Moderate Sedation/Analgesia (Conscious Sedation)

1. Moderate Sedation/Analgesia (Conscious Sedation) Lesson 1: Introduction Lesson 2: The Sedation Continuum Lesson 3: Guidelines & Regulations

2. Introduction Welcome to the introductory lesson on moderate sedation/analgesia [glossary]. This lesson gives the course rationale, goals, and outline.

3. Coarse Rationale Sedation and anesthesia are important risk factors for morbidity and mortality during procedures. Giving sedation safely is critical to: • Help prevent negative outcomes • Comply with regulations This course will teach you: • How moderate sedation relates to other types of anesthetic services, and how this relates to patient safety • How The Joint Commission [glossary] expects accredited facilities to manage moderate sedation

4. Course Goals After completing this course, you should be able to: • List the levels of the continuum [glossary] of sedation • Identify key features of each level • Recognize the significance of the continuum for sedation safety • List the The Joint Commission standards for moderate sedation • Identify key requirements of each standard

5. Course Outline Lesson 1 provided the course rationale and goals Lesson 2 will describe the sedation continuum Lesson 3 will list and explain The Joint Commission standards for moderate Sedation

6. Lesson 2: The Sedation Continuum Welcome to the lesson on the sedation continuum. After completing this lesson, you should be able to: • List the levels of sedation continuum • Identify key features of each level • Recognize the significance of the sedation continuum

7. The Sedation Continuum Moderate sedation is on a continuum with other levels of sedation. The levels on this continuum are: • Minimal sedation (anxiolysis [glossary]) • Moderate sedation/analgesia [glossary] (“formerly conscious sedation”) • Deep sedation/analgesia • General Anesthesia Let’s take a closer look at each level on the following screens

8. Minimal Sedation: Anxiolysis Minimal sedation is also called anxiolysis. In this drug-induced state: • The patient feels relaxed . • The patient responds normally to speech. • Thinking and coordination may be affected. • Breathing and heart function are not affected

9. Moderate Sedation/Analgesia “Moderate sedation/analgesia” was called “conscious sedation.” In this drug-induced state: • The patient has depression of consciousness • The patient will respond purposefully to spoken words, or spoken words with a light touch. For this definition, “purposeful” movement does not include reflex movement away from pain. • The airway remains patent without help. • The patient’s breathing is adequate. • Heart function is usually maintained.

10. Deep sedation/Analgesia Deep sedation/Analgesia is the next level on the continuum. In this drug-induced state: • The patient has depression of consciousness and is difficult to awaken. • The patient will respond purposefully to repeated or painful stimulation. Reflex movement away from pain is not “purposeful”. • The Patient may need help to keep the airway open. • The patient’s own breathing may not be adequate. • Heart function is usually maintained.

11. General Anesthesia General Anesthesia is the deepest form of sedation. In this drug-induced state: • The patient loses consciousness. • The patient cannot be awakened, even by painful stimuli. • The patient often needs assistance maintaining the airway and ventilations. This often requires positive pressure ventilation [glossary]. • Heart function may be impaired.

12. The Sedation Continuum: Summary Continuum of Depth of Sedation This table summarizes the sedation continuum.

13. Significance of the Continuum Why is it important to understand the continuum of sedation? Because sedation is a continuum, the response of any one patient may be unpredictable. For example, a patient may be moderately sedated for a procedure. However, the patient may respond to the drug in an unexpected way, and enter a state of deep sedation instead. This is the rationale for many of the regulations related to moderate sedation. Moderate sedation does not usually put a patient’s breathing or heart function at risk. But a moderately sedated patient may progress to deep sedation. Therefore, moderate sedation must be monitored just as carefully as deep sedation and anesthesia.

14. Review The best description of “moderate sedation” is: • A risk-free treatment • A point on the continuum of sedation • A lesser form of sedation than “minimal sedation” • A treatment entirely different from general anesthesia MULTIPLE CHOICE INTERACTION Correct: B A: Incorrect. Moderate sedation is not risk-free. The correct answer is B. B: Correct C: Incorrect. Moderate sedation is deeper than minimal sedation. The correct answer is B. D: Incorrect. Moderate sedation and general anesthesia are both points on the continuum of sedation. The correct answer is B.

15. Summary You have completed the lesson on the sedation continuum. Remember: • Moderate sedation is a point on a continuum. It falls between minimal sedation and deep sedation. • Because sedation is a continuum, the response of any patient is individual and may be unpredictable.

16. Lesson 3: Guidelines & Regulations Introduction & Objectives Welcome to the lesson on guidelines and regulations. After completing this lesson, you should be able to: • List the The Joint Commission standards related to moderate sedation • Identify key requirements of each standard

17. The Joint Commission Standards The Joint Commission has several standards for anesthesia services, including moderate sedation. For Moderate sedation, these standards are: • Moderate sedation must be given by a qualified provider. • Patients who will receive moderate sedation must be assessed ahead of time. • Sedation options and risks must be discussed with the patient and family prior to the sedation/procedure. • The patient must be re-assessed immediately before the sedation is given. • The patient’s oxygenation, ventilation and circulation must be monitored during sedation. • The patient must be assessed in the post-sedation recovery area before discharge. • A qualified provider must discharge the patient from the post-sedation recovery area, or discharge must be based on established criteria [glossary].

18. Pre-sedation Assessment (1) All patients must be assessed before sedation. Hospitals with obstetric or emergency services should be able to perform an assessment quickly. These hospitals should be able to gather enough information to give moderate sedation safely within 30 minutes after deciding to sedate the patient. The patient must give informed consent before moderate sedation can be administered.

19. Pre-Sedation Assessment (2) The pre-sedation assessment should include information about the procedure and the patient. The Assessment should include: • Indication for the procedure • Determination that the patient is an appropriate candidate for sedation and the procedure The Pre-sedation assessment should also include: • Patient history—should include: • Allergies or adverse drug events • Prior sedative or anesthesia experiences • Potential for pregnancy • Physical History—should include: • Baseline vital signs and oxygen saturation • Weight • Airway status • Appropriate fasting interval • Aspiration risk factors • Status of cardiac, pulmonary, and neurologic systems • Mental status and level of consciousness • Appropriate lab tests • ASA status

20. Pre-Sedation Assessment (3) The patient’s ASA [glossary] status should be determined. The ASA describe five physical status classes: • ASA class I patients are healthy with no medical problems. • ASA class II patients have a mild, well-controlled disease. • ASA class III patients have multiple medical problems or a moderately-controlled disease. • ASA class IV patients have a poorly controlled disease that is a threat to life • ASA class V patients are moribund Patients in ASA classes I and II can be given moderate sedation. Medical consultation is suggested for class III patients. Patients in ASA classes IV and V should not be given moderate sedation by a non anesthesia provider.

21. Pre-sedation Assessment (4) Conditions that will affect the use of moderate sedation include: • Indication for the procedure • Altered mental status • Atypical airway anatomy • Obesity • Pregnancy • Sleep apnea [glossary] • Current medications • Substance abuse • Cardiovascular disease • Respiratory disease • Liver disease • Kidney disease • Central nervous system dysfunction

22. Discussion of Options & Risks Sedation options and risks may be discussed with the patient and family before giving moderate sedation. Patients must give informed consent for nay treatment. This includes moderate sedation. Part of informed consent is a full understanding of the options and risks of treatment. Discussing the sedation procedure ahead of time also can help calm patient fears. Patient education also should include information on: • Resuming activity • Consciousness checks • Dietary restrictions • When medications can be resumed • Potential post-procedural complications • Whom to contact for questions for help

23. Sedation Care Plan The Moderate sedation of each patient must be carefully planned. The Plan of care should: • Take into account the physical status of the patient (ASA class) • Meet any other patient needs identified during the pre-sedation assessment All providers should be informed of: • The patient’s care needs • The sedation plan of care The patient should be assessed again immediately before moderate sedation is given.

24. Qualified Provider (1) The qualified provider requirement covers the training and credentials of the provider who gives moderate sedation. A provider “qualified” to give moderate sedation must be trained in: • How to evaluate patients before sedation • How to give drugs for moderate sedation • How to monitor patients to keep them moderately sedated • How to “rescue” patients from deep sedation The ability to “rescue” patients from deep sedation includes training in: • How to manage an airway • How to give oxygen and ventilation • How to deliver appropriate reversal agents

25. Qualified Provider (2) “Rescue” of patients from sedation may also include the use of “reversal drugs.” [glossary] Patients given reversal drugs must be monitored. Seizures or other heart and nervous system problems may occur. Note: The effect of the reversal drug may wear off before the effect of the sedating drug. Extended monitoring will be needed.

26. Qualified Provider (3) Moderate sedation procedures are performed by a licensed independent practitioner (LIP) The qualified provider requirement also covers the number of personnel during a procedure. In addition to the LIP, there must be enough other qualified personnel to: • Evaluate the patient before the sedation • Give the sedation • Perform the procedure • Monitor the patient • Recover and discharge the patient

27. Monitoring Patients must be monitored during moderate sedation. The person monitoring the patient can not have additional assignments. Physiological monitoring is the only way to ensure that patients get the supportive treatment they need. The following need to be monitored in some or all patients: • Heart rate and oxygenation—should be continuously monitored by pulse oximetry. • Respiratory rate--& pulmonary ventilation should be continuously monitored • Blood pressure—should be measured at regular intervals. • EKG—should be monitored: • If the patient has significant cardiovascular disease • If cardiac arrhythmias are expected or detected. Data from monitoring must be recorded in the patient’s medical record.

28. Post-Sedation Assessment & Discharge After moderate sedation, patients must be: • Assessed in the post-sedation recovery area • Discharged by a qualified LIP or according to established criteria • Discharged home with a responsible adult Meeting discharge criteria should be documented in the medical record.

29. Review A provider qualified to give moderate sedation is trained in: • How to evaluate patients before sedation • How to rescue patients from deep sedation • How to give drugs to achieve moderate sedation • How to monitor patients to keep them moderately sedated • All the above MULTIPLE CHOICE INTERACTION Correct: E A: Not quite. The best answer is E. A qualified provider is trained in all these areas B: Not quite. The best answer is E. A qualified provider is trained in all these areas C: Not quite. The best answer is E. A qualified provider is trained in all these areas D: Not quite. The best answer is E. A qualified provider is trained in all these areas E: Correct.

30. Review The physical status of a patient with well-controlled hypertension would be: • ASA class I • ASA class II • ASA class III • ASA class IV • ASA class V MULTIPLE CHOICE INTERACTION Correct: B A: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation. B: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation. C: Correct. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation. D: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation. E: Incorrect. Patients with one well-controlled medical problem are classified as ASA class II. ASA class II patients can be given moderate sedation.

31. Summary You have completed the lesson on guidelines and regulations. Remember: • Patients must be assessed before moderate sedation. ASA class should be determined • Sedation options and risks must be discussed with each patient. • A sedation care plan must be developed for each patient. • Moderate sedation must be given by a qualified provider. • Patients must be monitored during sedation. • Patients must be assessed after sedation. They may be discharged from the post-sedation recovery area only by a qualified LIP or according to established criteria.

32. [Moderate Sedation] Course Glossary