Sedation Policy



Adult Conscious Sedation Guidelines

Recommendations for the Safe Conduct of Patients (Aged 16 and Over) Undergoing Sedation Procedures in the Absence of General Anaesthesia

Requested/

Required by: Medicines Management Committee

Main authors: Consultant Anaesthetist

Nurse Consultant, Radiology

Document lead: Consultant Anaesthetist,

Consultant Gastroenterologist

Supersedes: Adult Conscious Sedation Guidelines (Version 2.0: May 2010)

Approved by: Trust Clinical Governance Committee, 16th December 2016

Ratified by: N/A

Review date: December 2019

Disclaimer: Printed copies of this document may not be the most recent version.

The master copy is held on Q-Pulse Document Management System

This copy – REV3.0

Document History

|Requirement for |These guidelines, which supersede the Trust Sedation of Patients, Clinical Guideline (2007), and conform to the |

|document: |National Patient Safety Agency Rapid Response Report 2008/RRR011, are to be used within the Maidstone and Tunbridge |

| |Wells NHS Trust, for the proper and safe use of conscious sedation. They set out: |

| |Guidance on the identification of patients that can be safely sedated by non-anaesthetist clinical staff and those |

| |requiring a greater level of clinical support. |

| |A description of the facilities within which conscious sedation should be undertaken. |

| |A description of the competence of the personnel required to support the patient undergoing conscious sedation. |

| |A guide to the agents that may be used for this procedure. |

| |A guide to the recovery of sedated patients. |

| |To take note of the recommendations made by the Working Party of the UK Academy of Medical Royal Colleges and their |

| |Faculties and the recommendations by the Royal College of Radiologists BFCR (03) 4. |

|Cross References / |Clinical Director, Anaesthetics (2007) Sedation of Patients Clinical Guidelines. |

|Associated Documents: |Sedation Policy, Hammersmith Hospitals NHS Trust. |

| |Lang D, Alpern M, Visintainer P, Smith S (1993) Elevated risk of anaphylactoid reaction from radiographic contrast |

| |media is associated with both beta-blocker exposure and cardiovascular disorders. Arch Intern Med Sept 13 |

| |153(17):2033-40. |

| |Midazolam, Summary of Product Characteristics. |

| |Miller M, Levy P, Patel M (2005) Procedural sedation and analgesia in the emergency department: What are the risks? |

| |Emergency Medical Clinics of North American, 23 551 -572. |

| |National Patient Safety Agency (NPSA) (2008) Reducing risk of overdose with Midazolam injections in adults. Rapid |

| |Response Report, NPSA/2008/RRR011. |

| | |

| |The Royal College of Radiologists (2003) Safe Sedation Analgesia and Anaesthesia with the Radiology Department. BFCR |

| |(03)4. |

| |U.K Academy of Medical Royal Colleges and their Faculties (2001) Implementing and ensuring safe sedation practice for |

| |healthcare procedures in adults. Report of an intercollegiate Working Party chaired by the Royal College of |

| |Anaesthetists. |

| |The Royal College of Radiologists March (2009) Guidelines for Radiologists in implementing the NPSA Safe Surgery |

| |requirement. |

| |World Health Organisation Surgical Safety Check list 1st Edition NPSA Alert/2009/PSA002/U1 WHO Surgical Check list. |

| |MTW PGD 323 Midazolam 1mg/ml for conscious sedation and PGD 324 Flumazenil for emergency reversal of Midazolam in |

| |conscious sedation. |

| |Academy of Medical Colleges – safe sedation practice for healthcare procedure. Standards and Guidance October 2013 |

| |.uk |

| |NHS England Revised Never Events Policy and Framework March 2015. |

| |NHS England National Safety Standards for invasive procedures September 2015. |

| | |

| |Maidstone and Tunbridge Wells NHS Trust Medicines Policy and Procedure RWF-OPPPCSS-C-PHAR1. |

| | |

| |Maidstone and Tunbridge Wells NHS Trust Incident Management Policy and Procedure RWF-OPPPCS-NC-CG22. |

| | |

| | |

| | |

| | |

|Version control: |

|Issue: |Description of changes: |Date: |

|1.0 |Original Guidelines initially written by Dr J DaFonseca, Consultant Anaesthetist and|November 2007 |

| |Sue Backhouse, Consultant Nurse Radiology | |

|2.0 |Updated supporting references |May 2010 |

| |Reformatted | |

|3.0 |Updated : references, dosages on page 10, monitoring of the use of Flumazenil on p11|December 2016 |

Adult Conscious Sedation Guidelines

Contents Page

1. Background 5

2. Consent 6

3. Patient Selection and Preparation 6

4. Facilities 7

5. Staff Undertaking Non Anaesthetic Sedation 8

6. Technique 9

7. Recovery 11

8. Clinical Governance 11

APPENDIX 1: Process Requirements 12

1.0 Implementation and Awareness 12

2.0 Review 12

3.0 Archiving 12

APPENDIX 2: Consultation Table 13

APPENDIX 3: Equality Impact Assessment Table 14

APPENDIX 4: Further Information 15

APPENDIX 5: Recommendations from the Report 17

1. Background

Sedation is a ‘ technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out during which verbal contact with the patient is maintained throughout the period of sedation’. BFCR (03)4.

Sedation techniques are difficult and in many instances pose a greater risk to patients than a standard general anaesthetic, particularly in areas outside the operating theatre site.

Best practice would require sedation to be carried out by an anaesthetist; however, staffing constraints may prevent this. Nonetheless, for humane reasons, sedation (or analgesia) needs to be administered by clinical staff to patients undergoing invasive procedures, in the absence of an anaesthetist. Within the Trust procedures involving the use of non-anaesthetic sedation are frequently carried out by clinicians from a range of specialities and by nurses qualified in nurse prescribing or working to Patient Group Directions (PGD).

The UK Academy of Medical Royal Colleges and their Faculties asked the Royal College of Anaesthetists to establish a multi-disciplinary Working Party to review the evidence on the safe provision of sedation services and produce recommendations applicable to the full range of training and practice. The Working Group has now produced a report and a set of General Principles and New Measures, which the Trust must ensure, where locally relevant, are covered in our local sedation policy and practices. In producing the guidance within this document, we have taken into account the recommendations of this report.

The Working Party Report identified the fact that many organisations have guidelines, but that the recommendations contained in these guidelines were not implemented fully and that as a result, patients were exposed to unnecessary risk. The report stated that “little short of a change in culture is needed in some areas". These guidelines represent the first comprehensive guidelines on conscious sedation for MTW.

The recommendations of the working party are summarised within this document (Appendix 5), however, it should be highlighted that they give very little practical advice in regard to the construction of guidelines for the administration on non-anaesthetic sedation. They describe general principles which the Trust must take cognisance of and ensure are disseminated to all clinicians who are involved in the practice of non-anaesthetic sedation. The report also recommends that “each hospital should nominate two consultants, one an anaesthetist and the other a user of sedation, to collaborate in the local implementation of guidelines and the provision of a specialist service for patients with particular problems.”

2. CONSENT

A patient information leaflet regarding the procedure and conscious sedation should be given to the patient, prior to the consenting process.

Assessment and Patient Consent (Consent Form 1) should be performed by the person undertaking the procedure (see Maidstone and Tunbridge Wells NHS Trust Policy); preliminary assessment and consent can be performed by the nursing staff. The signed consent form (white copy) should be given to the patient and the top copy (orange) placed in the patient’s notes.

3. PATIENT SELECTION and PREPARATION

a) Before offering the patient non-anaesthetic sedation, the referring clinician should take note of the recommendations made by the Working Party Report on the appropriateness of the use of non-anaesthetic sedation.

• Proper informed consent should be undertaken and full explanation and reassurance given to the patient (see Trust Consent Policy).

• All patients should be given a detailed explanation of what ‘sedation’ means, what they will experience and the likely duration of the procedure.

• Ambulatory patients must be accompanied home following the procedure and supervised for a minimum of 24 hours by a responsible adult who must be given written instructions as to what to do and who to contact in the event of problems.

• Patients must be advised in writing not to drive or to carry out any activity involving motor skills or to sign legally-binding agreements for a minimum of 24 hours after intravenous/oral sedation.

• Patients must be co-operative and able to communicate with staff.

• Basic pre-procedural investigations should be undertaken as defined for that procedure.

• Patients should be advised of the role of additional local anaesthesia (if it is required) and the effects that such agents will have on the soft tissues and nerves.

• Patients should be fasted as if they were for General Anaesthesia (as per Maidstone and Tunbridge Wells NHS Trust Nil by Mouth Guidelines 6 hours for solid food and milk, and 2 hours for clear fluids).

b) It is important to identify patients who may be at an increased risk for an adverse event in response to conscious sedation. Such patients may require anaesthetic support or pre-sedation anaesthetic advice. Patient notes must be available to include a list of currently prescribed medication and self-medication. Higher risk patients can be identified by the following characteristics:

• Patients of a nervous disposition, claustrophobic and/or needle phobic.

• Previous poor responses to local anaesthetic techniques or unwilling to accept conscious sedation

• Adverse reaction to sedation in the past, especially breathing or circulatory complications.

• Outpatients who have attended without assistance or companion to take them home.

• Uncontrolled hypertension: diastolic>110; systolic > 160.

• Presence of angina or myocardial infarction (within last 6 months) (Miller et al 2005).

• Recent cerebral event including stroke, haematoma, aneurysm

• Increased risk of anaphylaxis in patients taking beta blockers or with asthma in combination with contrast media. (Lang et al 1993).

• Any pre-existing respiratory disease whether active or quiescent that has required either admission to hospital or regular medication; or that causes episodes of shortness of breath on minimal exertion or at rest.

• COPD

• Obstructive sleep apnoea.

• Tissue oxygen saturation < 92% on air at rest, respiratory rate> 25/min.

• Patients who suffer acid reflux when supine.

• Bowel obstruction.

• Renal failure (creatinine >150)/dialysis.

• Insulin dependent diabetic, HbA1c >8.

• Any metabolic disorder.

• Morbid obesity (BMI > 30).

• Patients on MAO inhibitors (e.g. Phenelzine, Isocarboxazid, Tranylcypromine), St. John’s Wort, or already on Benzodiazepine or opioid medication.

4. FACILITIES

Conscious sedation may only be carried out in departments that are appropriately staffed and equipped, including any recovery areas.

All facilities will be expected to contain:

• Moving and handling equipment (e.g. pat slide, slide sheets) and a recent risk assessment.

• Tipping trolley/operating table.

• High quality lighting.

• Working telephone ext. to call for help.

• Alarm buzzer.

• Means to measure, pulse rate, blood oxygen saturation, ECG, non-invasive blood pressure.

• Glucose monitor.

• Drugs for analgesia/sedation and appropriate reversal agents

• Anti-convulsant, anti-emetic drugs

• Piped (or cylinder) and metered oxygen supply and means to deliver by the nasal or oro-tracheal route.

• Mains or portable suction facility (The suction facilities should conform to the Trust's Guidelines).

• ‘Ambu-bag’ resuscitator.

• Resuscitation equipment to be located within reach of an area as agreed by the Maidstone and Tunbridge Wells resuscitation team. To include: defibrillator, apparatus for endotracheal intubation, intravenous crystalloid (electrolyte solutions i.e. saline, dextrose saline) and colloid fluids (plasma expanders) and all emergency drugs necessary to manage anaphylaxis or a cardio respiratory arrest.

• Maintenance of an adequate range of analgesic, sedative anaesthetic and resuscitative drugs are the responsibility of the lead nurse for that modality (area) following advice from the appropriate clinicians, anaesthetists and hospital pharmacy. Expiry dates should be checked at least monthly.

5. STAFF UNDERTAKING NON- ANAESTHETIC SEDATION

a) Intravenous sedation should be administered in the presence of at least two appropriately trained clinicians (not necessarily medically qualified).

b) Clinical teams using sedation should develop specific lists for higher risk patients with increased anaesthetic doctor / nurse support.

c) On all occasions before each procedure where sedation is used, one clinician will be designated to monitor the patient while the second clinician undertakes the procedure. The names of these two clinicians should be documented in the medical notes.

d) The clinician designated to monitor the patient must be free to undertake the appropriate observations throughout the procedure (monitor colour, pulse, breathing, sedation level, etc).

e) The clinician monitoring the patient must ensure that they are able to alert the operating clinician should the patient’s condition deteriorate. There should be training and rehearsals to ensure this can occur.

f) Both clinicians should have completed an Intermediate Life Support course or the equivalent, have received training in managing semi-conscious patients and have a working knowledge of the drugs being administered including:

• Concentration and possible dilution

• Speed of onset and duration of the drug

• Rates of administration for all patient groups

• Synergism with other sedative drugs

• Potential interactions with drugs regularly taken by patient

• Reversal agents and dosage

• Maximum dosage and toxicity

6. TECHNIQUE

Prior to conscious sedation

• Confirm patient’s identity with patient

• Check Name, Date of birth, Hospital Number

• Patient ID Band to agree with notes.

• Confirmation of procedure to be performed with patient request and allergies documented.

• Ensure site marked if laterality an issue (WHO 2009, RCR 2009)

Successful sedation practice relies upon and involves an understanding of the mode of action of the drugs employed as well as an awareness of the implications of a number of cardinal signs.

a) Supplemental oxygen 2-4 L/min via nasal cannulae intravenous cannulation and commencement of monitoring, are required for all patients prior to the start of the procedure. Confirm that all observations are within the normal range before administration of sedation.

b) No drug which is described as an anaesthetic agent (e.g. Propofol, Remifentanil) will be given in the absence of an anaesthetist.

c) No drugs should be diluted before administration unless there is a specific indication.

d) Appropriate reversal agents for all drugs used should be immediately available (e.g. Flumazenil with Midazolam, Naloxone with Pethidine etc).

e) Monitoring must be undertaken by a suitably trained person. The parameters that may be monitored are:

• Heart rate/ ECG.

• Respiratory rate and pattern.

• Blood pressure.

• Level of sedation (see sedation score).

• Hydration – infusion pumps.

• Urine output (if catheterised).

• Undesirable side effects.

• Spo2 below 90% is dangerous and requires immediate intervention. Routine administration of oxygen by nasal cannulae at 2 l/min is mandatory for all patients having intravenous sedation.

• Cardinal signs to be aware of the following:

|Situation |Causative factors |

|Restlessness |Hypoxia, pain, disorientation. |

|Respiratory depression |Anxiolytics, opiate analgesics. |

|Cardiovascular collapse |Hypoxia, local anaesthetics. |

|Bradycardia |Vagal over activity, local anaesthetics. |

|Confusion |Anxiolytics, local anaesthetics, opiates. |

|Regurgitation |Anxiolytics and opiate analgesics. |

|Convulsions |Local anaesthetics and hypoxia. |

f) The following agents are available for use without anaesthetist support:

• Oral benzodiazepines

• Inhalation - oxygen/ nitrous oxide (Entonox/Equanox) (See PGD for Entonox/Equanox)

• Intravenous methods

o Midazolam up to 5mg in 1 mg increments

OR Pethidine up to 10 - 50mg

In patients aged 70 years and over or who are debilitated or chronically ill, no more than 2mg of Midazolam should be drawn up into a syringe prior to the procedure. The initial dose should be 0.5-1.0mg. A dose of 1mg is usually sufficient for this group but further doses of 0.5-1.0mg may be given as necessary to a total dose usually not greater than 3.5mg.

In patients under the age of 70 no more than 2mg of Midazolam should be drawn up into a syringe prior to the procedure. The initial dose is 2-2.5mg. A dose of 2mg is usually sufficient for this group but further doses of 1mg may be given as necessary. Total dose range 3.5-5mg.

Top up doses of Midazolam must only be given once the full effect of the initial dose is seen. Titration doses must be given carefully to avoid over sedation.

NB. Where short term conscious sedation techniques are carried out, Midazolam should only be stocked in ‘low strength’ ampoules (i.e. 5mg in 5ml) as per National Patient Safety Agency (NPSA) Rapid Response Report (NPSA, 2008).

The following must be documented throughout the treatment period: record of patient’s vital signs

• sedation score (see table 1 AVPU)

• procedure carried out

• equipment used

• staff present and their role

• drugs used including dose, time administered, administration route, batch number & expiry dates

• any aftercare instructions.

7. RECOVERY

Post procedure recovery must be provided by an appropriately trained practitioner who is responsible for the patient until transfer back to the ward. (Appropriately trained, means at least Intermediate Life Support, but ideally Advanced Life Support and able to deal with airway management and respiratory depression).

Oxygen, suction, means of monitoring the patient and appropriate staffing levels must be available in recovery area.

The appropriate reversal agent should be readily available in the department for cases of over sedation; e.g. Flumazenil to reverse the effects of Midazolam. Staff should be familiar with the use of reversal drugs. This includes knowledge of appropriate dose, rate and method of administration and duration of action (especially in comparison to the duration of action of the sedative). Flumazenil should only be used in an emergency setting. It must not be routinely used to reverse the effects of Midazolam. If Flumazenil is used, the responsible clinician must remain with the patient until the effects have worn off to ensure sedation and/or respiratory depression does not re-occur.

Transfer of patient back to the ward should only occur once set criteria are met; namely, an acceptable sedation score (i.e. patient able to respond to commands and communicate e.g. thumbs up test), along with stable oxygen saturation, blood pressure, and a respiratory rate between 10 and 20. In addition, there should be no immediate post procedure complications. All of this should be agreed in conjunction with the ward staff. Patient to be transferred to ward with qualified staff only.

8. CLINICAL GOVERNANCE

All incidents must be reported for any sedation procedure that fails or which requires the use of reversal agent or which results in an emergency call for additional anaesthetic assistance. This is important to ensure that the incident is investigated to facilitate safe practice in the future

The use of Flumazenil should be audited regularly to highlight any over use of Midazolam. All occasions where Flumazenil is used must be recorded on the Trust Incident Reporting ‘Datix’ system and incidents reviewed by the medication safety and safe prescribing group.

APPENDIX ONE

Process requirements

1. Implementation and Awareness

• Once ratified the document lead will email this document to the Clinical Governance Assistant (CGA) who will activate it on the Trust approved document management database on the intranet, under ‘Policies & Q-Pulse’.

• A monthly publications table is produced by the CGA which is published on the Trust intranet under ‘Policies & Q-Pulse’; notification of the posting is included on the intranet “News Feed” and in the Chief Executive’s newsletter.

• On reading of the news feed notification all managers should ensure that their staff members are aware of the new publications.

2. Review

These guidelines will be reviewed no later than three years from the date of approval or sooner if changes are required to reflect new national or local requirements.

3. Archiving

The Trust intranet retains all superseded files in an archive directory in order to maintain document history.

APPENDIX TWO

CONSULTATION ON: Adult Conscious Sedation Guidelines

Consultation process – Use this form to ensure your consultation has been adequate for the purpose.

Please return comments to: Acting Chief Pharmacist

By date: 30 September 2016

|Job title: |Date sent |Date reply |Modification suggested?|Modification made? |

| | |received |Y/N |Y/N |

| | | | | |

|Consultant Anaesthetist (RL) |30.8.16 |12.9.16 |Y |Y |

|Consultant Gastroenterologist (HS) |30.8.16 |15.9.16 |Y |Y |

|Consultant Anaesthetist (JDF) |30.8.16 | | | |

|Endoscopy Unit Manager (MD) |30.8.16 | | | |

|Endoscopy Unit Sister TWH (SC) |30.8.16 |31.8.16 |Y |Y |

|Lead Nurse Endoscopist (GBM) |30.8.16 |31.8.16 |Y |Y |

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|Members of the Trust Medicines Management Committee |15.9.16 |16.9.16 |Y |Y |

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|The role of those staff being consulted upon as above is to ensure that they have shared the policy for comments with all staff within their sphere of |

|responsibility who would be able to contribute to the development of the policy. |

APPENDIX THREE

Equality impact assessment

This policy includes everyone protected by the Equality Act 2010.  People who share protected characteristics will not receive less favourable treatment on the grounds of their age, disability, gender, gender identity, marital or civil partnership status, maternity or pregnancy status, race, religion or sexual orientation. The completion of the following table is therefore mandatory and should be undertaken as part of the policy development and approval process. Please note that completion is mandatory for all policy and procedure development exercises.

|Title of policy or practice |Adult Conscious Sedation Guidelines |

|What are the aims of the policy or practice? |To ensure proper and safe use of conscious sedation in adult |

| |patients |

|Is there any evidence that some groups are affected differently|See document history |

|and what is/are the evidence sources? | |

|Analyse and assess the likely impact on equality or potential |Is there an adverse impact or potential discrimination |

|discrimination with each of the following groups. |(yes/no). |

| |If yes give details. |

|Gender identity |No |

|People of different ages |No |

|People of different ethnic groups |No |

|People of different religions and beliefs |No |

|People who do not speak English as a first language (but |No |

|excluding Trust staff) | |

|People who have a physical or mental disability or care for |No |

|people with disabilities | |

|Women who are pregnant or on maternity leave |No |

|Sexual orientation (LGBT) |No |

|Marriage and civil partnership |No |

|Gender reassignment |No |

|If you identified potential discrimination is it minimal and |N/A |

|justifiable and therefore does not require a stage 2 | |

|assessment? | |

|When will you monitor and review your EqIA? |Alongside these guidelines every three years |

|Where do you plan to publish the results of your Equality |As Appendix 3 of this policy/procedure on the Trust approved |

|Impact Assessment? |document management database on the intranet, under ‘Trust |

| |policies, procedures and leaflets’. |

APPENDIX FOUR

Further information

Table 1: Complications of Sedation

|Complication |Primary Response |Secondary response |

|Hypotension |Stop sedation. |Posture feet up. |

| |Give O2 . |Reversal agents. |

| |Increase IVI. |If BP unresponsive call for help. |

|Respiratory depression |Check sats, capnograph if used. |Maintain verbal contact. |

| |Give O2. |Give reversal. |

| |RR,P, BP, ECG, sedation score. |Call for help. |

|Nausea/vomiting |Anti-emetic I.V. |1.Ondansetron 4mg I.V. 2.Cyclizine 50mg |

| | |slow IV. |

|Agitation/ aggression |Give O2. |Deepen sedation if light or allow to wake|

| |Check oxygen saturation, BP, sedation |up as clinically indicated. |

| |score, pain score. |Blood glucose. |

| |Maintain verbal communication. |Call for help. |

|Myocardial Ischaemia |Increase oxygen. |Reversal if necessary. |

| |Check vital signs. |GTN patch 5mg. |

| |Call for help. |12 lead ECG. |

Table 2: Sedation Score

[pic]

Table 3 : Continuum of sedation depth based on guidelines published by the American Society of Anestheologists Task Force on Sedation and Analgesia by Non – Anestheologists (34)

| |Minimal sedation |Moderate/analgesia |Deep sedation/analgesia |General anesthesia |

| |(anxiolysis) |(conscious sedation) | | |

|Responsiveness |Normal response to |Purposeful [1]responsive to |Purposeful 1response after |Unrousable, even |

| |verbal stimulation |verbal or tactile stimulation |repeated or painful |with painful |

| | | |stimulation |stimulus |

|Airway |Unaffected |No intervention required |Intervention maybe required |Intervention often |

| | | | |required |

|Spontaneous ventilation |Unaffected |Adequate |Maybe adequate |Frequently |

| | | | |inadequate |

|Cardiovascular function |Unaffected |Usually maintained |Usually maintained |May be impaired |

APPENDIX FIVE

Recommendations from the Report on Implementing and Ensuring Safe Sedation Practice for Healthcare Procedures in Adults, produced by the Intercollegiate Working Party of the UK Academy of Medical Royal Colleges and their Faculties.

General Principles

Sympathetic patient management is the foundation of all clinical care. Explanation at each and every stage of any procedure is essential, particularly where sudden manoeuvres may disturb the patient acutely.

1. Anxiety, discomfort and pain may still occur. They are inter-related and each may increase the other. As a result the procedure will become more difficult for all parties, but any drug treatment must be specifically related to each symptom.

2. Often a careful explanation, a sympathetic attitude and expert clinical management can alleviate anxiety. Drug sedation should not be used for operator convenience, but as a supplement to behavioural management.

3. The nature and site of potentially painful components of the procedure should be identified in advance so that local anaesthetic or systemic analgesic drugs can be administered to prevent pain whenever possible.

4. If pain is variable or unpredictable the patient should be made aware of this and the operator should have in place a safe strategy for dealing with any pain that occurs during the course of the procedure.

5. In many situations, good analgesia and expert management suffice. The need for additional sedation should be related to the individual patient’s psychological and medical status of both the response to, and the need for, sedation.

6. When conscious sedation is employed, the agents and doses chosen must be adjusted to the patient’s requirements and ensure that verbal contact is possible at all times.

If verbal responsiveness is lost the patient requires a level of care identical to that needed for general anaesthesia.

7. Interactions between drugs of different types (especially opioids and sedatives) are often synergistic so that both the degree of effect and its rate of onset are increased significantly. Drug combinations must be used with particular care.

8. The resources needed to support a particular drug sequence should relate to the clinical status of the typical patient, the clinical setting in which it is normally used, and the number and type of drugs administered.

9. Clinical and instrumental monitoring, to a degree relevant to the patient’s medical status and the sedation method, should be used. In addition, one member of the care team must have a defined responsibility for patient observation and record keeping.

New Measures

1. Royal Colleges, in association with the relevant sub-speciality organisations, should develop guidelines on sedation appropriate to clinical practice in their sphere of influence.

2. Royal Colleges and their Faculties should incorporate the necessary instruction and assessment into training ands revalidation programmes of those specialities that use sedation techniques.

3. The clinical governance framework should deliver safe sedation practice at hospital level by enabling a patient centred culture in which:

a) Multidisciplinary team training ensures all staff understand their roles

b) Those who actually administer sedative drugs are aware of the possible adverse consequences and are able to deal with these; and

c) Audit of adverse incidents, complications (particularly severe ones such as admission to intensive care) and adherence to agreed national and local protocols promotes continuous quality improvement.

4. NHS Trusts should apply to sedation techniques the Standard of Clinical Negligence Scheme which requires that all medical and dental staff in training be, on appointment, competent in the technical skills and specified task expected of them.

5. Each hospital should nominate two consultants, one an anaesthetist and the other a user of sedation, to collaborate in the local implementation of guidelines and the provision of a specialist service for patients with particular problems.

6. Those responsible for commissioning and providing healthcare in the primary and private sectors should ensure that similar processes are in place to ensure a high standard of sedation practice.

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[1] Reflex withdrawal from painful stimulus is not considered a purposeful response

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Sedation Score

• A Alert

• V Responds to voice

• P Responds to pain only

• U Unresponsive

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