Association of periOperative Registered Nurses | AORN



ADMINISTRATIVE APPROVAL

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Purpose

To provide guidance to perioperative RNs for care of the patient receiving moderate sedation/analgesia. The expected outcomes are that the patient is free from harm related to medications administered within the perioperative environment, the patient’s respiratory status is maintained or improved from baseline levels, the patient’s cardiovascular status is maintained at or improved from baseline levels, and the patient demonstrates or reports adequate pain control.

Policy

It is the policy of [insert name of facility] that:

• The patient’s suitability for moderate sedation/analgesia will be determined based on selection criteria established by an interdisciplinary team.

• The perioperative RN will collaborate with the patient and a licensed independent practitioner (eg, surgeon, endoscopist, dentist, podiatrist) or anesthesia professional in developing and documenting the sedation/analgesia plan of care. The sedation plan will include the

o medications and route of administration,

o need for IV access,

o predetermined depth of sedation to complete the procedure,

o length of the procedure and sedation, and

o recovery time.

• A licensed independent practitioner or anesthesia professional will directly supervise the perioperative RN monitoring the patient and administering medications.

• The supervising practitioner will be physically present and immediately available in the procedure suite for diagnosis, treatment, and management of complications while the patient is sedated.

• Emergency resuscitation equipment and supplies will be immediately available in every location in which moderate sedation is administered.

• Supplemental oxygen will be immediately available for the patient receiving moderate sedation/analgesia.

• Opioid antagonists and benzodiazepine antagonists will be readily available whenever opioids and benzodiazepines are administered.

• Emergency equipment and supplies will include age- and size-appropriate

o resuscitation medications,

o opioid and benzodiazepine antagonists,

o airway and ventilator equipment (eg, laryngoscopes, endotracheal tubes, a laryngeal mask airway, oral and nasal airways, a mechanical positive bag-valve mask device),

o defibrillators and defibrillation pads, and

o IV fluids and access equipment.

• Clinical alarms will be audible and set to alert for critical changes in the patient’s status.

• The perioperative RN must administer moderate sedation/analgesia within the scope of nursing practice as defined by the state board of nursing and the state nurse practice act.

• The perioperative RN should know the recommended dose, recommended dilution, onset, duration, effects, potential adverse reactions, drug compatibility, and contraindications for each medication used during moderate sedation.

• The perioperative RN will complete a patient assessment before administering moderate sedation/analgesia.

• Two perioperative RNs will be assigned to care for the patient receiving moderate sedation/analgesia. One RN will administer the sedation medication and monitor the patient and the other RN will perform the circulator role.

• The perioperative RN monitoring the patient will have no competing responsibilities that would compromise continual monitoring assessment of the patient during the administration of moderate sedation.

• The perioperative RN providing moderate sedation/analgesia will be in constant attendance with unrestricted immediate visual and physical access to the patient.

• The perioperative RN caring for the patient receiving moderate sedation/analgesia may perform short interruptible tasks (eg, opening additional suture, tying a gown) to assist the perioperative team while remaining within the operating or procedure room, as long as these tasks do not compromise the continual monitoring of the patient.

• The RN providing moderate sedation/analgesia will not perform any other tasks when propofol is used and will monitor the patient without interruption.

• Medical supervision of the patient’s recovery and discharge after moderate sedation/analgesia is the responsibility of the anesthesia professional or another qualified licensed independent practitioner.

• Discharge criteria for patients receiving moderate sedation/analgesia will be established by a multidisciplinary team. Discharge criteria will include

o return to preoperative baseline level of consciousness (eg, alert and oriented),

o stable vital signs,

o sufficient time interval (eg, 2 hours) since the last administration of an antagonist (eg, naloxone, flumazenil),

o use of an objective patient assessment discharge scoring system (eg, Aldrete Recovery Score, Post-Anesthetic Discharge Scoring System),

o absence of protracted nausea,

o intact protective reflexes,

o adequate pain control,

o return of motor/sensory control,

o duration of at least 30 minutes after the last sedative or analgesic medication administered by the intravenous route, and

o arrangement for safe transport from the facility.

• A qualified provider, as defined by [facility-specific policy], will be available in the facility to discharge the patient in accordance with established discharge criteria.

• The perioperative RN must give the patient and their caregiver verbal and written discharge instructions.

o A copy of the written discharge instructions must be given to the patient and a copy will be placed in the patient’s medical record.

Procedure Interventions

Patient Assessment

• Perform a nursing assessment before administering moderate sedation that includes a review of the patient’s

o allergies and sensitivities (eg, medications, food, environment, adhesives, latex);

o age;

o height, weight, and body mass index;

o current medical and surgical history and physical examination (eg, history and physical);

o current medications (eg, prescribed, over-the-counter, alternative/complementary therapies, supplements), dosage, last dose, and frequency;

o history and current drug use (eg, street drugs, non-prescribed prescription drugs);

o history and current cannabis use;

o history and current tobacco and alcohol use;

o laboratory test results (eg, serum electrolytes, coagulation studies);

o diagnostic test results (eg, 12-lead electrocardiogram, echocardiogram, pulmonary function test);

o baseline cardiac status (eg, heart rate, blood pressure);

o baseline respiratory status (eg, rate, rhythm, blood oxygen level [SpO2]);

o baseline neurological status (eg, level of consciousness);

o airway (eg, obstructive sleep apnea, difficult mask ventilation);

o physical limitations or sensory impairment (eg, visual, auditory, vocal);

o level of anxiety;

o level of pain;

o pregnancy test results when applicable;

o NPO status;

o previous adverse experiences with anesthesia or moderate sedation, including

▪ delayed emergence from anesthesia or sedation,

▪ postprocedure nausea and/or vomiting,

▪ reported adverse effects from anesthetic or sedative medications,

▪ malignant hyperthermia, and

▪ airway or breathing problems;

o informed consent (ie, explaining the risks, benefits, and alternatives to sedation); and

o arrangement for a responsible adult caregiver to escort the patient home or two adults (ie, driver and observer) for an infant or toddler riding home in a car safety seat.

• For older adult patients (ie, > 65 years), assess the patient’s

o frailty, using [facility-specific screening tool (eg, frailty index, frailty phenotype, frail scale)];

o functional status, using [facility-specific screening tool (eg, activities of daily living, instrumental activities of daily living)]; and

o cognitive impairment (eg, delirium), using [facility-specific screening tool (eg, clock drawing test, Mini-Cog, mini-mental status exam)].

• For pediatric patients (ie, [facility-specific age limit]), assess the patient’s

o history of premature birth,

o congenital anomalies,

o presence of autism spectrum disorder,

o behavioral issues,

o traumatic childhood experiences,

o developmental or physical delays, and

o [facility-specific criteria].

• Use the American Society of Anesthesiologists (ASA) Physical Status Classification to determine patient acuity.

o ASA I: A normal, healthy patient.

o ASA II: A patient with mild systemic disease.

o ASA III: A patient with severe systemic disease.

o ASA IV: A patient with severe systemic disease that is a constant threat to life.

o ASA V: A moribund patient who is not expected to survive without the operation.

o ASA VI: A declared brain-dead patient whose organs are being removed for donor purposes.

• Consider patients who are classified as ASA I, ASA II, and medically stable ASA III as appropriate for RN-administered moderate sedation/analgesia.

• Assess the patient for characteristics that may indicate difficulty with mask ventilation, including

o age > 55 years;

o obesity;

o a history of snoring, stridor, or sleep apnea;

o missing teeth, protruding incisors, loose teeth, or dental appliances (eg, dentures, partials, veneers);

o presence of a beard;

o a short neck;

o limited neck extension;

o cervical spine disease or trauma;

o presence of a neck mass;

o decreased hyoid-mental distance (eg, < 3 finger breadths in an adult);

o dysmorphic facial features (eg, Pierre-Robin syndrome);

o a small mouth opening (eg, < 3 cm in an adult);

o a high, arched palate;

o macroglossia;

o a nonvisible uvula;

o a Mallampati classification III or IV;

o jaw abnormalities (eg, micrognathia, retrognathia);

o a history of problems with anesthesia or sedation;

o advanced rheumatoid arthritis;

o chromosomal abnormality (eg, trisomy 21); and

o tonsillar hypertrophy.

• Assess the patient for risk of obstructive sleep apnea, using [facility-specific screening tool that has been validated in surgical patients (eg, STOP-Bang tool, Berlin questionnaire, P-SAP score, ASA checklist)].

• Screen pediatric patients for obstructive sleep apnea, using [facility-specific screening tool that has been validated in pediatric surgical patients (eg, Snoring, Trouble Breathing, Un-Refreshed [STBUR])].

• Consult with the supervising licensed independent practitioner and an anesthesia professional if the patient presents with a history of obstructive sleep apnea or is identified during screening as at high risk for obstructive sleep apnea.

• Implement additional precautions (eg, non-invasive positive pressure ventilation with continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP], careful titration of opioids, non-opioid analgesia techniques, multimodal pain management) for patients with sleep apnea who will undergo moderate sedation.

• Consult with the supervising licensed independent practitioner and an anesthesia professional and develop a perioperative plan of care if the patient presents with any of the following:

o previous difficulties with anesthesia or sedation, including difficult airway;

o obstructive sleep apnea or other airway-related issues (eg, obesity hypoventilation syndrome);

o known history of respiratory instability (eg, chronic obstructive pulmonary disease) or hemodynamic instability;

o history of coagulation abnormality;

o moderate to severe neurologic disease (eg, stroke, cerebrovascular accident, transient ischemic attack) or cardiac disease (eg, coronary artery disease, congestive heart failure, poorly controlled hypertension, implanted pacemaker, recent myocardial infarction);

o moderate to severe endocrine disease (eg, poorly controlled diabetes mellitus);

o history of renal disease (eg, acute renal failure, end stage renal disease) or liver disease (eg, active hepatitis, cirrhosis, liver failure) that may affect metabolism of medications administered for moderate sedation/analgesia;

o one or more significant comorbidities;

o pregnancy;

o inability to communicate (eg, aphasia);

o inability to tolerate the procedure;

o multiple drug allergies;

o use of medications with potential for drug interaction with sedative analgesics;

o polypharmacy;

o current substance abuse (eg, street drugs, alcohol, non-prescribed prescription drugs);

o ASA physical status classification of ASA III; or

o ASA physical status classification of ASA IV or above.

Patient Monitoring

• Monitor and document the patient’s physiological and psychological responses, identify nursing diagnoses based on assessment of the data, and implement the plan of care.

• Obtain and document baseline patient monitoring of

o pulse,

o blood pressure,

o respiratory rate,

o SpO2 by pulse oximetry,

o end-tidal carbon dioxide by capnography,

o pain level,

o anxiety level, and

o level of consciousness.

• Obtain and document intraoperative patient monitoring of

o cardiac rate and rhythm,

o blood pressure,

o respiratory rate,

o SpO2 by pulse oximetry,

o end-tidal carbon dioxide by capnography,

o depth of sedation assessment,

o pain level,

o anxiety level, and

o level of consciousness.

• Obtain and document postoperative patient monitoring of

o cardiac rate and rhythm,

o blood pressure,

o respiratory rate,

o SpO2 by pulse oximetry,

o pain level,

o sedation level,

o level of consciousness,

o intravenous line (eg, patency, site, type of fluid),

o condition of dressing and wound, and

o type and patency of drainage tubes.

• Verify that monitoring equipment (eg, pulse oximetry, electrocardiogram, capnography, blood pressure measurement devices); oxygen source, tubing, cannulas and masks; and suction source, tubing, and tips are working correctly and immediately available in the room where the procedure will be performed.

• Verify that clinical alarms are audible and set to alert for critical changes in the patient’s status.

• Verify that the emergency resuscitation cart is immediately available in the location where moderate sedation/analgesia will be administered.

• Verify that opioid antagonists (ie, naloxone) and benzodiazepine antagonists (ie, flumazenil) are readily available when administering opioids and benzodiazepines.

• Before administering medications,

o verify the medication order,

o verify the correct dosing parameters, and

o identify the patient-specific maximum dose by consulting either the medication formulary, a pharmacist, a physician, or the product information sheet or other published reference material.

• Administer intravenous medications one at a time, in incremental doses, and titrated to the desired effect (ie, moderate sedation that enables the patient to maintain their protective reflexes, airway patency, and spontaneous ventilation).

• Adjust doses of sedatives and analgesics when caring for an older adult, as directed by the supervising practitioner.

• Allow sufficient time for drug absorption and onset before considering additional medication when administering medications by a non-intravenous route (eg, oral, rectal, intramuscular, intranasal, transmucosal).

• Assess the patient’s level of consciousness by evaluating the patient’s ability to respond purposefully to verbal commands, either alone or with light tactile stimulation.

• Assess and document the depth of sedation using the [facility-specific objective scale that has been validated for use in surgical patients (eg, ASA Continuum of Sedation Scale, Ramsay Sedation scale)].

• Determine the necessity, method, and flow rate of oxygen administration under the direction of the supervising practitioner based on the patient’s optimal level of oxygen saturation as measured with pulse oximetry.

• Document the moderate sedation/analgesia medications administered, including the

o medication,

o strength,

o amount administered,

o route,

o time of each dose,

o patient’s response, and

o adverse reactions.

Patient Discharge

• Evaluate the patient for discharge readiness based on established discharge criteria.

• Evaluate the need for delaying discharge when the patient

o has obstructive sleep apnea,

o receives medications by a nonintravenous route,

o receives an antagonist,

o experiences postoperative nausea and vomiting,

o has a high frailty score,

o has impaired functional status, or

o has cognitive impairment (eg, delirium).

• Evaluate the need for prolonged pediatric patient discharge when

o the child receives a medication with a long half-life (eg, chloral hydrate), and

o only one responsible adult is accompanying a child recovering from moderate sedation/analgesia.

• Provide additional discharge instruction for the adult responsible for care of an infant or toddler riding home in a car seat, including the need for

o careful observation of the child’s position to avoid airway obstruction and

o care by two responsible adults (ie, driver and observer).

• Verify that the patient or a responsible adult is able to verbalize an understanding of the discharge instructions.

Documentation

The perioperative RN will document the care of the patient receiving moderate sedation/analgesia throughout the continuum of care.

Competency

Perioperative RNs participating in procedures involving moderate sedation/analgesia will receive education and complete competency verification activities on managing patients receiving moderate sedation/analgesia.

Quality

Perioperative RNs will participate in quality assurance and performance improvement activities related to managing patients receiving moderate sedation/analgesia.

Glossary

Cognitive impairment: Delirium or a neurodegenerative condition (eg, dementia, Alzheimer’s disease, Parkinson’s disease) that increases the risk for delirium. Common in older adults but differs from the cognitive changes of normal aging. Cognitive impairment is often assessed by a screening tool, such as the clock drawing test, Mini-Cog, mini-mental status exam, or short-orientation memory concentration test.

Continual: Repeated regularly and frequently in steady rapid succession.

Frailty: An age-related, multi-dimensional state of decreased physiologic reserve that results in diminished resilience, loss of adaptive capacity, and increased vulnerability to stressors. Frailty is most often measured by either the frailty index, frailty phenotype, or a screening tool that is based on these assessments (eg, Risk Analysis Index, Edmonton Frail Scale, modified frailty index, Clinical Frail Scale, FRAIL scale, single variable assessments).

Functional status: The assessment of an individual’s ability to perform activities of daily living (eg, walking, bathing, eating, dressing) and instrumental activities of daily living (eg, transportation, cooking, housekeeping).

Licensed independent practitioner: A practitioner (eg, surgeon, endoscopist, dentist, podiatrist) who is permitted by law and the organization to provide supervision and oversight of the RN administering moderate sedation/analgesia, within the scope of the individual’s license, and consistent with individually granted clinical privileges.

Older adult: A person aged 65 years or older. Further subdivided into

• Young old: ages 65 to 74 years;

• Middle old: ages 75 to 84 years;

• Old old: age 85 years and older.

Polypharmacy: The concurrent use of multiple medications by a patient to treat a single condition or multiple coexisting conditions, which may result in adverse drug interactions. Commonly defined as the use of five or more medications, but can vary from two to 11 or more concurrent medications.

References

ASA Physical Status Classification System. American Society of Anesthesiologists. . Accessed June 15, 2021.

Guideline for care of the patient receiving moderate sedation. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2021.

AORN Syntegrity® Solution. AORN Syntegrity® On-line Companion Guide; 2021.

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