cardiac rate and rhythm, and level of consciousness.

f) Have the knowledge and skills to intervene appropriately in the event of complications.

2. Physician Credentialing

Moderate sedation

a) Initial credentialing - Physicians desiring moderate sedation/analgesia privileges must do the following:

▪ Indicate this request on initial application for privileges.

▪ Demonstrate evidence of successful completion of six (6) or more moderate sedation/analgesia cases done in the last 12 consecutive months

▪ Demonstrate evidence of current BLS certification or comparable training or have documentation of completing a course in basic airway management sufficient to rescue the patient from deep sedation.

▪ Sign an acknowledgement indicating they have read the institution’s policy (and Appendices) and that it is understood.

▪ Have the privileges approved by the board of trustees based on the recommendation from the medical executive committee.

b) Re-credentialing (every 2 years) – Physicians that desire to continue with moderate sedation/analgesia privileges must do the following:

▪ Indicate this request on re-application for privileges

▪ Comply with all of the requirements of initial credentialing

Deep Sedation

a) Initial credentialing - Physicians desiring deep sedation/analgesia privileges must do the following:

▪ Indicate this request on initial application for privileges.

▪ Demonstrate evidence that he/she has twelve (12) cases where deep sedation has been administered in the last twelve (12) consecutive months.

▪ Demonstrate evidence of current BLS certification or comparable training or have documentation of completing a course in basic airway management sufficient to rescue the patient from general anesthesia.

▪ Sign an acknowledgement indicating they have read the institution’s policy (and Appendices) and that it is understood.

▪ Have the privileges approved by the board of trustees based on the recommendation from the medical executive committee.

b) Re-credentialing (every 2 years)– Physician that desire to continue with deep sedation/analgesia privileges must do the following:

▪ Indicate this request on re-application for privileges.

▪ Comply with all of the requirements of initial credentialing

B. ELIGIBILITY FOR SEDATION

1. Eligibility for Sedation. Patients who are American Society of Anesthesiologists (ASA) Class I and II are considered appropriate candidates for sedation/analgesia or deep sedation out of the operating room environment. Patients in ASA III, IV, or V present special problems that require additional and individual consideration. The physician performing the sedation/analgesia procedure will use his/her professional judgment in requesting an anesthesia consult. ASA Classifications are determined by the physician ordering sedation.

|Table 1. American Society of Anesthesiologists – Physical Status Classification |

|Class |Summary |

|Class I |A normal healthy patient. |

|Class II |A patient with mild systemic disease and no functional limitations. Examples: non-OR only slightly limiting organic |

| |heart disease; mild diabetes, essential hypertension, or anemia. Patients with extreme obesity and chronic bronchitis |

| |may be included in this category. |

|Class III |A patient with severe systemic disease with definite functional limitations. Examples: severely limiting organic |

| |heart disease; severe diabetes with vascular complications; moderate to severe degrees of pulmonary insufficiency; |

| |angina pectoris, or healed myocardial infarction. |

|Class IV |A patient with severe systemic disease that is a constant threat to life. Example: Patients with organic heart disease|

| |showing marked signs of cardiac insufficiency, persistent anginal syndrome, or active myocarditis; advanced degrees of |

| |pulmonary, hepatic, renal, or endocrine insufficiency. |

|Class V |A moribund patient who is not expected to survive with or without the operation. Example: burst abdominal aneurysm |

| |with profound shock; major cerebral trauma with rapidly increasing intracranial pressure; massive pulmonary embolus. |

| |Most of these patients require operation as a resuscitative measure. |

C. GOALS OF SEDATION/ANALGESIA

1. Guard the patient’s safety and welfare

2. Minimize physical discomfort or pain

3. To allay the anxiety and fear of the patient, thus ensuring an accepting/cooperative patient.

4. Control behavior

5. Return the patient to a state in which safe discharge is possible.

D. MODERATE AND DEEP SEDATION/ANALGESIA

Involves the administration of pharmacological agents to predictably achieve desired levels of sedation, and monitoring patients carefully in order to maintain them at the desired level of sedation.

1. Pre-Assessment for Moderate or Deep Sedation/Analgesia and Plan of Care

A pre-sedation assessment will be performed and documented for each patient before moderate or deep sedation use. The pre-sedation should collect information needed to:

▪ Select and plan sedation (moderate or deep sedation)

▪ Safely administer moderate or deep sedation, and

▪ Interpret findings of patient monitoring

Physician Responsibilities include:

a.) Documentation of a baseline health assessment is to include but not limited to:

1. Vital signs

2. Results of labs/x-rays ordered

3. Results of consultations, when ordered

4. Health history including:

▪ Age of the patient

▪ Allergies

▪ Previous adverse drug responses with anesthesia and/or sedation

▪ Current medications

▪ Review of systems

▪ Diseases, disorders, abnormalities,

▪ Prior hospitalizations

5. Results of physical exam reflecting:

▪ Height and weight

▪ Baseline vital signs

▪ Pulmonary and cardiac examination, and

▪ Risk assessment including ASA classification

▪ Patent airway

6. Pregnancy status (if warranted);

7. Informed consent(s) (for procedure and for sedation/analgesia)

8. ASA status (See Table 1)

9. Attest that the patient is a candidate for the planned sedation/analgesia

The RN will:

▪ Conduct the pre-sedation/procedure assessment to include,

o NPO status, time of last food and fluid intake;

o Current blood pressure, pulse and respirations, oxygen saturation;

o Level of consciousness / sedation status; (Baseline Ramsay)

o Pain level and goal;

o Pulse oximeter value on room air

In addition, the RN should:

▪ Verify that the medical record contains evidence of:

o Informed consent(s), and

o An H&P

▪ Establish intravenous access;

▪ Document the patient pain goal and level of pain

▪ Individualize and prioritize the nursing plan of care; and

▪ Document baseline vital signs on the Sedation/Analgesia Flowsheet taken immediately prior to sedation/analgesia use.

b.) The pre-sedation and pre-procedure plan of care will be developed by the physician and documented in the patient’s medical record. The RN individualizes and prioritizes the patient’s nursing care needs and documents the findings on the Sedation/Analgesia Flowsheet. The patient’s plan of care is communicated among care provider.

.

Personnel

a.) Staffing Protocol

Moderate sedation/analgesia. The minimum number of personnel involved in the care of a patient undergoing moderate sedation/analgesia during the entire procedure shall be two (2). The personnel shall consist of the Physician who performs the procedure and the Registered Nurse. The Registered Nurse’s sole responsibility during the performance of the procedure is to monitor the patient, the patient’s response to both the medications administered, and the procedure. In addition, the Registered Nurse is capable of assisting with any supportive or resuscitative measures.

Deep sedation/analgesia. The minimum number of personnel involved in the care of a patient undergoing deep sedation/analgesia is three - a registered nurse, an LVN/Tech and the Physician performing the procedure.

b.) The Physician and/or Registered Nurse must be with the patient at all times to:

▪ Appropriately evaluate the patient prior to beginning moderate or deep sedation.

▪ Provide the moderate or deep sedation

▪ Perform the procedure

▪ Monitor the patient, and

▪ Recover and discharge the patient from the post-sedation recovery area or from the organization with the use of approved criteria.

c.) Training of Personnel/ Competency

▪ The individual responsible for monitoring the patient shall be trained in the appropriate use of drugs used for sedation/analgesia and be able to recognize the associated complications (respiratory or cardiovascular depression).

▪ The RN and physician who manage the care of the patient undergoing sedation/analgesia must demonstrate competency to administer and monitor sedation/analgesia and are required to:

o Be knowledgeable with proper dosages, administration, adverse reactions, and interventions for adverse reactions and over-dosage;

o Know how to recognize an airway obstruction and demonstrate skills in basic life support; have BLS certification or comparable training;

o Be ACLS certified (RN for moderate and deep sedation); physicians should be BLS certified or comparable training for moderate and deep sedation (ACLS certification is preferred for physicians, but not required)

o Assess total patient care requirements or parameters, including but not limited to respiratory rate, oxygen saturation, blood pressure, cardiac rate, and level of consciousness; and

o Have the knowledge and skills to intervene in the event of complications.

o Have the knowledge on use of the Ramsay Sedation Scale and the Aldrete Scale

3. Environment / Equipment

Patients shall receive sedation/analgesia in areas of the facility that can accommodate special monitoring requirements (e.g. EKG, blood pressure and pulse oximetry monitoring) and can provide emergency care. The following emergency equipment will be readily available prior to, during and after the procedure, until the patient is recovered:

▪ Emergency cart (age appropriate) with reversal agents and defibrillator

▪ Oxygen source, cannulas, masks, airway adjuncts

▪ Adequate suction with catheters, Yankeur tips

▪ Bag-valve-mask device with appropriate fitting masks

▪ Monitors for ECG, blood pressure, pulse oximeter

▪ Equipment and supplies for IV access

4. Re-evaluation

Immediately prior to administration of sedation/analgesia, the Physician performing the moderate or deep sedation/analgesia procedure will re-evaluate the patient for the appropriateness of the plan of care for sedation/analgesia. The RN will record vital signs on the Sedation/Analgesia Flowsheet.

5. Medications

The medications and recommended dosages for moderate or deep sedation/analgesia are listed in Appendices B and C.

1) Medications will be given according to the Physician’s order and the Physician must be present prior to the administration of sedation/analgesia. The dose is determined by the Physician and administered by the Physician or nurse. Dosage is based on age, weight, physical status, and drug tolerance.

Titration of Sedative/Analgesic Medications. The medications used for sedation/analgesia shall be given in small, incremental doses and titrated to effect or a desired endpoint for analgesia and sedation as described in the Dosing Guidelines for Sedation/analgesia. Sufficient time must elapse between doses (at least 2 minutes) to allow the effect of each dose to be assessed before subsequent doses are given. The doses are recommended guidelines that may be modified according to the judgment and practice of the Physician. Follow the adage: “Start Low and Go Slow”. Individualize dosages; do not administer by rapid or single bolus injection; expect individual response.

2) Medication Endpoints for Moderate Sedation/analgesia. The target Ramsay score for moderate sedation/analgesia is 3. Patients should be awake and continue to breathe spontaneously after receiving the drug. The Ramsay score should be re-assessed before supplemental doses of drugs to maintain the desired level of sedation.

3) Medication Endpoints for Deep Sedation/Analgesia. The target Ramsay score for deep sedation/analgesia is 4 or 5. Patients should be asleep and spontaneous ventilation may be inadequate. Ventilatory function may be impaired and patients may require assistance in maintaining a patent airway. Assist with ventilation and oxygen supplementation if needed.

4) Reversal Agents Use of reversal agents is discouraged. The following is criteria for appropriate and inappropriate use of reversal agents in sedation/analgesia.

▪ Appropriate:

▪ Opioid / benzodiazepine toxicity

▪ Opioid / benzodiazepine overdose

▪ Inappropriate:

▪ To accelerate discharge

▪ As a substitute for an adequate period of post-procedure monitoring

6. Ramsay Scale The Ramsay Sedation Scale will be used to assess sedation/analgesia during diagnostic, therapeutic or invasive procedures. A sedation score of 1 - 2 will correspond to minimal sedation (anxiolysis); a sedation score of 3 will correspond to moderate sedation/analgesia. Sedation scores of 4 – 5 are considered appropriate for deep sedation/analgesia. A sedation score of 6 is considered general anesthesia.

|Table 3 Ramsay Sedation Scale |

|Level |Response |

|1 |None / Minimal |Awake, anxious, and agitated |

|2 |Minimal |Awake, cooperative, oriented, and tranquil |

|3 |Moderate |Awake, responds to commands only |

|4 |Deep |Asleep, brisk response to stimuli |

|5 |Deep |Asleep, sluggish response |

|6 |Anesthesia |Asleep, no response |

CAUTION: If used concomitantly, benzodiazepines potentiate the effects of narcotics. BOTH, the narcotic and benzodiazepine dosage should be reduced appropriately to avoid complications.

7. Intravenous Access Intravenous access will be secured in all patients prior to administering moderate or deep sedation/analgesia. IV access should be readily available, but not secured or initiated, when oral midazolam or PO/PR chloral hydrate are used for sedation/analgesia.

8. Adult Outpatients – Designated Driver Adult outpatients will have a designated driver available. If the patient does not have a designated driver, sedation/analgesia will NOT be administered.

9. Pediatric Patients All pediatric patients should be accompanied to and from the procedure by a parent, legal guardian or other responsible person.

10. Supplemental Oxygen

All patients undergoing a sedation/analgesia procedure will be placed on a pulse oximeter to decrease the likelihood of adverse outcomes. Equipment to administer supplemental oxygen should be present when sedation/analgesia is administered. If hypoxemia is anticipated or develops during sedation/analgesia, supplemental oxygen should be administered. If supplemental oxygen is indicated, it should be administered by mask or nasal prongs to maintain an O2 saturation level >= 90%.

11. Monitoring –Intra-Procedure by the RN

During the procedure the patient’s physiological status is monitored, including

a) Reassessment of

▪ Respiratory status

▪ Cardiac status

▪ Level of consciousness

b) Monitoring

▪ Blood pressure

▪ Oxygen saturation

▪ Heart rate and rhythm

▪ Level of sedation

▪ Hypersensitivity to medications

c) Plan of Care

The plan of care shall be revised as the patient’s condition and response to the procedure dictate.

Documentation – Intra-Procedure

The following are documented a minimum of every 5 minutes on the Sedation/Analgesia Flow Sheet:

a) Physiologic and Neurologic

▪ Blood pressure

▪ Oxygen saturation

▪ Heart rate and rhythm

▪ Level of sedation

b) Procedure Times

▪ Time assessed prior to procedure

▪ Time when the procedure was initiated

▪ Time when the procedure ended

c) Medications. Dosage, route, time and effects of all medications used for the procedure. (e.g., “Patient sedated with patent airway and Ramsay score of 3 after midazolam 2 mg and meperidine 25 mg “).

d) Adverse reactions. Any hypersensitivity reactions, unusual occurrences and resolutions.

The Physician is immediately alerted of changes in the patient’s physical condition and/or vital signs.

F. POST-PROCEDURE

1. Physician Responsibilities:

a. Record a post-procedure/sedation progress note.

b. The physician may leave the immediate area when the patient’s vital signs are stable OR the patient meets discharge criteria OR the Aldrete score is the same as baseline.

2. Nurse Responsibilities. The responsible nurse must remain with the patient for the duration of the procedure and for the recovery phase of the procedure. The nurse may not engage in other tasks or leave the patient unattended until the patient returns to baseline status. The nurse to patient ratio during the recovery phase may not exceed 2 patients to 1 nurse.

▪ Post-procedure monitoring:

After the procedure is complete, the following is to be done:

Assessment

a) Respiratory status

b) Circulatory status

c) Color

d) Level of consciousness/level of sedation

e) Activity

f) Dressing / Procedure Site

g) Pain level

h) Nausea

i) Neurovascular checks

Monitoring

a) Vital signs: BP, HR, RR

b) Pulse oximetry

c) EKG

d) Level of sedation

e) Monitoring shall be continued for a minimum of sixty (60) minutes following the last dose of medication when no reversal agent has been used.

f) When a reversal agent has been used, monitoring will continue for a minimum of 2 hours.

Documentation

The nurse shall document the following a minimum of every 15 minutes or more frequently as the patient’s condition dictates.

a) Vital signs including oxygen saturation on room air

b) Color

c) Level of consciousness/level of sedation

d) Activity

e) Dressing / Procedure Site

f) Pain level

g) Nausea

h) Neurovascular checks

Other documentation

a) Patient’s tolerance of the procedure

b) Place transferred to and name of person receiving the patient

c) Patient’s recovery and status at discharge

Prior to discontinuing post-procedure monitoring, the patient’s vital signs, pulse oximetry value, and level of consciousness and response must be stable as compared to baseline readings taken pre-procedure.

Recovered patients must:

▪ Be discharged from the post-sedation recovery area by the Physician OR

▪ Meet the established discharge criteria approved by the Dept. of Anesthesia

4. Aldrete Scoring for Discharge

Prior to discharge, patients will be scored with use of the Aldrete Scale. A discharge score of >= 8 or return to baseline is required prior to discharge. Scores will be documented a minimum of every 15 minutes after the last dose of sedation/analgesia X 4 sets if no reversal agent was used or 8 sets if a reversal agent was used.

|Aldrete Score For Discharge | |

| |Score at 15-Minute Intervals |

| |Post-Sedation |

| |

4. Discharge

Discharge criteria allow the qualified registered nurse to discharge a patient when criteria have been met. Before discharge, the patient’s parent or guardian should be instructed on potential post-sedation effects, limitation of activities, behavior, and an understanding of the instructions should be verbalized. An outpatient may not be discharged to his or her own care. A responsible adult escort must accompany the patient from the hospital. A staff member will escort the patient out of the facility. The need for a responsible adult to observe the child should be emphasized. The discharge plan and time of discharge should be noted on the flow sheet. Inpatients will be discharged to their respective units.

5. Discharge Criteria. Patients may be discharged from the procedure area to their respective units or home if they meet all of the following criteria:

▪ Patient is as alert and oriented as at baseline (pre-procedure)

▪ Stable vital signs documented for a minimum of 60 minutes after the last dose was given (or 120 minutes if reversal agent used [Narcan or Romazicon])

▪ Documentation that includes BP, pulse rate, respiratory rate and oxygen saturation on room air (> 95% or at baseline) and level of consciousness at or near pre-sedation levels.

▪ Cardiac rhythm consistent with baseline

▪ Temperature not above 101 F

▪ A discharge score >= 8 (Aldrete score) or equivalent to pre-sedation baseline

▪ Dry surgical dressings or minimal drainage anticipated

▪ Minimal or absent nausea

▪ Pain controlled by analgesics or rated at or below baseline

▪ Voiding (may be required by the Physician)

▪ Presence of protective reflexes (swallow and gag) and tolerating fluids by mouth as ordered by the Physician

▪ Patient is able to ambulate as well as he/she was able to prior to the procedure (age and physical status appropriate); able to use extremities similar to baseline (age appropriate)

▪ If an outpatient, a responsible adult is present to drive the patient home and remain with the patient during the post-procedure recovery phase

6. Patients undergoing IV sedation/analgesia should not operate machinery or a motor vehicle for 24 hours or until the physician deems appropriate.

7. Written discharge instructions are provided to the patient and family member. The patient/family are asked to verbalize their understanding of the instructions and sign for instructions.

8. The disposition of inpatients will include documentation of the patient care unit, time the patient’s care was turned over and name of individual that received the patient.

Performance Improvement

The Department of Anesthesia will monitor the following outcome measures to assess the sedation/analgesia program:

▪ Any case of resuscitations and/or intubations required during sedation/analgesia;

▪ Any case with unplanned admission resulting from sedation

▪ Any desaturation of oxygen below 90% sustained for 5 minutes

▪ Any patient requiring assisted ventilation (bag breathing)

▪ Any failure to return to baseline

▪ Use of reversal agents

▪ Appropriateness of monitoring and documentation;

The assessment of the program will occur on a regular basis and will be reported through the Department of Anesthesia.

_________________

References

1. Revisions to Anesthesia Care Standards, Comprehensive Accreditation Manual for Hospitals, Standards and Intents for Sedation and Anesthesia Care, 2000. standard/aneshap.html

2. Anonymous, Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: A Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by non-Anesthesiologists. Anesthesiology. Feb 1996. Vol. 84 (2): 459-471.

3. Anonymous, Sedation/analgesia for Invasive and Diagnostic Procedures, City of Hope National Medical Center, Duarte, CA. mayday.policies/COHconsed.html

4. Pasero, CL, Sedation/analgesia/Analgesia for Adults, Policy and Procedure, Distributed by City of Hope Pain Resource Center. mayday.policies/paserosedation.html

5. Sedation/Analgesia and Anesthesia Care Standards, Policy and Procedure #AP09, MountainView Hospital, Las Vegas, NV, Revised 2/01.

FASTING GUIDELINES

APPENDIX A

▪ Because sedatives and analgesics tend to impair airway reflexes in proportion to the degree of sedation/analgesia achieved, pre-procedure fasting before sedation/analgesia is recommended.

▪ Patients undergoing sedation/analgesia for “elective” procedures should not drink fluids or eat solid food for a sufficient period of time to allow for gastric emptying before their procedure.

|Fasting Guidelines |

|Patient Type |Solids and Non-Clear Liquids |Clear Liquids * |

|Adults |6 – 8 hours or none after midnight |2 hours |

|Children > 3 years |8 hours |2 hours |

|6 to 36 months |6 hours |2 hours |

|< 6 months |6 hours |2 hours |

|Gastric emptying may be influenced by many factors, including anxiety, pain, abnormal autonomic function (e.g., diabetes), pregnancy, and |

|mechanical obstruction. Therefore, the suggestions listed do not guarantee that complete gastric emptying has occurred. |

|Source: Anonymous, Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: A Report by the American Society of |

|Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. Feb 1996. Vol. 84 (2): 459-471. |

|* Intake of clear liquids prior to sedation/analgesia should be small amounts, such as less than or equal to 2 ounces. |

Note:

Physicians may deviate from the Fasting Guidelines during urgent or emergent sedation/analgesia procedures if in their judgment the benefits of sedation outweigh the risks.

Dosing Guidelines for Moderate Sedation/Analgesia – ADULT

Appendix B

|Dosing Guidelines for Sedation/analgesia - ADULTS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Diazepam (Valium) |IV: 2.5 mg in increments, (not to exceed 5 mg per |Onset: 30 seconds to 2 minutes|Administer into a large vein; monitor airway, |

| |single dose over 60 seconds). |(may take up to 5 min) |02 sats and HR. |

| |(individual response is variable.) | | |

| | |Duration: 60 – 180 mins (may |Titrate to desired level of sedation. |

| |Do not dilute with saline or H20 |last up to 4 hours); sedative |Contraindicated in untreated narrow-angle |

| |Do not mix with other drugs |effects usually last for 3 |glaucoma; irritating to veins-may cause |

| |Reduce dose of narcotic by a third when used with |hours |phlebitis, thrombosis, and local inflammation.|

| |diazepam; reduce diazepam dose by 30-50% in | |Avoid in pregnant women, esp. during first |

| |elderly. | |trimester. |

|Midazolam |IV: 1 to 2.5 mg over at least 2 minutes. Repeat |Onset: 1.5 to 5 minutes |Titrate to desired level of sedation. Monitor|

|(Versed) |in 2 minutes, if needed, in small increments of | |airway, oxygen saturation, HR. Contraindicated|

| |initial dose over at least 2 minutes to achieve |Duration: 2 to 6 hours. |in acute narrow-angle glaucoma. |

|Healthy, |desired effect. | | |

|Adults < 60 | |Recovery usually occurs within|May potentiate adverse effects of opioids - |

| |Titrate with small increments allowing 2 minutes |2 hours, but effects may last |including respiratory depression - when used |

| |after each dose to evaluate effect. Once sedation |as long as 6 hours. |in combination. |

| |is achieved, additional doses should be 25% of the | | |

| |dose required to produce the sedative endpoint; for| |Reduce dose in patients with compromised renal|

| |maintenance, use 0.25 mg to 1 mg. | |or hepatic dysfunction. |

| | | | |

| |Total dose: usu. < = 5 mg | | |

| |Reduce dose by 30% if patient was premedicated with| | |

| |a narcotic or other CNS depressant. | | |

|Midazolam |IV: 1.5 mg or less over at least 2 minutes. If |Onset: 1.5 to 5 minutes |Titrate to desired level of sedation. Monitor |

|(Versed) |additional titration is needed, give at a rate not | |airway, oxygen saturation, HR. Contraindicated|

| |exceeding 1 mg over 2 min. |Duration: 2 to 6 hours. |in acute narrow-angle glaucoma. |

|Adults > 60; debilitated| | | |

|or chronically ill |Usual max total dose: 3.5 mg |Recovery usually occurs within|May potentiate adverse effects of opioids - |

| | |2 hours, but effects may last |including respiratory depression - when used |

| |Reduce dose by 50% if patient was premedicated with|as long as 6 hours. |in combination. |

| |a narcotic or other CNS depressant. | | |

| | | |Reduce dose in patients with renal or hepatic|

| | | |dysfunction. |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Moderate Sedation/Analgesia – ADULTS

Appendix B, cont’d

|Dosing Guidelines for Sedation/analgesia - ADULTS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Meperidine |IV: Dilute to achieve concentration of 10mg/mL |Onset: 1 min |Titrate to desired level of sedation. |

|(Demerol) |and administer 12.5 – 25 mg over 2 minutes. May | | |

| |repeat incremental dose at 2 minute intervals to |Duration: 2 – 4 H |Contraindicated in patients with |

|Pure opioid agonist |achieve desired endpoint for sedation. | |hypersensitivity to the drug and in those who |

| | | |have received an MAO inhibitor within the past|

| |Do not exceed 200 mg in 1 H | |14 days. |

| | | | |

| |(It is 1/10 as potent as morphine) | |Use cautiously in geriatric or debilitated |

| | | |patients and in those with respiratory |

| |Reduce dose in elderly or debilitated patients. | |conditions (COPD, asthma). More N/V versus |

| | | |morphine. |

|Morphine |IV: Dilute to achieve concentration of 1mg/mL. |Onset: 5 min |Titrate to desired level of sedation. Monitor|

| |Administer: 1 or 2 mg over 1 to 2 min. May repeat| |respiratory rate and depth continuously; |

|Pure opioid |incremental dose at 5 minute intervals to achieve |Duration: 4 – 5 H |respiratory depression may occur. Be prepared|

|Agonist |desired endpoint for sedation. | |to assist ventilation. |

| | | | |

| |Usual max total dose: 10 mg | |Contraindicated if drug allergy; use |

| | | |cautiously in elderly and debilitated patient.|

| |Reduce dose in elderly or debilitated patients. | | |

| | | |Hypotension is possible especially if the |

| | | |patient is hypovolemic. Nausea and vomiting |

| | | |may occur. Less N/V versus meperidine. |

|Butorphanol (Stadol) |IV: 1 to 2 mg over 2 min. May repeat incremental|Onset: 2 – 3 min |Titrate to desired level of sedation. Monitor |

| |dose of 1 mg at 2 minute intervals to achieve | |respiratory rate and depth continuously; |

|Mixed opioid agonist / |desired endpoint for sedation. |Duration: 3 – 4 H |respiratory depression may occur. |

|antagonist | | | |

| |Usual Max: 4 mg | |Contraindicated in patients with |

| | | |hypersensitivity to drug or the preservative |

| | | |(benzethonium chloride). Use cautiously in |

| | | |emotionally unstable patients and in those |

| | | |with history of drug abuse and those with |

| | | |respiratory, cardiac disease or if there is |

| | | |renal or hepatic dysfunction. May precipitate|

| | | |withdrawal syndrome |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Moderate Sedation/Analgesia – PEDIATRIC

APPENDIX C

|Dosing Guidelines for Sedation/analgesia - PEDIATRICS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Diazepam |IV: 0.1 to 0.15 mg/kg over 60 seconds. May |Onset: 30 seconds to 2 minutes|Administer into a large vein; monitor airway, |

|(Valium) |repeat incremental doses to achieve desired |(may take up to 5 min) |02 sats and HR. |

| |sedation endpoint. | | |

| | |Duration: 60 – 180 mins (may |Titrate to desired level of sedation. |

| |Do not exceed 0.25mg/kg |last up to 4 hours); sedative |Contraindicated in untreated narrow-angle |

| |Do not dilute with saline or H20 |effects usually last for 3 |glaucoma; irritating to veins-may cause |

| |Do not mix with other drugs |hours |phlebitis, thrombosis, and local inflammation.|

| |Reduce narcotic dose by a third when used with | | |

| |diazepam; | | |

|Midazolam |PO: Syrup, age > 6 months: |Onset: 1.5 to 5 minutes |Titrate to desired level of sedation. Monitor|

|(Versed) |0.25 – 0.5 mg/kg as a SINGLE DOSE given 15 – 30 | |airway, oxygen saturation, HR. Contraindicated|

| |minutes before a procedure. |Duration: 2 to 6 hours. |in acute narrow-angle glaucoma. |

| | | | |

| |If age > 6 months to 6 years, may require up to 1 |Recovery usually occurs within|May potentiate adverse effects of opioids - |

| |mg/kg. If obese, use ideal body weight. |2 hours, but effects may last |including respiratory depression - when used |

| | |as long as 6 hours. |in combination. |

| |IV - Dilute to 0.1 mg/ml | | |

| | | |Reduce dose in patients with renal or hepatic |

| |< 6 months old: 0.025 – 0.05 mg/kg over at least 2| |dysfunction. |

| |minutes. | | |

| | | | |

| |6 months to 5 years: 0.05 to 0.1 mg/kg over at | | |

| |least 2 min. | | |

| | | | |

| |6 – 12 years: 0.025 – 0.05 mg/kg over at least 2 | | |

| |min. | | |

| | | | |

| |12 – 16 years: Same as adult, but use incremental | | |

| |dosing | | |

| | | | |

| |IV Only: Repeat doses in 2 minutes, if needed, in | | |

| |small increments of initial dose over at least 2 | | |

| |minutes to achieve desired endpoint. Titrate with| | |

| |small increments allowing 2 minutes after each | | |

| |dose to evaluate effect. Once sedation is | | |

| |achieved, additional doses should be 25% of the | | |

| |dose required to produce the endpoint | | |

| | | | |

| |Reduce dose by 30% if patient was pre-medicated | | |

| |with a narcotic or other CNS depressant. | | |

|Chloral Hydrate |Oral or Rectally: 25 – 50 mg/kg/dose 30 to 60 |Onset: 30 to 60 min |May cause disorientation, excitement, delirium|

| |minutes prior to a procedure. May repeat dose in | |drowsiness, ataxia, “hangover” |

| |30 mins to a max dose of 100 mg/kg or 500 mg per |Duration: unknown |Contraindicated in patients with marked |

| |single dose (sedative) or 1g per single dose | |hepatic or renal impairment; severe cardiac |

| |(hypnotic). Max total: 2 g | |disease; gastritis; hypersensitivity or |

| | | |idiosyncrasy to chloral derivatives. |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Moderate Sedation/Analgesia – PEDIATRICS

Appendix C, cont’d

|Dosing Guidelines for Sedation/analgesia - PEDIATRICS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Meperidine |IV: Dilute with NS or H20 to a concentration of 5|Onset: 1 min |Titrate to desired level of sedation. |

|(Demerol) |mg/ml | | |

| |Administer 1 to 1.5 mg/kg over 2 to 3 minutes. |Duration: 2 – 4 H |Contraindicated in patients with |

|Pure opioid agonist |May repeat dose to achieve desired endpoint. | |hypersensitivity to the drug and in those who |

| | | |have received an MAO inhibitor within the past|

| |IM/SC: 1 to 2 mg/kg 15 – 45 minutes prior to a | |14 days. |

| |procedure. | | |

| | | |Use cautiously in patients with respiratory |

| | | |conditions (COPD, asthma). More N/V versus |

| | | |morphine. |

|Morphine |IV: Dilute with NS or H20 to achieve concentration|Onset: 5 min |Titrate to desired level of sedation. Monitor|

| |of 0.5 mg/mL. | |respiratory rate and depth continuously; |

|Pure opioid |Administer: 0.05 – 0.2 mg/kg over 3 to 5 min. |Duration: 4 – 5 H |respiratory depression may occur. Be prepared|

|Agonist |May repeat incremental dose at 5 minute intervals | |to assist ventilation. |

| |to achieve desired endpoint for sedation. |Onset and duration may be | |

| | |longer in PO |Contraindicated if drug allergy; use |

| |PO: 0.3 mg/kg | |cautiously in debilitated patient. |

| | | | |

| |Reduce dose if used with a benzodiazepine. | |Hypotension is possible especially if patient |

| | | |is hypovolemic. Nausea and vomiting may |

| | | |occur. Less N/V versus meperidine. |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Deep Sedation – ADULT and PEDIATRIC

APPENDIX D

The following medications must be administered by a physician with clinical privileges for deep sedation or by a qualified anesthesia provider

|Dosing Guidelines for Sedation/analgesia - ADULTS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Fentanyl |Adults: IV: |Onset: Within 30 seconds |Dilute the 250mcg/5ml ampule in 10 mL saline |

| |0.05 - 2 mcg/kg IV slow push over 1-2 minutes | |to achieve a concentration of 25 mcg/mL. Give |

| |Usual dose for a 70 kg adult: 70 mcg (It’s 100 |Duration/Adult: |IV slow push until reach target Ramsay score. |

| |times as potent as morphine). |30 – 60 minutes |The target Ramsay scores should be 4 or 5 . |

| | | |Monitor for arrhythmias, respiratory |

| |PEDIATRIC: |Half-life/Pedi: |depression. Provide supplemental oxygen via |

| |IV: Administered in increments of 0.6 – 1 mcg/kg.|1.5-6H |nasal prongs or mask if oxygen saturations |

| |Give in increments of Q 5 – 15 minutes | |fall below 90%. |

| | |Duration/Pedi: | |

| | |30-80 mins | |

| | | | |

|Methohexital (Brevital) |ADULT: |Onset: few seconds |No reversal agent. |

| |Initial dose: 20 – 40 mg IVP, slowly Q 4-7 |Duration: 6-8 min |The target Ramsay scores should be 4 or 5 . |

| |minutes | |CNS/respiratory depression, hypotension, |

| | | |convulsions. |

| |PEDIATRIC: |May last up to 40 –60 minutes | |

| |IV – 1-1.5 mg/kg |in pediatrics | |

| | | | |

| |IM – 5 – 10 mg/kg | | |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Sedation/Analgesia

REVERSAL AGENTS – ADULT AND PEDIATRIC

Appendix E

| Dosing Guidelines for Sedation/analgesia – Reversal Agents |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Flumazenil (Romazicon) |ADULT |Onset: immediate |Benzodiazepine antagonist. |

| |IV: 0.2 mg over 15 seconds. If patient does not | | |

|For Benzodiazepine |reach desired level of consciousness after 45 sec,|Duration: |Use has been associated with occurrence of |

|Reversal |repeat dose. Dose may be repeated at 1 min | |seizures. Monitor for recurrence of sedation.|

| |intervals until a cumulative dose of 1 mg has been|Initial half-life: |Monitor ventilation, HR, O2 sats. |

| |given. |7 – 15 min | |

| |Dose may be repeated after 20 minutes if | |NOTE: The effects of flumazenil may wear off |

| |re-sedation occurs, but no more than 1 mg should |Terminal half-life: |before the effects of the benzodiazepine. |

| |be given at one time. |41 – 79 min |Repeat doses may be required. |

| |Do not exceed 3 mg in 1 hour. | | |

| | | |Flumazenil is not generally recommended for |

| |PEDIATRIC | |use in children. |

| |IV: 0.01 mg/kg given IV over 15 seconds (up to 0.2| | |

| |mg total dose). May repeat the dose at 1 minute | | |

| |intervals until desired endpoint is reached or up | | |

| |to 5 total doses of 0.01 mg/kg. Maximum dose is | | |

| |0.05 mg/kg or 1 mg, whichever is lower. | | |

|Physostigmine (for |0.5 – 1 mg IV (to desired effect). No more than 1|Onset: immediate |Watch for cholinergic side effects |

|antichollinergic syndrome)|mg per minute |Duration: 0.5-4H |(bradycardia, emesis, cramping, and |

| | | |salivation) |

|Naloxone (Narcan) |ADULTS |Onset: 2 – 3 min |Narcotic antagonist. |

| |IV: 0.1 mg over 2 minutes with repeated doses at | |Contraindicated in patients with |

|Narcotic |2 to 3 minute intervals; titrate to desired |Duration: 45 min to 4 H |hypersensitivity to naloxone. |

|Antagonist |effect. Max total dose = 10 mg | | |

| | |Half-life |NOTE: The effects of naloxone may wear off |

| |PEDIATRIC |Adults - 30-80 min |before the effects of the narcotic. Repeat |

| |IV: 0.01 mg/kg over 2 minutes and may repeat with|Neonate: 2.5-3.5H |doses may be required. |

| |a dose of 0.1 mg/kg if needed; titrate to desired | | |

| |effect. | | |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Comparison of Equipment and Personnel for Moderate and Deep Sedation/Analgesia

Ramsay Sedation Scale

Appendix F

|Comparison of Equipment and Personnel for Sedation/Analgesia |

|Comparison |Moderate Sedation |Deep Sedation |

|Ramsay Scores |< = 3 |> 3 (target = 4 or 5) |

|Typical procedures |Endoscopy, ERCP, MRI (Pedi) |Cardioversion, EP Studies |

|Monitoring |Pulse oximetry continuous |Pulse oximetry continuous |

| |Heart rate monitoring continuous |Heart rate monitoring continuous |

| |Respiratory rate continuous |Respiratory rate continuous |

| |Level of consciousness continuous |Level of consciousness continuous |

| |Blood Pressure Q 5 mins |Blood Pressure Q 5 mins |

|Charting - Intra |Pulse oximetry every 5 mins |Pulse oximetry every 5 mins |

| |Heart rate every 5 min |Heart rate every 5 min |

| |Respiratory rate every 5 min |Respiratory rate every 5 min |

| |Level of consciousness every 5 min |Level of consciousness every 5 min |

| |Blood pressure every 5 min |Blood pressure every 5 min |

|Charting – Post |Aldrete score every 15 mins |Aldrete score every 15 mins |

| |Pain every 15 mins |Pain every 15 mins |

| |Pulse oximetry every 15 mins |Pulse oximetry every 15 mins |

| |Heart rate every 15 min |Heart rate every 15 min |

| |Respiratory rate every 15 min |Respiratory rate every 15 min |

| |Level of consciousness every 15 min |Level of consciousness every 15 min |

| |Blood pressure every 15 min |Blood pressure every 15 min |

|Personnel |Registered Nurse |Registered Nurse |

| |Physician |Physician |

| | |1 extra person: RN or LVN or GI Lab Tech or Rad Tech, etc. |

|Equipment |Pulse oximeter |Pulse oximeter |

| |Blood pressure device |Blood pressure device |

| |Stethoscope |Stethoscope |

| |ECG monitor / defibrillator |ECG monitor / defibrillator |

| |Emergency crash cart |Emergency crash cart |

|Airway equipment |Age and size appropriate |Age and size appropriate |

|Medications |Meperidine, Morphine, Diazepam, Midazolam, Chloral |Meperidine, Morphine, Diazepam, Midazolam, Fentanyl, |

| |Hydrate |Methohexital |

|Reversal Agents |Naloxone and Flumazenil |Naloxone and Flumazenil |

|Aldrete score for discharge |>=8 |>=8 |

|Ramsay Sedation Scale |

|Level |Response |

|1 |None/Minimal sedation |Awake, anxious, and agitated |

|2 |Minimal sedation |Awake, cooperative, oriented, and tranquil |

|3 |Moderate sedation |Awake, responds to commands only |

|4 |Deep sedation |Asleep, brisk response to stimuli |

|5 |Deep sedation |Asleep, sluggish response |

|6 |Anesthesia |Asleep, no response |

PRE-SEDATION INSTRUCTIONS – PATIENT

INSTRUCCIONES PARA EL PACIENTE TOCANTE EL EXAMEN

To be given to patient at the time the procedure is scheduled.

Se le deben dar estas instrucciones cuando haga cita para el examen.

ENGLISH – BEFORE THE PROCEDURE

Patient should not eat or drink anything the day of the procedure unless otherwise instructed by the Physician. Eating of food and liquids should be as follows:

|Guidelines for Pre-Procedure Fasting |

|Patient Type |Solids and Non-Clear Liquids |Clear Liquids |

|Adults |6 – 8 hours or none after midnight |2 hours before procedure |

|Children > 3 years |8 hours before procedure |2 hours before procedure |

|6 to 36 months |6 hours before procedure |2 hours before procedure |

|< 6 months |6 hours before procedure |2 hours before procedure |

▪ The patient should be in bed by 10:00 PM the night before the procedure and be awakened by _____: _____ AM on the morning of the procedure.

▪ The patient should report to the Admitting Department in the Outpatient Pavilion at least 1 hour prior to the scheduled procedure.

▪ History and physical by the Physician will be complete if it has not bee done. Clearance for sedation must be obtained from Physician.

▪ Patients requiring sedation should be prepared to stay longer for observation after completion of the procedure.

▪ If you will be going home after the procedure, a designated driver/caregiver should be available to take the patient home and care for the patient.

ESPANOL - ANTES DEL EXAMEN

Pacientes no deben comer o beber nada el dia del examen, a menos que el medico indique. Las recomendaciones tocante bebidas o comida antes del examen son:

|Recomendaciones Tocante Bebidas or Comida Antes De Un Examen |

|Tipo de Paciente |Tiempo que se debe esperar antes de un examen para Bebidas o |Liquidos claros |

| |Comida | |

|Adultos |6 – 8 horas antes del examen o nada despues de medianoche |2 horas antes del examen |

|Ninos mayor de 3 anos |8 horas antes del examen |2 horas antes del examen |

|Ninos de 6 a 36 meses |6 horas antes del examen |2 horas antes del examen |

|Ninos menor de 6 meses |6 horas antes del examen |2 horas antes del examen |

▪ El paciente debe acostarse a las 10:00 PM la noche antes del examen y debe despertar a las _____:_____ AM en la manana del examen.

▪ El paciente debe reportarse al Departamento de Registro en el Outpatient Pavilion una hora antes del examen.

▪ El medico debe tener su fisico y examen completo antes de empezar con el nuevo examen. El medico dira si usted puede recibir medicamento para el examen.

▪ Es posible que necesite esperar mas tiempo despues del examen para que se recupere y pueda andar. Si usted se va ir para su casa hoy, necesita tener una persona que pueda manejar y llevarlo para su casa despues del examen.

DISCHARGE INSTRUCTIONS FOLLOWING SEDATION/ANALGESIA - ADULT

The following instructions have been prepared for your information as well as your protection.

Following the procedure:

▪ Do not drive any motor vehicle for 24 hours.

▪ Do not operate any machinery with blades or fans.

▪ Do not cook if you are still drowsy.

▪ Do not take any medication other than those authorized by your Physician.

▪ Do not drink any alcoholic beverages for 24 hours.

▪ Do not sign any important legal documents for 24 hours.

▪ Do not bathe or shower unattended for 24 hours.

▪ You must have a responsible person accompany you to the hospital and home and stay with you the day of your procedure; otherwise, the procedure may not be done.

DIET

▪ After medications, you may have some nausea. Try liquids first and then a light diet. If you do not become nauseated, you may resume your previous diet.

▪ At ________ AM/ PM, you should try to take a sip of water. If you can swallow this without coughing or gagging, you may resume your previous diet. Otherwise, wait an additional _________ minutes and try a sip of water once again.

ACTIVITY

▪ Resume normal activities after 24 hours, unless otherwise stated by your Physician.

▪ The area where you received intravenous medication may become tender. Warm compresses applied three or four times a day, for 15 minutes, should help. If the site does not improve in several days, contact your Physician.

▪ You may experience a small amount of bleeding from the new IV site. If bleeding increases, report this to your doctor.

▪ Do not take any aspirin, aspiring products or ibuprofen for 10 days if a polyp was removed.

▪ Ask your Physician about resuming aspirin, aspirin products, or other blood thinners.

▪ New Medications: Use as Directed.

▪ Food/Drug Interactions: Identified

▪ Drug/Drug Interactions: Identified

OTHER:

___________________________________ ______/_______/_______

Patient’s Signature Date

___________________________________ ______/_______/_______

Nurse Signature Date

White: Chart Yellow: Patient Copy

DISCHARGE INSTRUCTIONS FOLLOWING SEDATION/ANALGESIA – PEDIATRIC

The following instructions have been prepared for your information as well as your protection.

After medication sedation (oral, injectable), your child may experience some nausea:

▪ Offer clear liquids such as fruit juices and non-carbonated beverages at _________ AM / PM.

▪ If your child does not become nauseated, the previous diet may be resumed.

▪ If your child becomes nauseated, do not be alarmed. The best management of nausea is to lie down and restrict intake of heavy (greasy) solid foods. Again, encourage your child to drink non-carbonated liquids and try dry foods such as crackers.

Watch your child carefully for the remainder of the day for excessive drowsiness and inappropriate behavior. Observe your child if placed in a car seat, his/her head can fall forward if drowsy and block the child’s airway.

▪ Encourage your child to participate in quiet activities.

▪ Do not allow your child to climb, ride bicycles, play on swings, or participate in strenuous exercise.

▪ Encourage your child to rest and take naps today.

▪ Do not give your child any medication other than that ordered by his/her Physician.

▪ It is recommended that you have another adult with you to assist you in the care of your child and the drive home.

Estimate recovery time:

[ ] 30 minutes [ ] 1 to 1 ½ hours [ ] 5 – 6 hours [ ] Other _______________

If there are any questions or problems that you feel are related to this procedure, call:_______________

I, the patient and/or guardian have received, read and understand the instructions given to me by the Physician and/or nurse.

▪ New Medications: Use as Directed Food/Drug Interactions: Identified

▪ Drug/Drug Interactions: Identified

OTHER:

__________________________________ ______/_______/_______

Patient’s Signature Date

__________________________________ ______/_______/_______

Nurse Signature Date

White: Chart Yellow: Patient Copy

SEDATION / ANALGESIA

WORKSHOP

AND

COMPETENCY PROGRAM

PROFESSIONAL STAFF

Sedation/Analgesia Workshop and Competency Program

Objectives

The candidate should be able to:

▪ Define minimal sedation, sedation/analgesia, deep sedation and anesthesia.

▪ Assess a patient prior to a procedure that will involve sedation/analgesia.

▪ Educate patients about the procedure and what to expect during and after the procedure.

▪ Describe the fasting requirements for procedures involving sedation/analgesia.

▪ Assemble appropriate equipment to monitor the patient before, during and after the procedure.

▪ Recognize approved medications for sedation/analgesia and deep sedation.

▪ Recognize appropriate doses and incremental dosing technique to achieve desired endpoints.

▪ Recognize common adverse effects of medications used in sedation/analgesia

▪ List appropriate reversal agents and doses

▪ Use the Ramsey Sedation Scale to achieve a desired endpoint.

▪ Recognize and perform standard monitoring and documentation for sedation/analgesia.

▪ Use the Aldrete Discharge Scale

▪ Provide discharge instructions to patients that undergo sedation/analgesia

Candidate Pre-Requisites

Moderate Sedation/Analgesia: BLS Certification or comparable training – RN, MD

ACLS Certification or comparable training – RN

Deep Sedation/Analgesia: BLS Certification or comparable training – RN, MD

ACLS Certification or comparable training – RN

NOTE: Completion of the sedation workshop will be considered “comparable” training.

Initial Privileges:

▪ Demonstrate BLS certification or comparable training

▪ Read and sign that policy has been read and understood OR complete Video Workshop

Re-Credentials:

▪ Demonstrate BLS certification or comparable training

▪ Read and sign that policy has been read and understood

Sedation/Analgesia Workshop and Competency Program

Definitions

Anesthesia – Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Sedation - represents a continuum of consciousness to unconsciousness with three levels most commonly described: minimal sedation, moderate sedation/analgesia, and deep sedation/analgesia.

Minimal sedation (anxiolysis) – A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

Moderate sedation/analgesia (sedation/analgesia) – A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Sedation/analgesia is generally achieved when there is slurred speech, but the patient is arousable, able to respond, and retains the ability to independently maintain a patent airway.

(Note: Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.)

Deep sedation/analgesia – A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

Objectives of Moderate Sedation (Conscious Sedation)

▪ Mood alteration

▪ Maintaining consciousness and cooperation

▪ Decrease pain

▪ Elevating the patient’s pain threshold with minimal changes in vital signs.

▪ Partial amnesia

▪ Prompt and safe return to activities of daily living.

|Moderate Sedation |Deep Sedation |

|Mood altered. Cognitive function impaired |Depressed consciousness |

|Patients respond purposefully to verbal commands. Respond to verbal commands|Patients cannot be easily aroused. Respond purposefully following repeated or|

|alone or accompanied by light tactile stimulation. |painful stimulation. |

|Patient cooperative |Not awake enough to cooperate. |

|Can maintain own airway. Spontaneous ventilation is adequate. |Ability to maintain ventilatory function may be impaired. |

|Cardiovascular function OK |Cardiovascular function is usually OK |

|Vital signs stable |Vital signs may be labile. |

Moderate sedation is NOT minimal sedation or local anesthesia

AIRWAY MANAGEMENT

Airway Control Measures

▪ Upper airway obstruction, tongue – most common

▪ Head-tilt, chin lift maneuver

Placement of Oral Airway

▪ Used for unconscious patients

▪ Turn airway so the curved tip is upward; rotate into position

▪ Size: measure airway from corner of mouth to tip of ear.

Factors Associated with Difficulty in Airway Management

History

▪ Previous problems with anesthesia or sedation

▪ Stridor, snoring or sleep apnea

▪ Dysmorphic facial features

▪ Advanced rheumatoid arthritis

Physical Examination

Patency of Airway/Airway Assessment : Mallampati Scoring (Physicians)

Habitus

▪ Significant obesity (especially involving the neck and facial structures)

Head and Neck

▪ Short neck, limited neck extension, decreased hyoid-mental distance (< 3 cm in an adult), neck mass, cervical spine disease or trauma, tracheal deviation.

Mouth

▪ Small opening (< 3 cm in an adult), edentulous, protruding incisors, loose or capped teeth, high arched palate, macroglossia, tonsillar hypertrophy, nonvisible uvula

Jaw

▪ Micrognathia, retrognathia, trismus, significant malocclusion

Pulse Oximetry

▪ Non-invasive method of measuring the oxygen saturation of arterial blood. It is based on the absorption of light at specific wavelengths by red blood cells.

▪ Measure O2 sats on any patient at risk of developing hypoxemia (insufficient oxygenation or arterial blood)

▪ Hypoxemia is often a late sign of hypoventilation or airway obstruction --- should not replace monitoring of respirations and airway patency.

▪ Signs and symptoms of hypoxemia are vague and it may be difficult to detect clinically. Therefore, an easy and quick way to detect hypoxemia is very useful.

▪ Generally, keep O2 sats > 90% or at whatever it was at baseline. May need O2 supplemental if O2 sats fall below 90%.

Selected References for Airway Section

Central DuPage Health System, Compiled by Janis Noone, Central DuPage Hospital, Winfield, IL.

Maricopa Integrated Health System, Policy/Procedure and Consent For Sedation, Phoenix, AZ.

Triumph HealthCare, Policy and Procedure, Sedation/Analgesia.

PRE-PROCEDURE

FASTING / RAMSAY SCALE / ASA CLASSIFICATION / EQUIPMENT

|Fasting Guidelines |

|Patient Type |Solids and Non-Clear Liquids |Clear Liquids ( 3 years |8 hours before procedure |2 hours before procedure |

|6 to 36 months |6 hours before procedure |2 hours before procedure |

|< 6 months |6 hours before procedure |2 hours before procedure |

RAMSAY SEDATION SCALE (moderate sedation/analgesia: 60), use lower initial doses and lower subsequent doses than normally used in healthy adults < 60.

▪ Common agents used for moderate sedation can be dosed to achieve deep sedation.

▪ Fentanyl and Brevital are agents reserved for Deep Sedation. Must be administered by MD. (NOTE: Texas State Law does not permit RN to administer these agents)

▪ Propofol (Diprivan) and Ketamine are not approved for sedation/analgesia; must be an anesthesia provider to use these drugs.

BENZODIAZEPINES – PHARMACOLOGICAL EFFECTS

▪ Bind to specific receptor sites in the CNS, particularly in the cerebral cortex.

▪ Produce anxiolysis, sedation, anticonvulsant effects and amnesia (retrograde / anterograde)

▪ Decrease CO, arterial BP, PVR

▪ Synergism with opiates on respiratory

▪ Depressed ventilatory response to CO2

▪ Anterograde amnesia

▪ Decreases cerebral blood flow, cerebral oxygen consumption and intracranial pressure.

▪ Effective in treating seizure disorders

▪ Noted for centrally mediated muscle relaxant properties

|Drug |Onset |Half-Life |Duration |

|Diazepam (Valium) |2 – 5 min |21 – 37 H |15 – 60 min |

|Midazolam (Versed) |1.5 – 5 min |2 – 5 H |Usual: 20 – 30 min |

| | | |2 – 6 H |

|Flumazenil (Romazicon) |1 – 2 min |41 – 79 min |titrate |

BENZODIAZEPINES - DIFFERENCES

Midazolam Water-soluble; selective metabolism to INACTIVE metabolite (1-hydroxymidazolam)

Diazepam Lipid-soluble; Metabolized to desmethyldiazepam, oxazepam (active) nordiazepam;

suspended in propylene glycol

BENZODIAZEPINES – ADVERSE EFFECTS

Decreased respiratory rate, apnea, hypotension, drowsiness, over-sedation, N/V; local reactions at injection site

MEDICATIONS AND REVERSAL AGENTS

OPIOIDS – PHARMACOLOGICAL EFFECTS

Stimulate receptors for sedation, analgesia and other organ systems

▪ Mu-1 receptors – supraspinal analgesia, spinal analgesia, euphoria, miosis, urinary retention

▪ Mu-2 receptors – spinal analgesia, respiratory depression, bradycardia, constipation, phys. dependence

▪ Kappa – supraspinal analgesia, spinal analgesia, dysphoria, sedation, miosis

▪ Delta – supraspinal analgesia, spinal analgesia, respiratory depression, physical dependence

Pharmacological Effects

CV: Bradycardia and (BP; ( Tachycardia with Meperidine; ( Histamine for both

Pulmonary: ( respiratory rate and tidal volume; ( levels of CO2

CNS: ( cerebral blood flow, intracranial pressure and cerebral metabolic O2 consump.

|Drug |Onset |Half-Life |Duration |

|Morphine |< 5 min |2 – 4 H |4 – 5 H |

|Meperidine (Demerol) |1 min |2.5 – 4 H |2 – 4 H |

| | | | |

|Naloxone (Narcan) |2 min |0.5 – 1.5 H |1 – 4 H |

OPIOIDS – ADVERSE EFFECTS

Decreased respiratory rate, apnea, hypotension, drowsiness, N/V (more with Meperidine); pain at injection site

REVERSAL AGENTS

Appropriate:

▪ Benzodiazepine/opioid toxicity or overdose

Inappropriate:

▪ As a substitute for an adequate period of post-procedure monitoring

▪ To accelerate discharge

Dosing Guidelines for Moderate Sedation/Analgesia – ADULT

|Dosing Guidelines for Sedation/analgesia - ADULTS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Diazepam (Valium) |IV: 2.5 mg in increments, (not to exceed 5 mg per |Onset: 30 seconds to 2 minutes|Administer into a large vein; monitor airway, |

| |single dose over 60 seconds). |(may take up to 5 min) |02 sats and HR. |

| |(individual response is variable.) | | |

| | |Duration: 60 – 180 mins (may |Titrate to desired level of sedation. |

| |Do not dilute with saline or H20 |last up to 4 hours); sedative |Contraindicated in untreated narrow-angle |

| |Do not mix with other drugs |effects usually last for 3 |glaucoma; irritating to veins-may cause |

| |Reduce dose of narcotic by a third when used with |hours |phlebitis, thrombosis, and local inflammation.|

| |diazepam; reduce diazepam dose by 30-50% in | |Avoid in pregnant women, esp. during first |

| |elderly. | |trimester. |

|Midazolam |IV: 1 to 2.5 mg over at least 2 minutes. Repeat |Onset: 1.5 to 5 minutes |Titrate to desired level of sedation. Monitor|

|(Versed) |in 2 minutes, if needed, in small increments of | |airway, oxygen saturation, HR. Contraindicated|

| |initial dose over at least 2 minutes to achieve |Duration: 2 to 6 hours. |in acute narrow-angle glaucoma. |

|Healthy, |desired effect. | | |

|Adults < 60 | |Recovery usually occurs within|May potentiate adverse effects of opioids - |

| |Titrate with small increments allowing 2 minutes |2 hours, but effects may last |including respiratory depression - when used |

| |after each dose to evaluate effect. Once sedation |as long as 6 hours. |in combination. |

| |is achieved, additional doses should be 25% of the | | |

| |dose required to produce the sedative endpoint; for| |Reduce dose in patients with compromised renal|

| |maintenance, use 0.25 mg to 1 mg. | |or hepatic dysfunction. |

| | | | |

| |Total dose: usu. < = 5 mg | | |

| |Reduce dose by 30% if patient was premedicated with| | |

| |a narcotic or other CNS depressant. | | |

|Midazolam |IV: 1.5 mg or less over at least 2 minutes. If |Onset: 1.5 to 5 minutes |Titrate to desired level of sedation. Monitor |

|(Versed) |additional titration is needed, give at a rate not | |airway, oxygen saturation, HR. Contraindicated|

| |exceeding 1 mg over 2 min. |Duration: 2 to 6 hours. |in acute narrow-angle glaucoma. |

|Adults > 60; debilitated| | | |

|or chronically ill |Usual max total dose: 3.5 mg |Recovery usually occurs within|May potentiate adverse effects of opioids - |

| | |2 hours, but effects may last |including respiratory depression - when used |

| |Reduce dose by 50% if patient was premedicated with|as long as 6 hours. |in combination. |

| |a narcotic or other CNS depressant. | | |

| | | |Reduce dose in patients with renal or hepatic|

| | | |dysfunction. |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Moderate Sedation/Analgesia – ADULTS

cont’d

|Dosing Guidelines for Sedation/analgesia - ADULTS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Meperidine |IV: Dilute to achieve concentration of 10mg/mL |Onset: 1 min |Titrate to desired level of sedation. |

|(Demerol) |and administer 12.5 – 25 mg over 2 minutes. May | | |

| |repeat incremental dose at 2 minute intervals to |Duration: 2 – 4 H |Contraindicated in patients with |

|Pure opioid agonist |achieve desired endpoint for sedation. | |hypersensitivity to the drug and in those who |

| | | |have received an MAO inhibitor within the past|

| |Do not exceed 200 mg in 1 H | |14 days. |

| | | | |

| |(It’s 1/10 as potent as morphine) | |Use cautiously in geriatric or debilitated |

| | | |patients and in those with respiratory |

| |Reduce dose in elderly or debilitated patients. | |conditions (COPD, asthma). More N/V versus |

| | | |morphine. |

|Morphine |IV: Dilute to achieve concentration of 1mg/mL. |Onset: 5 min |Titrate to desired level of sedation. Monitor|

| |Administer: 1 or 2 mg over 1 to 2 min. May repeat| |respiratory rate and depth continuously; |

|Pure opioid |incremental dose at 5 minute intervals to achieve |Duration: 4 – 5 H |respiratory depression may occur. Be prepared|

|Agonist |desired endpoint for sedation. | |to assist ventilation. |

| | | | |

| |Usual max total dose: 10 mg | |Contraindicated if drug allergy; use |

| | | |cautiously in elderly and debilitated patient.|

| |Reduce dose in elderly or debilitated patients. | | |

| | | |Hypotension is possible especially if the |

| | | |patient is hypovolemic. Nausea and vomiting |

| | | |may occur. Less N/V versus meperidine. |

|Butorphanol (Stadol) |IV: 1 to 2 mg over 2 min. May repeat incremental|Onset: 2 – 3 min |Titrate to desired level of sedation. Monitor |

| |dose of 1 mg at 2 minute intervals to achieve | |respiratory rate and depth continuously; |

|Mixed opioid agonist / |desired endpoint for sedation. |Duration: 3 – 4 H |respiratory depression may occur. |

|antagonist | | | |

| |Usual Max: 4 mg | |Contraindicated in patients with |

| | | |hypersensitivity to drug or the preservative |

| | | |(benzethonium chloride). Use cautiously in |

| | | |emotionally unstable patients and in those |

| | | |with history of drug abuse and those with |

| | | |respiratory, cardiac disease or if there is |

| | | |renal or hepatic dysfunction. May precipitate|

| | | |withdrawal syndrome |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Moderate Sedation/Analgesia – PEDIATRIC

|Dosing Guidelines for Sedation/analgesia - PEDIATRICS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Diazepam |IV: 0.1 to 0.15 mg/kg over 60 seconds. May |Onset: 30 seconds to 2 minutes|Administer into a large vein; monitor airway, |

|(Valium) |repeat incremental doses to achieve desired |(may take up to 5 min) |02 sats and HR. |

| |sedation endpoint. | | |

| | |Duration: 60 – 180 mins (may |Titrate to desired level of sedation. |

| |Do not exceed 0.25mg/kg |last up to 4 hours); sedative |Contraindicated in untreated narrow-angle |

| |Do not dilute with saline or H20 |effects usually last for 3 |glaucoma; irritating to veins-may cause |

| |Do not mix with other drugs |hours |phlebitis, thrombosis, and local inflammation.|

| |Reduce narcotic dose by a third when used with | | |

| |diazepam; | | |

|Midazolam |PO: Syrup, age > 6 months: |Onset: 1.5 to 5 minutes |Titrate to desired level of sedation. Monitor|

|(Versed) |0.25 – 0.5 mg/kg as a SINGLE DOSE given 15 – 30 | |airway, oxygen saturation, HR. Contraindicated|

| |minutes before a procedure. |Duration: 2 to 6 hours. |in acute narrow-angle glaucoma. |

| | | | |

| |If age > 6 months to 6 years, may require up to 1 |Recovery usually occurs within|May potentiate adverse effects of opioids - |

| |mg/kg. If obese, use ideal body weight. |2 hours, but effects may last |including respiratory depression - when used |

| | |as long as 6 hours. |in combination. |

| |IV - Dilute to 0.1 mg/ml | | |

| | | |Reduce dose in patients with renal or hepatic |

| |< 6 months old: 0.025 – 0.05 mg/kg over at least 2| |dysfunction. |

| |minutes. | | |

| | | | |

| |6 months to 5 years: 0.05 to 0.1 mg/kg over at | | |

| |least 2 min. | | |

| | | | |

| |6 – 12 years: 0.025 – 0.05 mg/kg over at least 2 | | |

| |min. | | |

| | | | |

| |12 – 16 years: Same as adult, but use incremental | | |

| |dosing | | |

| | | | |

| |IV Only: Repeat doses in 2 minutes, if needed, in | | |

| |small increments of initial dose over at least 2 | | |

| |minutes to achieve desired endpoint. Titrate with| | |

| |small increments allowing 2 minutes after each | | |

| |dose to evaluate effect. Once sedation is | | |

| |achieved, additional doses should be 25% of the | | |

| |dose required to produce the endpoint | | |

| | | | |

| |Reduce dose by 30% if patient was pre-medicated | | |

| |with a narcotic or other CNS depressant. | | |

|Chloral Hydrate |Oral or Rectally: 25 – 50 mg/kg/dose 30 to 60 |Onset: 30 to 60 min |May cause disorientation, excitement, delirium|

| |minutes prior to a procedure. May repeat dose in | |drowsiness, ataxia, “hangover” |

| |30 mins to a max dose of 100 mg/kg or 500 mg per |Duration: unknown |Contraindicated in patients with marked |

| |single dose (sedative) or 1g per single dose | |hepatic or renal impairment; severe cardiac |

| |(hypnotic). Max total: 2 g | |disease; gastritis; hypersensitivity or |

| | | |idiosyncrasy to chloral derivatives. |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Moderate Sedation/Analgesia – PEDIATRIC

cont’d

|Dosing Guidelines for Sedation/analgesia - PEDIATRICS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Meperidine |IV: Dilute with NS or H20 to a concentration of 5|Onset: 1 min |Titrate to desired level of sedation. |

|(Demerol) |mg/ml | | |

| |Administer 1 to 1.5 mg/kg over 2 to 3 minutes. |Duration: 2 – 4 H |Contraindicated in patients with |

|Pure opioid agonist |May repeat dose to achieve desired endpoint. | |hypersensitivity to the drug and in those who |

| | | |have received an MAO inhibitor within the past|

| |IM/SC: 1 to 2 mg/kg 15 – 45 minutes prior to a | |14 days. |

| |procedure. | | |

| | | |Use cautiously in patients with respiratory |

| | | |conditions (COPD, asthma). More N/V versus |

| | | |morphine. |

|Morphine |IV: Dilute with NS or H20 to achieve concentration|Onset: 5 min |Titrate to desired level of sedation. Monitor|

| |of 0.5 mg/mL. | |respiratory rate and depth continuously; |

|Pure opioid |Administer: 0.05 – 0.2 mg/kg over 3 to 5 min. |Duration: 4 – 5 H |respiratory depression may occur. Be prepared|

|Agonist |May repeat incremental dose at 5 minute intervals | |to assist ventilation. |

| |to achieve desired endpoint for sedation. |Onset and duration may be | |

| | |longer in PO |Contraindicated if drug allergy; use |

| |PO: 0.3 mg/kg | |cautiously in debilitated patient. |

| | | | |

| |Reduce dose if used with a benzodiazepine. | |Hypotension is possible especially if patient |

| | | |is hypovolemic. Nausea and vomiting may |

| | | |occur. Less N/V versus meperidine. |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Deep Sedation – ADULT and PEDIATRIC

The following medications must be administered by a physician with clinical privileges for deep sedation; or by a qualified anesthesia provider

|Dosing Guidelines for Sedation/analgesia - ADULTS |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Fentanyl |Adults: IV: |Onset: Within 30 seconds |Dilute the 250mcg/5ml ampoule in 10 mL saline |

| |0.05 - 2 mcg/kg IV slow push over 1-2 minutes | |to achieve a concentration of 25 mcg/mL. Give |

| |Usual dose for a 70 kg adult: 70 mcg (It’s 100 |Duration/Adult: |IV slow push until reach target Ramsay score. |

| |times as potent as morphine). |30 – 60 minutes |The target Ramsay scores should be 4 or 5 . |

| | | |Monitor for arrhythmias, respiratory |

| |PEDIATRIC: |Half-life/Pedi: |depression. Provide supplemental oxygen via |

| |IV: Administered in increments of 0.6 – 1 mcg/kg.|1.5-6H |nasal prongs or mask if oxygen saturations |

| |Give in increments of Q 5 – 15 minutes | |fall below 90%. |

| | |Duration/Pedi: | |

| | |30-80 mins | |

| | | | |

|Methohexital (Brevital) |ADULT: |Onset: few seconds |No reversal agent. |

| |Initial dose: 20 – 40 mg IVP, slowly Q 4-7 |Duration: 6-8 min |The target Ramsay scores should be 4 or 5 . |

| |minutes | |CNS/respiratory depression, hypotension, |

| | | |convulsions. |

| |PEDIATRIC: |May last up to 40 –60 minutes | |

| |IV – 1-1.5 mg/kg |in pediatrics | |

| | | | |

| |IM – 5 – 10 mg/kg | | |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

Dosing Guidelines for Sedation/Analgesia

REVERSAL AGENTS – ADULT AND PEDIATRIC

| Dosing Guidelines for Sedation/analgesia – Reversal Agents |

|Drug |Dose |Onset/Duration |Monitoring/Comments |

|Flumazenil (Romazicon) |ADULT |Onset: immediate |Benzodiazepine antagonist. |

| |IV: 0.2 mg over 15 seconds. If patient does not | | |

|For Benzodiazepine |reach desired level of consciousness after 45 sec,|Duration: |Use has been associated with occurrence of |

|Reversal |repeat dose. Dose may be repeated at 1 min | |seizures. Monitor for recurrence of sedation.|

| |intervals until a cumulative dose of 1 mg has been|Initial half-life: |Monitor ventilation, HR, O2 sats. |

| |given. |7 – 15 min | |

| |Dose may be repeated after 20 minutes if | |NOTE: The effects of flumazenil may wear off |

| |re-sedation occurs, but no more than 1 mg should |Terminal half-life: |before the effects of the benzodiazepine. |

| |be given at one time. |41 – 79 min |Repeat doses may be required. |

| |Do not exceed 3 mg in 1 hour. | | |

| | | |Flumazenil is not generally recommended for |

| |PEDIATRIC | |use in children. |

| |IV: 0.01 mg/kg given IV over 15 seconds (up to 0.2| | |

| |mg total dose). May repeat the dose at 1 minute | | |

| |intervals until desired endpoint is reached or up | | |

| |to 5 total doses of 0.01 mg/kg. Maximum dose is | | |

| |0.05 mg/kg or 1 mg, whichever is lower. | | |

|Physostigmine (for |0.5 – 1 mg IV (to desired effect). No more than 1|Onset: immediate |Watch for cholinergic side effects |

|antichollinergic syndrome)|mg per minute |Duration: 0.5-4H |(bradycardia, emesis, cramping, and |

| | | |salivation) |

|Naloxone (Narcan) |ADULTS |Onset: 2 – 3 min |Narcotic antagonist. |

| |IV: 0.1 mg over 2 minutes with repeated doses at | |Contraindicated in patients with |

|Narcotic |2 to 3 minute intervals; titrate to desired |Duration: 45 min to 4 H |hypersensitivity to naloxone. |

|Antagonist |effect. Max total dose = 10 mg | | |

| | |Half-life |NOTE: The effects of naloxone may wear off |

| |PEDIATRIC |Adults - 30-80 min |before the effects of the narcotic. Repeat |

| |IV: 0.01 mg/kg over 2 minutes and may repeat with|Neonate: 2.5-3.5H |doses may be required. |

| |a dose of 0.1 mg/kg if needed; titrate to desired | | |

| |effect. | | |

|References: Drug Facts and Comparisons, Facts and Comparisons, Inc: St. Louis, MO: 2000 |

|Micromedex, Volume 107, expires 3/31/2001. |

|McEvoy, GK. Pharmacist’s Drug Handbook, American Society of Health-System Pharmacists; Springhouse Corp: 2001. |

PRE-PROCEDURE

PRE-PROCEDURE PHYSICIAN RESPONSIBILITIES

a.) Documentation of a baseline health assessment is to include but not limited to:

1. Vital signs

2. Results of labs/x-rays ordered

3. Results of consultations, when ordered

4. Health history including:

▪ Age of the patient

▪ Allergies

▪ Previous adverse drug responses with anesthesia and/or sedation

▪ Current medications

▪ Review of systems

▪ Diseases, disorders, abnormalities,

▪ Prior hospitalizations

Results of physical exam reflecting:

▪ Height and weight

▪ Baseline vital signs

▪ Pulmonary and cardiac examination, and

▪ Risk assessment including ASA classification

▪ Patent airway

Pregnancy status (if warranted);

Informed consent(s) (for procedure and for sedation/analgesia)

ASA status (See Table 1)

Attest that the patient is a candidate for the planned sedation/analgesia

PRE-PROCEDURE REGISTERED NURSE RESPONSIBILITIES

The RN will:

▪ Conduct the pre-sedation/procedure assessment to include,

▪ NPO status, time of last food and fluid intake;

▪ Current blood pressure, pulse and respirations, oxygen saturation;

▪ Level of consciousness / sedation status; (Baseline Ramsay)

▪ Pain level and goal;

▪ Pulse oximeter value on room air

In addition, the RN should:

▪ Verify that the medical record contains evidence of:

▪ Informed consent(s), and

▪ An H&P

▪ Establish intravenous access;

▪ Document the patient pain goal and level of pain

▪ Individualize and prioritize the nursing plan of care; and

▪ Document baseline vital signs on the Sedation/Analgesia Flowsheet taken immediately prior to sedation/analgesia use.

INTRA-PROCEDURE

During the procedure the patient’s physiological status is monitored, including

a) Reassessment of

▪ Respiratory status

▪ Cardiac status

▪ Level of consciousness

b) Monitoring

▪ Blood pressure

▪ Oxygen saturation

▪ Heart rate and rhythm

▪ Level of sedation

▪ Hypersensitivity to medications

d) Plan of Care

The plan of care shall be revised as the patient’s condition and response to the procedure dictate.

Documentation – Intra-Procedure

The following are documented a minimum of every 5 minutes on the Sedation/Analgesia Flow Sheet:

a) Physiologic and Neurologic

▪ Blood pressure

▪ Oxygen saturation

▪ Heart rate and rhythm

▪ Level of sedation

e) Procedure Times

▪ Time assessed prior to procedure

▪ Time when the procedure was initiated

▪ Time when the procedure ended

f) Medications. Dosage, route, time and effects of all medications used for the procedure. (e.g., “Patient sedated with patent airway and Ramsay score of 3 after midazolam 2 mg and meperidine 25 mg “).

g) Adverse reactions. Any hypersensitivity reactions, unusual occurrences and resolutions.

The Physician is immediately alerted of changes in the patient’s physical condition and/or vital signs.

POST-PROCEDURE

Assessment

▪ Respiratory status

▪ Circulatory status

▪ Color

▪ Level of consciousness/level of sedation

▪ Activity

▪ Dressing / Procedure Site

▪ Pain level

▪ Nausea

▪ Neurovascular checks

Monitoring

▪ Vital signs: BP, HR, RR

▪ Pulse oximetry

▪ EKG

▪ Level of sedation

▪ Monitoring shall be continued for a minimum of sixty (60) minutes following the last dose of medication when no reversal agent has been used.

▪ When a reversal agent has been used, monitoring will continue for a minimum of 2 hours.

Documentation

The nurse shall document the following a minimum of every 15 minutes or more frequently as the patient’s condition dictates.

▪ Vital signs including oxygen saturation on room air

▪ Color

▪ Level of consciousness/level of sedation

▪ Activity

▪ Dressing / Procedure Site

▪ Pain level

▪ Nausea

▪ Neurovascular checks

Other documentation

▪ Patient’s tolerance of the procedure

▪ Place transferred to and name of person receiving the patient

▪ Patient’s recovery and status at discharge

Prior to discontinuing post-procedure monitoring, the patient’s vital signs, pulse oximetry value, and level of consciousness and response must be stable as compared to baseline readings taken pre-procedure.

Recovered patients must:

▪ Be discharged from the post-sedation recovery area by the Physician OR

▪ Meet the established discharge criteria approved by the Dept. of Anesthesia

Physician Responsibilities

Physician Responsibilities:

▪ Record a post-procedure/sedation progress note.

▪ The physician may leave the immediate area when the patient’s vital signs are stable OR the patient meets discharge criteria OR the Aldrete score is the same as baseline.

Nurse Responsibilities. The responsible nurse must remain with the patient for the duration of the procedure and for the recovery phase of the procedure. The nurse may not engage in other tasks or leave the patient unattended until the patient returns to baseline status. The nurse to patient ratio during the recovery phase may not exceed 2 patients to 1 nurse.

Aldrete Scoring for Discharge

Prior to discharge, patients will be scored with use of the Aldrete Scale. A discharge score of > =8 or return to baseline is required prior to discharge.

|Aldrete Score For Discharge | |

| |Score at 15-Minute Intervals Post-Sedation |

| |

DISCHARGE CRITERIA. Patients may be discharged from the procedure area if they meet all of the following criteria:

▪ Patient is as alert and oriented as at baseline (pre-procedure)

▪ Stable vital signs documented for a minimum of 60 minutes after the last dose was given (or 120 minutes if reversal agent used [Narcan or Romazicon])

▪ Documentation that includes BP, pulse rate, respiratory rate and oxygen saturation on room air (> 95% or at baseline) and level of consciousness at or near pre-sedation levels.

▪ Cardiac rhythm consistent with baseline

▪ Temperature not above 101 F

▪ A discharge score >= 8 (Aldrete score) or equivalent to pre-sedation baseline

▪ Dry surgical dressings or minimal drainage anticipated

▪ Minimal or absent nausea

▪ Pain controlled by analgesics or rated at or below baseline

▪ Voiding (may be required by the Physician)

▪ Presence of protective reflexes (swallow and gag) and tolerating fluids by mouth as ordered by the Physician

▪ Patient is able to ambulate as well as he/she was able to prior to the procedure

▪ Responsible adult is present to drive patient home and remain with patient during recovery phase

DISCHARGE INSTRUCTIONS

Patients undergoing IV sedation/analgesia must not operate machinery or a motor vehicle for 24 hours or until the Physician deems appropriate.

Written discharge instructions are provided to the patient and family member. The patient/family is asked to verbalize their understanding of the instructions and sign for instructions.

SUMMARY OF MODERATE AND DEEP SEDATION/ANALGESIA

|Comparison of Equipment and Personnel for Sedation/Analgesia |

|Comparison |Moderate Sedation |Deep Sedation |

|Ramsay Scores |< = 3 |> 3 (target 4 or 5) |

|Typical procedures |Endoscopy, ERCP, MRI (Pedi) |Cardioversion, EP Studies |

|Monitoring |Pulse oximetry continuous |Pulse oximetry continuous |

| |Heart rate monitoring continuous |Heart rate monitoring continuous |

| |Respiratory rate continuous |Respiratory rate continuous |

| |Level of consciousness continuous |Level of consciousness continuous |

| |Blood Pressure Q 5 mins |Blood Pressure Q 5 mins |

|Charting - Intra |Pulse oximetry q 5 mins |Pulse oximetry every 5 mins |

| |Heart rate/rhythm q 5 min |Heart rate/rhythm every 5 min |

| |Respiratory rate q 5 min |Respiratory rate every 5 min |

| |Level of consciousness q 5 min |Level of consciousness every 5 min |

| |Blood pressure q 5 min |Blood pressure every 5 min |

|Charting – Post |Aldrete score q 15 mins |Aldrete score q 15 mins |

| |Pain/nausea q 15 mins |Pain/nausea q 15 mins |

| |Pulse oximetry q 15 mins |Pulse oximetry q 15 mins |

| |Heart rate q 15 min |Heart rate q 15 min |

| |Respiratory rate q 15 min |Respiratory rate q 15 min |

| |Level of consciousness q 15 min |Level of consciousness q 15 min |

| |Blood pressure q 15 min |Blood pressure q 15 min |

| |Neurovascular checks q 15 min |Neurovascular checks q 15 min |

|Personnel |Registered Nurse |Registered Nurse |

| |Physician |Physician |

| | |1 other person: RN or LVN or GI Lab Tech or Radiology Tech, |

| | |etc. |

|Equipment |Pulse oximeter |Pulse oximeter |

| |Blood pressure device |Blood pressure device |

| |Stethoscope |Stethoscope |

| |ECG monitor / defibrillator |ECG monitor / defibrillator |

| |Emergency crash cart |Emergency crash cart |

|Airway equipment |Age and size appropriate |Age and size appropriate |

|Medications |Meperidine, Morphine, Diazepam, Midazolam, Chloral |Meperidine, Morphine, Diazepam, Midazolam, Fentanyl, |

| |Hydrate |Methohexital |

|Reversal Agents |Naloxone and Flumazenil |Naloxone and Flumazenil |

|Aldrete score for discharge |>=8 |>=8 |

Name: ______________________________

Date: _______________________________

Competency Assessment: Moderate and Deep Sedation

|COGNITIVE SKILLS | |

|Objectives |Met |Not Met |

|Candidate able to correctly define sedation/analgesia and its purposes. | | |

|Candidate able to identify the differences between moderate sedation/analgesia, deep | | |

|sedation and general anesthesia. | | |

|Candidate able to identify staff qualifications for administration of sedation/analgesia. | | |

|Candidate able to describe pre-procedure, intra-procedure, and post-procedure assessment | | |

|and monitoring. | | |

|Candidate able to demonstrate knowledge of pharmacological agents and reversal agents used| | |

|for sedation/analgesia. | | |

|Candidate able to recognize potential complications of IV sedation/analgesia in relation | | |

|to the type of medication administered. | | |

|Candidate able to demonstrate skills in airway management, cardiopulmonary resuscitation, | | |

|dysrhythmia recognition, and treatments. | | |

|Candidate has reviewed hospital policy and successfully completed a written exam on | | |

|sedation/analgesia. | | |

| | |

|Teaching Methodology |Method of evaluation: |

|Review local policy and procedure on sedation/analgesia. |Closed book/written test/ 90% |

|Review dosage guidelines for drugs and reversal agents. |Frequency of Reverification: Annual |

| |Re-verification Requirements: Retest |

|Written test passed on ________/________/ _________. | |

| | |

|__________________________________ ________/_______/_______ | |

|Evaluator Signature Date | |

|PERFORMANCE SKILLS | |

|Objectives |Met |Not Met |

|Candidate uses hospital guidelines to prepare patient for sedation/analgesia. | | |

|Candidate ensures consent form has been signed. | | |

|Candidate obtains baseline vital signs to include pulse oximetry, last oral intake, weight| | |

|and allergies. | | |

|Candidate initiates a patent intravenous access. | | |

|Candidate obtains all drugs to be used and their antagonists before start of procedure. | | |

|Candidate has all equipment for resuscitation available and operational, including oxygen.| | |

|Candidate maintains all flow sheets according to documentation policies. | | |

|Candidate never leaves the patient unattended. | | |

|Candidate communicates effectively with providers, other nurses, and family | | |

|Candidate initiates appropriate treatments in response to complications; notifies | | |

|Physician. | | |

|Part 1 – Pre-Procedure Assessment | | |

|Prepare the patient for sedation/analgesia. | | |

|Ensure History and Physical on chart. | | |

|Check for allergies. | | |

|Ensure informed consent is done. | | |

|Establish last oral intake. | | |

|Obtain weight. | | |

|Obtain initial vital signs to include pulse oximetry. | | |

|Establish level of consciousness. | | |

Competency Assessment: Moderate and Deep Sedation, cont’d

|Performance Skills Checklist |Met |Not Met |

|Obtain medications and antagonists | | |

|Verify correct medication dosages with Physicians order. | | |

|Draws up medication dosages in diluted form to allow for incremental dosing. | | |

|Check expiration date on all medication. | | |

|Demonstrates knowledge of medication: dosages, routes of administration, dilution if | | |

|needed, expected actions and contraindications. | | |

|Assemble equipment / supplies | | |

|Automatic BP monitor (manual cuff) | | |

|Patent IV site/emergency drugs available | | |

|Oxygen via nasal cannula at 2L/min | | |

|Functioning suction apparatus. | | |

|Cardiac monitor with electrodes. | | |

|Bag-valve-mask apparatus with appropriate size masks. | | |

|Airway adjuncts. | | |

|Defibrillator | | |

|Part II: Intra-procedure Assessment / Notes | | |

|Position patient to maintain patent airway. | | |

|Monitor VS and record Q 5 minutes to include pulse oximetry. | | |

|Document medication dosage, route, and patient’s response to medication. | | |

|Constantly monitor patient’s level of consciousness, respiratory status, and response to | | |

|procedure. Notify Physician of any changes. | | |

|Part III: Post-procedure Assessment | | |

|Monitor vital signs and record (chart every 5 min), monitor respiratory effort, level of | | |

|consciousness, and pulse oximetry. | | |

|Assess and document patient’s Ramsey score every 5 minutes. | | |

|Document patient’s response to sedation. | | |

|Remain with the patient at all times. | | |

|Monitor the patient for a minimum of 60 minutes for moderate sedation/analgesia and 120 | | |

|minutes if reversal agent used. | | |

|Part IV: Discharge Data | | |

|Recommend discharge when Aldrete score reaches >= 8 (after 60 minutes). | | |

|Document patient’s condition at discharge. | | |

|Document patient’s disposition (with whom, where – e.g., “with spouse to home”) | | |

|Ensure follow-up appointment is given to patient/escort. | | |

|Ensure a written instruction sheet is given and reviewed with patient or caregiver / | | |

|responsible adult and patient/caregiver verbalize understanding of post sedation care. | | |

|Document time of discharge and complete all documentation. | | |

|Teaching Methodology |Method of Evaluation: |

|Demonstration, supervised practice, and record review. |Based on the observation of critical behaviors from a |

|Note: Stop procedure and correct deficiencies if candidate is failing to meet standards. |Performance Checklist. |

|Performance Skills Test passed on _______/________/ ________ |Frequency of re-verification: Annual |

| |Re-verification requirements: Same as initial |

|_______________________________ _____/______/_________ |requirements. |

|Evaluator Signature Date | |

Name: ____________________________________

Date: _______/_______/_______

Post-Test for Sedation/Analgesia – Moderate and Deep Sedation

True / False - General

1. _____In sedation/analgesia, patients are awake and able to maintain a patent airway on their own.

2. _____Sedation/analgesia is performed in an area that can support resuscitation if needed.

3. _____ Informed consent is usually obtained and documented after the procedure.

4. _____ The staffing protocol for moderate sedation/analgesia is 1RN: 1 MD and for deep sedation it is 2RN: 1 MD and 1 RT.

5. ______ A pulse oximeter is never used during a sedation/analgesia procedure.

6. _____ Adults should not have any solid or non-clear liquids for 6-8 hours prior to a procedure.

7. _____The MD makes the ASA classification.

8. _____An anesthesiologist is available for consult if ASA classification is greater than or equal to 3.

9. _____In moderate sedation/analgesia, the target Ramsay sedation score is < = 3.

10. _____In deep sedation, the target Ramsay sedation score is > 3 (usually 4 or 5).

11. _____ Patients are scored with the Aldrete scale and a score > 8 out of 10 is required for discharge.

12. _____Patient’s must meet discharge criteria before they are dismissed from the facility.

13. _____Patients are provided with written and verbal instructions after sedation/analgesia (i.e., no driving or operating machinery X 24H).

14. _____Patient MONITORING is the same for sedation/analgesia and deep sedation. CHARTING of vitals and LOC is done every 5 minutes for moderate and deep sedation/analgesia.

15. _____ The physician is responsible for documenting the sedation plan (moderate or deep sedation) and that the patient is an eligible candidate for the level of sedation selected.

T/F Drug Therapy

1. ____The sedation/analgesia policy is used when opiates are used with benzodiazepines in recommended doses (IV/IM).

2. ____Single oral doses of benzodiazepines (except Versed syrup) prior to a procedure are exempt from the sedation policy.

3. ____An appropriate combination regimen for moderate sedation/analgesia is Meperidine 25 mg and Versed 2 mg, given in increments.

4. ____Titration of doses is used in sedation/analgesia. No bolus dosing is used.

5. ____Versed syrup is indicated for SINGLE DOSE only.

6. ____Drugs for sedation/analgesia include meperidine, morphine, diazepam, midazolam, pentobarbital and chloral hydrate.

7. ____Drugs for deep sedation include meperidine, morphine, diazepam, midazolam, fentanyl and methohexital (Brevital).

8. ____Respiratory depression and/or cardiovascular depression may occur during sedation/analgesia.

9. ____A crash cart with emergency drugs / supplies is not required prior to sedation/analgesia.

10. ____Appropriate doses of opiates in adults include Meperidine 12.5 – 25 mg; Morphine 1 – 2 mg; Butorphanol 1-2 mg; each given over 2 mins.

11. ____Appropriate doses of midazolam in adults include doses of 1 – 2 .5 mg if ................
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