Moderate Sedation

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Moderate Sedation

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1. Moderate Sedation A Universal Approach at MUSC Updated 1/10/2007

2. Four Levels of Sedation & Anesthesia Sedation occurs along a continuum Minimal sedation (anxiolysis) Moderate sedation Deep sedation General Anesthesia

7. Intent and Goals of Moderate Sedation The patient remains: Anxiety & pain free Arousable, but relaxed Cooperative on demand Intact protective reflexes

8. Personnel and Staffing Requirements Licensed Independent Practitioner (LIP) or Advanced Practice Nurse (APN) must be present during the sedation procedure Only RNs or Registered Respiratory Therapists with documented competency participate in moderate sedation care. Residents must be supervised by an Attending MD/DDS who is credentialed for moderate sedation.

9. Staff Role – Pre procedure Ambu bag (correct size for patient) Non Invasive blood pressure Pulse oximeter Oxygen and Suction with set up – ready to go Mayday cart immediately accessible Reversal Agents easily accessible Naloxone (NARCAN®) Flumazenil (Romazicon®)

10. Medication Guidelines

11. Sedation Medication Guidelines You must know dosage limits onset duration of action interactions precautions Policy link:

12. Safe Administration of Drugs “start low and go slow” Begin with lower dosage Titrate slowly Caution- when you are combining two classes of drugs Individualize dose Know drug to drug interactions Practice alert! Check if patient has recently received opioids or sedation

13. Drug Facts - Opiate Agonists Alter perception of pain, analgesic, useful in preoperative sedation ¦Fentanyl (Sublimaze®) ¦ Meperidine (Demerol®) ¦ Morphine

14. Drug Facts: Adverse Effects of Opiate Agonists Hypotension Nausea and vomiting Over sedation Respiratory depression Respiratory arrest

15. Caution in Administering - Opiate Agonists to Patients with: Acute asthma COPD Elderly or debilitated Obesity or “short neck” Hepatic or Renal disease Hypothyroidism Head Injury

16. Drug to Drug Interactions with Opiates Contraindicated with MAO inhibitors –(like Nardil®) Do not mix Demerol with Aminophylline Heparin Barbiturates Phenytoin Methicillin Alcohol Intoxicated patients may have additive effect when given narcotics.

17. A Mini Break from Ella Take time to enjoy yourself!

18. Function of Benodiazepines (Sedatives) Pre-operative sedation, to induce sleepiness and reduce anxiety Midazolam (Versed®) Diazepam (Valium®) Lorazepam (Ativan®)

19. Effects of Benzodiazepines Slurred speech Nystagmus Amnesia- 3 minutes antegrade Altered judgment

20. Adverse Effects of Benzodiazepines Respiratory depression Paradoxical behavior Over sedation Vein irritation/phlebitis (Valium®) Practice Alert! Assign patient as Fall Risk when given Benzodiazepines. These patients have a higher fall risk than those not taking similar medication.

21. Caution with Benzodiazepines Reduce dose with: Elderly or debilitated Acute alcohol intoxication Acute angle glaucoma - midazolam (Versed®) COPD

22. Other Agents ketamine (Ketalar®)-anesthetic adjunct chloral hydrate - sedative hypnotic, half life > 10 hours (See specific wakefulness test in peds) diphenhydramine (Benadryl®)-aids sleep pentobarbital (Nembutal®)-preoperative sedation droperidol (Inapsine®)-tranquilize/sedate- use with extreme caution, FDA warning Practice Alert! There are NO reversal agents for these drugs

23. Reversal Agents for Opioids Naloxone (Narcan®) Medications that reverse or improve respiratory suppression due to over sedation naloxone (Narcan®)-Reverses opiates Replaces narcotics from receptors, no other action Observe for tachypnea, pain, and agitation Practice Alert: After 20 minutes the reversal agent can wear off and the patient can re-sedate with a return of respiratory insufficiency.

24. Reversal Agent for Benzodiazepines Flumazenil (Romazicon®) Inhibits the action of the benzodiazepine Does not necessarily correct respiratory depression Use cautiously in patients at high risk for seizure or arrhythmia Monitor for re-sedation Observe for dizziness, nausea, vomiting Drug-drug interaction includes anti-depressants

25. Treating Unexpected Events Respiratory Depression Stimulate the patient Open airway Chin lift Jaw thrust maneuver Oxygen as indicated Support patient ventilation (Ambu, CPAP) Initiate CPR Call for assistance to place airway (MET or Mayday team)

26. Treating Unexpected Events Hypotension Leg elevation Fluid challenge (with M.D. order) Reversal agents (with M.D. order) Nausea & Vomiting Side position Modified trendelenberg Suction

27. Nursing Assessment, Physician History & Physical

28. Nursing assessment key points . . .

29. Nursing assessment key points . . . including patient medical history

30. Required - H&P by physician, review of systems and airway assessment

31. Reference Information, Airway Assessment

32. Reference Information

33. Reference Information

34. Procedure Documentation

35. Procedure Documentation

36. Procedure Documentation

37. Procedure Documentation

38. Addendum

39. Recovery and Discharge from Sedation Modified Aldrete Scale - utilized to document recovery status of patient Completion of recovery from sedation signifies “discharge” from moderate sedation protocol Patient may or may not be discharged from the unit or other MUHA location at this time Practice Alert: MD discharge from sedation is required if a reversal agent was administered post sedation.

40. Evaluation & Monitoring NORA- Non-Operating Room Anesthesia Committee meets quarterly for review of Patient Safety Net reports Reference information: MUHA Intranet Training and Staff Education- “Sedation” resource web page at:

41. PATIENT SAFETY NET (PSN) INSTRUCTIONS All adverse events related to sedation or use of reversal agents must be submitted in the Patient Safety Net (PSN) Examples including but not limited to: Prolonged or recurrent desaturation Use of reversal agent Post procedure - Altered mental status, difficulty awakening, resedation Urgent Airway care, Arrhythmia, Mayday, emergency drugs administered Rescue from inadvertent deeper sedation How to Report: Select F: Complication of procedure treatment or test Then select #2 Anesthesia/Sedation Event If Adverse event involves medication or reversal agents notify Pharmacy as consult department.

42. Summary Goal: Provide safe patient care Sedation is a continuum Know how to define your role in moderate sedation (pre, intra and post procedure) Provide safe administration of medication Provide ongoing monitoring until discharged from sedation Be prepared to “rescue the patient” Complete all documentation for sedation care

43. Moderate Sedation Question 1 Moderate Sedation is defined as a drug induced depression of consciousness in which the patient retains the ability to: a. Maintain spontaneous ventilation b. Maintain an unobstructed airway c. Respond purposefully to verbal commands d. All the above

44. Moderate Sedation Question 2 You administer lorazepam to a patient who is having difficulty sleeping. This is: a. Moderate sedation b. Minimal sedation c. Deep sedation d. General anesthesia

45. Moderate Sedation Question 3 During moderate sedation vital signs including pain score must be documented every: a.3-5 minutes b.10 minutes c. 30 minutes d. 5-15 minutes

46. Moderate Sedation Question 4 The following drug is used to reverse midazolam: a. flumazenil b. naloxone c. diphenhydramine c. chloral hydrate

47. Moderate Sedation Question 5 During moderate sedation, which of the following should be immediately available: a. Defibrillator b. Intubation equipment c. Anesthesiologist d. A and B

48. Moderate Sedation Question 6 Prior to moderate sedation, the physician must complete the following: a. Airway assessment and ASA classification b. Physical exam including cardiovascular and pulmonary assessment c. Deem the patient appropriate for sedation d. All the above

49. Moderate Sedation Question 7 True or False The patient safety procedure of “time out” will be performed immediately before the moderate sedation procedure begins.

50. Moderate Sedation Question 8 True or False Administration of a reversal agents or any adverse events during moderate sedation are to be reported by staff through the UHC Patient Safety Net (PSN).

51. Congratulations! You have completed the Moderate Sedation module. Your competency will be assessed in your practice area.

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