VA NATIONAL CENTER FOR PATIENT SAFETY Moderate Sedation ...

VA NATIONAL CENTER FOR PATIENT SAFETY

Moderate Sedation Toolkit

for Non-Anesthesiologists

Curriculum Guide

Content Produced by

The Durham VAMC Patient Safety Center of Inquiry (PSCI)

VA National Center for Patient Safety Moderate Sedation Toolkit for Non-Anesthesiologists

Curriculum Guide

2

Moderate Sedation Curriculum Guide

Introduction ? Objectives of Sedation Practice

Decrease anxiety, pain, discomfort Amnesia to the extent possible, but not guaranteed Minimize risk (optimize risk/benefit ratio) Rapid recovery

? Clinical Settings

Outpatient clinics and inpatient procedural areas ? Pulmonary, GI, dental, minor surgery, interventional radiology, interventional cardiology/electrophysiology

Emergency room ? Fracture/dislocation reduction, suturing of wounds, examinations

Operating room ? Procedures under sedation with local anesthesia by surgeon

? Contraindications

History of allergy to medications Hemodynamic instability High risk of pulmonary aspiration of gastric contents High risk of sedation failure, requiring assistance of anesthesiology service

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VA National Center for Patient Safety Moderate Sedation Toolkit for Non-Anesthesiologists

Curriculum Guide

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Levels of Sedation, a Continuum

Response (to simulation)

Minimal Sedation

*

Airway

Spontaneous Ventilation

Moderate Sedation

Purposeful** response to verbal/tactile

No intervention

Adequate

Deep Sedation

Purposeful** response to tactile/painful Intervention often

required

Possibly adequate

General Anesthesia

Unarousable

Intervention required

Inadequate

Vital Signs

May be impaired

* Indicates normal or minimal change from baseline **Localization to pain does not qualify as purposeful response

? Joint Commission Standards

Standards apply for sedation and anesthesia when patients receive "in any setting for any purpose, by any route, moderate or deep sedation as well as general, spinal or other major regional anesthesia."

"...must be able to manage a compromised airway..." Standards do not apply to minimal sedation

? Example (PO Diazepam [Valium] prior to MRI scan)

Pharmacology ? General Considerations

Sedation medications usually cause ? Decreased hypoxic and hypercarbic respiratory drive ? Decreased tone in upper airway leading to increased risk of upper airway obstruction ? Decreased protective airway reflexes causing increased risk of pulmonary aspiration and laryngospasm

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VA National Center for Patient Safety Moderate Sedation Toolkit for Non-Anesthesiologists

Curriculum Guide

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Duration of sedative drug effect usually due to redistribution of drug rather than metabolism, but dependent on other drugs in chronic use

Drug

Dose

Onset

Peak Effect (min) Duration (min)

Fentanyl

25 - 50 mcg IV

3 ? 5 min 5 ? 15 min

Midazolam 0.5 - 2 mg IV

1 ? 2 min 1 - 2 min

Naloxone * 0.1 ? 0.2 mg IV***

1 - 2 min *** 5 ? 15 min

Flumazenil** 0.2 mg IV (Max 1 mg) 1 ? 2 min 6 ? 10 min

30 ? 180 min 20 ? 40 min 30 ? 45 min 45 ? 60 min

*Use with care in patients on chronic opioids

**May precipitate seizures

*** Naloxone may be given IM, 0.4 mg IM with onset 2-5 min

? Opioids

Fentanyl, 25 to 50 mcg bolus doses ? Ultra-short-acting relative of morphine [80-100 X potency of morphine] ? Physiologic effects ? Potent respiratory depressant resulting in severe hypoventilation and apnea that may require assisted ventilation or tracheal intubation ? Cardiovascular depressant ? Bradycardia and hypotension ? Euphoria ? HIGHLY SYNERGISTIC WITH BENZODIAZEPINES

? Benzodiazepines

Midazolam (Versed), 0.5 to 2 mg bolus doses ? Water soluble, related to diazepam ? Duration of action determined by redistribution ? Physiologic effects ?? Anxiolysis, amnesia ?? Mild respiratory and cardiac depressant ?? Minimal respiratory depressant when given ALONE unless given in large doses; powerful depressant if given with opioid

?? Suppresses seizures

?? May cause paradoxical dis-inhibition and agitation

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VA National Center for Patient Safety Moderate Sedation Toolkit for Non-Anesthesiologists

Curriculum Guide

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?? In elderly or malnourished, decrease dose significantly (95 percent protein bound)

?? HIGHLY SYNERGISTIC WITH OPIOIDS

? Other Drugs Used for Sedation

Propofol (Diprivan) ? Lipid soluble hypnotic, ultra-short acting ? Bolus dosing highly likely to result in complete loss of protective airway reflexes, airway obstruction and apnea ? No pharmacologic reversal ? Potent cardiovascular depressant causing significant hypotension and decreases in cardiac output ? No analgesic properties ? Mild antiemetic activity ? Current use in VHA restricted to anesthesia-trained providers, consistent with drug package insert

? Adjuvant Medications

Lidocaine (topical) ? Useful as mucosal topical anesthetic for endoscopy ? Viscous (2 percent) or spray (atomized, 4 percent) ? Maximum suggested dose: 400 mg (10 ml 4 percent or 20 ml 2 percent)

? Reversal Agents

Routine use is NOT recommended These drugs should be available whenever moderate or deep sedation is administered Use should be considered in conjunction with other rescue maneuvers (e.g. supplemental

oxygen administration, patient stimulation, airway support or device use) After use, patient should be observed for 90 to 120 minutes to ensure event does not

recur Naloxone (Narcan), 0.1 to 0.2 mg bolus dose, up to 0.4 mg typical maximum

? Opioid antagonist ? May precipitate acute withdrawal in opioid dependent patient ? May precipitate pulmonary edema in some cases ? Initial dose can be as small as 0.04 mg (40 mcg) ? Larger dose, 0.4 mg (400 mcg) IV, should ONLY be used for emergency rescue in

the apneic patient

NCPS REV 03.29.2011

VA National Center for Patient Safety Moderate Sedation Toolkit for Non-Anesthesiologists

Curriculum Guide

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Flumazenil (Romazicon), 0.2 mg bolus dose, up to 1 mg maximum ? Benzodiazepine antagonist ? May cause headache, confusion, flushing, dysrhythmias and hypertension ? May precipitate seizures

Anatomy and Physiology ? Evaluation of the Airway

Airway evaluation should include: ? Quick look ?? Gross deformities, scarring of neck or face, large beard, other obvious issues that would make management of airway (ventilation or intubation) difficult ? Mouth opening ?? Three fingerbreadths between teeth ?? Chipped, loose or missing teeth ?? Ask about subluxation of jaw (pushing lower jaw forward), which predicts easy intubation (ask "can you bite your upper lip?") ? Mallampati score (relative tongue/palate size)

?? Class I predicts successful intubation

?? Class IV predicts difficult intubation

?? Class II and III is not predictive

? Neck extension (mainly occipito-atlanto-axial motion) ?? Minimum 35 degrees ?? Limited extension may predict difficult intubation, but not necessarily difficult ventilation ? Chin size (thyromental distance) ?? Distance from upper border of thyroid cartilage to chin ?? Should exceed three fingerbreadths or 6 cm ?? Shorter distance associated with receding chin, short, thick neck, predicts difficult intubation, but not necessarily difficult ventilation ? Predictors of difficult MASK VENTILATON: OBESE SCORE

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VA National Center for Patient Safety Moderate Sedation Toolkit for Non-Anesthesiologists

Curriculum Guide

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? Predictors of difficult TRACHEAL INTUBATION: LEMON SCORE

? Effects of Sedation on the Airway

Decreased hypoxic and hypercarbic respiratory drive ? Predisposes to hypoventilation and apnea

Loss of motor tone in upper airway ? Predisposes to upper airway obstruction

Loss of tone in submandibular muscles ? Predisposes to obstruction by tongue and soft palate

Diminished airway protective reflexes ? Predisposes to pulmonary aspiration of oral secretions or gastric contents

? Risks of Aspiration

Recent oral intake Gastroesophageal reflux disease (GERD), hiatal hernia Conditions that slow gastric emptying (pregnancy, diabetes, bowel obstruction, etc.) Previous esophageal surgery (HIGH RISK) Conditions associated with increased intragastric pressure (obesity, bowel obstruction,

abdominal compartment syndrome, etc.) Altered level of consciousness or decreased ability to protect airway for another reason

(e.g. over sedation, chronic bulbar neuromuscular disease, etc.)

? Effects of Changes in Position

Changes in position may make spontaneous ventilation or airway management more or less challenging

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Curriculum Guide

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? Lateral position decreases upper airway obstruction by shifting the relaxed airway structures off the posterior pharynx, but will probably make mask ventilation more difficult

? Upright position partially relieves upper airway obstruction by shifting obstructing tissue away from posterior pharyngeal structures

Pre-Procedure Assessment ? Purpose

Clinical utility ? Transmission of useful clinical information to other care providers ? To establish baseline patient condition and suitability for planned procedure and sedation ? Assess need for additional testing, consultation or intervention prior to procedure

Documentation and communication ? Must be accurate ? If not done immediately prior to the procedure, INTERVAL CHANGES occurring since the pre-procedure assessment was performed must be documented ? On occasion, changes in patient condition may alter planned procedure or sedation

? Components

Past medical history ? Height, weight, allergies, medications ? History of receiving sedation or anesthetics, any problems noted ? Indication for procedure ? Use of tobacco, ETOH, other drugs/OTC/alternative medications ? Significant co-morbidities ?? Severity, stability, recent changes in condition ?? Relative contraindications to moderate sedation (may vary slightly for urgent vs. elective procedures) Severe, untreated hypertension Hemodynamic instability Decompensated heart failure Unstable angina Acute dyspnea Recent PO intake Significant dysrhythmia or electrolyte disturbance

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