Self Study Guide For Procedural Sedation Credentialing by mikesanye

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									                        Sonoma Valley Hospital – Medical Staff
     Self-Study Guide for Procedural Sedation Credentialing

PURPOSE AND GOALS

In procedural sedation, the goals are to:
    1) maintain safety throughout the intervention
    2) minimize pain and/or anxiety, and
    3) facilitate the procedure or the investigation.
The patient must be able to respond rationally to commands and to maintain his/her own
airway. The ability to maintain a patent airway is not only dependent on the amount of
sedation given, but is also impacted by the patient’s underlying medical problems,
debilitation, and body habitus. Every physician must thoroughly evaluate these critical
factors prior to a sedation procedure. Deep sedation is not to be provided under any
circumstance by a physician who is only credentialed to deliver procedural sedation.
These guidelines are not intended to manage patients with other known medical
conditions (such as pain management patients, patient with seizure disorders, patients in
labor and/or patients being managed by an anesthesiologist. When procedural sedation is
used, it is crucial to understand and appreciate the different levels of sedation and general
anesthesia:

DEFINITIONS

Light Sedation/Anxiolytic: Route of medication can be oral, intramuscular (IM) or
intravenous (IV). These patients are basically awake. There is essentially no anesthesia.
Amnesia may or may not be present. All bodily functions are normal and their protective
reflexes are intact.

Procedural Sedation (previous terminology, Conscious Sedation): A minimal level of
depressed consciousness that retains the patient’s ability to maintain a patent airway
independently. The patient would be able to respond spontaneously to physical and
verbal stimuli. The drug and the dosage are not intended to produce loss of
consciousness. An ideal level of sedation is when one achieves the clinical presentation
of the patient’s slurring of speech.

Deep Sedation: A controlled state of depressed consciousness or unconsciousness from
which the patient is not easily aroused and is unable to respond purposefully to physical
stimuli or verbal commands. This may be accompanied by partial or complete loss of
protective airway reflexes and the patient’s inability to maintain a patent airway
independently.

General Anesthesia: A controlled state of unconsciousness accompanied by a loss of
protective reflexes, including loss of the ability to maintain a patent airway independently
or to respond purposefully to physical stimulation or verbal command.




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                       Sonoma Valley Hospital – Medical Staff
    Self-Study Guide for Procedural Sedation Credentialing

GUIDELINES

1. Patient Education and Participation
   Staff will educate patients about treatment or diagnostic procedures, including
   moderate sedation expectations so they can participate in their care plans to determine
   appropriate use of sedation and analgesia and promote best patient outcomes.
2. Personnel:
      A. The practitioner supervising the administration of drugs for procedural
         sedation shall be appropriately trained in the following:
         1) Airway management including: positioning of the airway, use of a oral
             pharyngeal airway, application of positive pressure ventilation with a bag
             and mask
         2) Safe use of drugs with recognition of their effects with patient variability
         3) Basic arrhythmia recognition course
      B. The practitioner (nurse) will complete competencies as defined and monitored
         by each department.
      C. The practitioner (nurse) monitoring the patient shall have no other assigned
         duties while the patient is under procedural sedation.
2. Quality Monitoring:
      A. The Department of Anesthesiology will monitor and evaluate procedural
         sedation practices throughout the hospital to promote uniform standard of
         care. The Anesthesia Department will review, on and on-going basis, cases
         that are identified by the Procedural Sedation Indicators.
      B. Procedural Sedation Indicators are defined as the following:
         1) Cardiopulmonary arrest
         2) Unanticipated admission to the hospital or the ICU
         3) Use of Narcan or Romazicon
         4) Oxygen saturation less that 90% despite supplemental oxygen
         5) Respiratory rate less than 8 per minutes for duration of greater than five
             minutes
         6) Any patient requiring any assisted ventilation.
3. Comprehensive Patient Assessment:
   Each patient should be assessed prior to a procedure. Assessment should include:
         1) History and a physical
         2) Medications
         3) Allergies
         4) Adverse reaction with prior anesthesia
         5) Vital signs
         6) NPO status
         7) Proper consent signed
         8) ASA classification (See ASA Classification Table.)


                                                                             Page 2 of 13
                      Sonoma Valley Hospital – Medical Staff
    Self-Study Guide for Procedural Sedation Credentialing


          American Society of Anesthesiology Patient Classification Table
           Class                          Description
      ASA I           Healthy patient without problems

      ASA II          Mild systemic disease or conditions that need to be treated
                      Examples: Diabetes Mellitus, smoking, asthma, thyroid
                      disease.
      ASA III         Severe systemic diseases that limit activity but are not
                      incapacitating
                      Examples: Complicated or uncontrolled Diabetes Mellitus,
                      uncontrolled hypertension, coronary artery disease (CAD),
                      chronic obstructive pulmonary disease (COPD), cardiovascular
                      vascular accident (CVA).
      ASA IV          Severe systemic disease that is incapacitating and is a constant
                      threat to life
                      Examples: Severe CAD, congestive heart failure (CHF), end
                      stage renal disease (ESRD), and steroid-dependent COPD.
      ASA V           A moribund patient not expected to survive 24 hours with or
                      without intervention.
      “E”             Added category if any of the above categories are an
                      emergency

4. Airway assessment
   A. Each patient must be assessed for potential airway complications prior to any
      procedural sedation.
   B. A Mallampati airway classification assessment must be documented.
      The Mallampati classification relates tongue size to pharyngeal size. The test is
      performed with the patient in the sitting position, the head held in a neutral
      position, the mouth wide open, and the tongue protruding to the maximum. The
      subsequent classification is assigned based upon the pharyngeal structures that are
      visible.
      1) Look at the size of the tongue relative to the size of the oral cavity. If the
          tongue obscures much of the pharynx, the patient is more likely to obstruct
          under sedation.
      2) Sit the patient upright and ask him or her to open their mouth as widely as
          possible and protrude their tongue. A good Mallampati airway assessment
          can be obtained without patients saying, AAAAAHH!
      A difficult airway may be recognized on a very gross and obvious level.
      However the potential difficult airway may be very subtle and requires careful
      examination. The basis of a difficult airway are numerous and are only briefly
      discussed here. Extreme caution (especially in selection of sedation level) is



                                                                                    Page 3 of 13
                        Sonoma Valley Hospital – Medical Staff
     Self-Study Guide for Procedural Sedation Credentialing
       required for the patient that presents with any of these conditions, especially if the
       patient is in the lateral or prone position.




                                 Mallampati Classification
   Class I        Visualization of the soft palate, fauces, uvula, anterior and posterior pillars
   Class II       Visualization of the soft palate, fauces, and uvula
   Class III      Visualization of the soft palate, and the base of the uvula
   Class IV       Soft palate is not visible at all.


The classification assigned by the clinician may vary if the patient is in the supine
(instead of sitting) position. If the patients phonates, this will falsely improve the view.
If the patient arches his or her tongue, the uvula will be falsely obscured. A Class I view
suggests ease of intubation (correlates laryngoscopic view, grade I) with a 99-100%
occurrence rate. Class IV view (correlates a poor laryngoscopic view, grade III or IV)
with a 100% occurrence rate. Beware of the intermediate Classes which may result in all
degrees of difficulty in laryngoscopic visualization.

5. Clinical Considerations and Interventions
If a patient has a small mouth, receding chin, and a short or immobile neck, management
of the airway could be difficult. These patients should be kept extremely light. It is
essential to constantly monitor these patients who have been given sedation. Be alert for
problems with ventilation and be cognizant of the fact that restlessness can be sign of
excessive sedation, as well as inadequate sedation. If the patient is breathing but the
oxygen saturation falls, it may only be necessary to stimulate the patient and instruct
him/her to take a deep breath. Hold sedation until saturation rises. Varying degrees of
stimulation during the procedure will result in comparable patient response. During the
periods of relative low level of stimulation, the patient can become more somnolent.
If the patient has some discomfort, it will be important to distinguish between pain and



                                                                                      Page 4 of 13
                        Sonoma Valley Hospital – Medical Staff
     Self-Study Guide for Procedural Sedation Credentialing

pressure. The administered intravenous anesthetic provides some pain relief, but it
cannot be totally relied upon for complete analgesia. Pain should be controlled by local
anesthetic administered by the surgeon. Narcotic analgesics can cause some degree of
respiratory depression and must be given judiciously.
If the patient's airway becomes obstructed during sedation, the chin should be lifted until
the tongue is lifts up from the pharynx allowing air to pass at the base of the tongue. If
the patient does not breathe with the now open airway, an Ambu bag must be used to
provide positive pressure ventilation until spontaneous ventilation returns. It is very
important to maintain an open airway with chin lift/jaw thrust and maintaining a tight fit
with the mask for ventilation.
Complications of procedural sedation can occur as with general anesthesia (including
cardiac arrest, pulmonary arrest, drop in blood pressure, aspiration, arrhythmia, allergic
reaction or shock). In the event, that the patient stops breathing and does not respond
to stimulus (such as: turning the patient supine, surgical stimuli, jaw thrust or chin
lift), a Code Blue must be called.

PROCEDURAL REQUIREMENTS
1. Practitioner/Nurse (with no other assigned duties) will continuously monitor and
   assess the patient under procedural sedations and will record (every 15 minutes or
   more frequently if needed) the following and communicate any abnormal conditions
   immediately:
   A. Blood pressure
   B. Heart rate
   C. Pulse oximetry
   D. Respiratory rate
   E. EKG
   F. Level of consciousness (Note: A patient starting to slur speech is an indication of
       ideal level of procedural sedation.)
   G. Temperature (for procedures lasting more than one hour).
2. Physician must be present or ―immediately‖ available for any procedural sedation that
   involves the administration of a controlled substance.
3. All medication being used must be properly labeled, handled, stored, and documented
   when administered.
4. In accordance with the hospital policy, all patients having procedural sedation must
   have intravenous access. (The only exception would be in the pediatric or ER
   population.)
5. Medication must be administered according to State statutes (given by a physician or
   a registered nurse).
6. Supplemental oxygen is required for patients with saturation levels less than 90% on
   room air. Supplemental oxygen prior to sedation will provide extra time for the
   health care provider to respond in the event that a patient experience apnea or signs of
   impending respiratory arrest.


                                                                               Page 5 of 13
                       Sonoma Valley Hospital – Medical Staff
       Self-Study Guide for Procedural Sedation Credentialing


7. The practitioner (nurse) will provide and document a post procedural clinical
   assessment based on the Aldrette Scoring System.

                          ALDRETTE SCORING SYSTEM
          ASSESSED                  DESCRIPTION                               SCORE
          FUNCTION
     Activity              Voluntary movements of all limbs to command             2
                           Voluntary movements of 2 extremities to command         1
                           Unable to move                                          0
     Respiration           Breathe deeply and cough                                2
                           Dyspnea, hypoventilation                                1
                           Apneic                                                  0
     Circulation           BP 20% of preanesthesia level                           2
                           BP 20-50% of preanesthesia level                        1
                           BP 50% of preanesthesia level                           0
     Consciousness         Fully awake or pre-procedure level                      2
                           Arousable                                               1
                           Unresponsive                                            0
     Color                 Pink                                                    2
                           Pale, blotch, jaundice                                  1
                           Cyanotic                                                0

ROOM SET-UP, EQUIPMENT, AND SUPPLIES REQUIREMENTS

The following is the required list of equipment and supplies that should be immediately
available in the procedural sedation room:

1.   Ambu bags and airway supplies
2.   Oxygen
3.   Suction equipment with Yankauer tip
4.   Monitoring equipment
5.   Pulse oximetry
6.   EKG
7.   Blood pressure monitor
8.   Crash cart unit
9.   Reversal agents

POST ANESTHESIA CARE UNIT (RECOVERY) REQUIREMENTS:

1. Monitor, assess, and document the following:
   A. Level of consciousness (including response to verbal interaction, commands)
   B. Level of comfort
   C. Level of knowledge, understanding
   D. Nature of a procedure and any complications

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                       Sonoma Valley Hospital – Medical Staff
    Self-Study Guide for Procedural Sedation Credentialing


2. Intervene appropriately based on results of continuous monitoring and assessment
   (i.e. repositioning, administering of meds, education, comfort, physician
   communication, etc.)

3. Explain procedure and educate patient as to expectations in the recovery and post
   recovery phase.

4. Be vigilant to the signs, symptoms of complications of procedural sedation (that are
   the same as general sedation)—including cardiac arrest, pulmonary arrest,
   hypotension, aspiration, arrhythmia, allergic reaction, and shock.

5. Provide a comprehensive, meaningful report (SBAR—situation, background,
   assessment, and recommendation—communication ) to the caregiver assigned to
   follow the patient’s care.




                                                                            Page 7 of 13
                                     Sonoma Valley Hospital – Medical Staff
                         Self-Study Guide for Procedural Sedation Credentialing


                 DRUGS USAGE GUIDELINES:


                                     Sedation Drugs and Reversal Agents



        Romazicon



           Narcan



          Diluadid



         Morphine
Drugs




           Versed



          Fentanyl



         Ketamine



        Etomidate


                     0        50      100          150             200    250   300          350
                                                         Minutes



                                            Duration of Clinical Effect




                                                                                      Page 8 of 13
                      Sonoma Valley Hospital – Medical Staff
    Self-Study Guide for Procedural Sedation Credentialing



              **These guidelines are derived from published resources.
      Doses in excess of these guidelines are at the discretion of the physician.**
                ADULT SEDATION DRUG DOSAGE GUIDELINES
1     Approved Medications

      Fentanyl (Sublimaze)
      Hydromorphone (Dilaudid)
      Midazolam (Versed)
      Morphine Sulfate
      Etomidate (Amidate) **ANESTHESIA AND ED ONLY**
      Ketamine (Ketalar) **ANESTHESIA AND ED ONLY**
      Naloxone HCL (Narcan)
      Flumazenil (Romazicon)
2     Drug Administration Guidelines
A.    Fentanyl (Sublimaze)
       Route:                            IV, IM
       Initial Dose:                    Administer 0.5 – 1.0 micrograms/kilogram (Give
                                        slow IV over 3-5 minutes; inject into infusing
                                        line.)
       Recommended Total Dose:          50-250 micrograms
       Onset:                           1-1.5 minutes
       Peak:                            5-15 minutes
       Duration:                        30-60 minutes
       Half-life:                       2-4 hours
       Potential Adverse Reactions: Respiratory depression, apnea, rigidity, bradycardia,
       hypotension, hypertension, dizziness, blurred vision, nausea, emesis, laryngospasm,
       diaphoresis, hypersensitivity, sedation, drowsiness, convulsions, respiratory
       depression,
       peripheral circulatory collapse, cardiac arrest, allergic reactions, suppression of
       cough reflex.
B.    Hydromorphone (Dilaudid)
      Route:                           IV
      Initial Dose:                    1-2 mg slow IV push
      Recommended Total Dose:          4 mg (DO NOT EXCEED 0.1 mg/kg)
      Onset:                           15-30 minutes
      Peak:                            0.5–1 hour
      Duration:                        4-5 hours
      Half-life:                       2-3 hours
      Potential Adverse Reactions:
      Drowsiness, thrombosis, and phlebitis at the site of injections, slurred speech,
      nausea, bradycardia, hypotension, respiratory depression, skin rash, blurred vision,
      nystagmus, fluctuations in vital signs, apnea, hiccoughs, vomiting, coughing, over
      sedation, and headache, increased CSF pressure.




                                                                                 Page 9 of 13
                     Sonoma Valley Hospital – Medical Staff
 Self-Study Guide for Procedural Sedation Credentialing
             **These guidelines are derived from published resources.
     Doses in excess of these guidelines are at the discretion of the physician.**
               ADULT SEDATION DRUG DOSAGE GUIDELINES
C.   Midazolam (Versed)
     Route:                        IV
     Initial Dose:                  0.5 mg – 2 mg slow IV over at least 2 min.; slowly
                                    titrate every 2-3 minutes;
     Recommended Total Dose: 2.5-5 mg (decrease dose in elderly)
     IV:
     Onset:                         1 minute-5 minutes (IV)
     Peak:                          2-4 minutes (IV)
     Duration:                      1-4 hours; increased in cirrhosis, CHF, obesity,
                                    elderly and acute renal failure)
     IM:
     Onset:                         Within 15 minutes
     Peak:                          0.5-1 hour
     Duration:                      2 hours mean, up to 6 hours
     Potential Adverse Reactions: Drowsiness, thrombosis, and phlebitis at the site of
     injection, slurred speech, nausea, bradycardia, hypotension, respiratory depression,
     skin rash, blurred vision, nystagmus, fluctuations in vital signs, apnea, hiccough,
     nausea, vomiting, coughing, over sedation and headache. May potentiate the action
     of other CNS depressants including opiate agonists or other analgesics, barbiturates,
     other sedatives or anesthetics.
D.   Morphine Sulfate
     Route:                       IV
     Initial IV Dose:            Administer 2-5 mg over at least 5 minutes into an
                                 infusing IV line.
     Recommended Total Dose: 15 mg (Do not exceed .15 mg/kg)
     Onset:                      1-7 minutes
     Peak:                       20 minutes
     Duration:                   4-5 hours
     Half-life:                  2-4 hours
     Potential Adverse Reactions: Respiratory depression, hypotension, bradycardia,
     CNS depression, nausea and vomiting, urinary retention.
E.   Etomidate (Amidate) – General Anesthetic
                  (**NOT RECOMMENDED FOR CHILDREN UNDER 10 YEARS**)
     Route:                        IV
     Initial Dose:                 0.2 – 0.6 mg/kg over 30-60 seconds
     Recommended Total Dose:
     Onset :                       1 minute
     Peak:                         2-3 minutes
     Duration:                     3-5 minutes
     Half-life:                    75 minutes
     Potential Adverse Reactions: nausea, vomiting, respiratory depression (15% of
     patients), muscle twitching, adrenal suppression, hypotension




                                                                              Page 10 of 13
                       Sonoma Valley Hospital – Medical Staff
     Self-Study Guide for Procedural Sedation Credentialing
               **These guidelines are derived from published resources.
       Doses in excess of these guidelines are at the discretion of the physician.**
                 ADULT SEDATION DRUG DOSAGE GUIDELINES
F.     Ketamine (Ketalar) – Anesthetic Adjunct
       Route:          IM / IV (**ADMINISTER OVER MINIMUM OF 60 SECONDS**)
       Initial Dose:      ADULT                PEDIATRIC
          IV :         1 - 4.5 mg/kg           0.2 – 1 mg/kg
          IM:          0.5 - 4 mg/kg           2 – 10 mg/kg
       Onset:          IV: 1 minute; IM: 5 minutes
       Peak:           4-5 minutes
       Half life:     10-15 minutes
       Duration:
                      IV: 10-20 minutes
                      IM: 15-45 minutes
       Potential Adverse Reactions: Contraindicated in patients with increased intracranial
       pressure, Coronary Artery disease, increased blood pressure, convulsion, delirium,
       hallucinations, amnesia, flashbacks possible for several weeks after use, agitation,
       transient laryngospasm, ptyalism, respiratory depression, oxygen desaturation <
       85% in < 1% of patients.
G.     Naloxone HCL (Narcan)
       Route:                        IV
       Initial Dose:                 Administer 0.1-2 mg every 2-3 minute intervals; Inject
                                     into infusing line; may repeat every 20-60 minutes.
       Onset:                        Within 2 minutes
       Half-life:                    1-1.5 hours
       Duration:                     20-60 minutes
       Recommended Total Dose: 10 mg
       Potential Adverse Reactions: Excitement, hypotension, hypertension, ventricular
       tachycardia and fibrillation, pulmonary edema, seizures, nausea, vomiting,
       sweating, circulatory stress.
H.     Flumazenil (Romazicon)
       Route:                       IV
       Initial Dose:                Administer 0.2 mg; administer over 15 seconds;
                                    inject into infusing line; wait additional 45 seconds
                                    before repeating, if necessary.
       Recommended Total Dose: 1 mg.; administer additional dosages at 0.2 mg
                                    (four additional times) at 1 minute intervals.
       Onset:                       1-3 minutes
       Peak:                        6-10 minutes
       Half-life:                   41-79 minutes
       Potential Adverse Reactions: Nausea and vomiting, dizziness, injection site pain,
       agitation, headache, sweating, flushing, hot flashes paresthesia, emotional liability,
       inflammation at injection site, abnormal vision, fatigue, convulsions for patients on
       benzodiazepines for seizure control.
        **Duration: Resedation can occur usually within 1 hour; duration is usually
                                     related to dose given.**



                                                                                  Page 11 of 13
                            Sonoma Valley Hospital – Medical Staff
        Self-Study Guide for Procedural Sedation Credentialing
                     **These guidelines are derived from published resources.
                Doses in excess of these guidelines are at the discretion of the physician.**
                               PEDIATRIC DRUG DOSAGE GUIDELINES
     Drug Administration guidelines: For pediatrics > 2 years. (Neonates and Adolescents excluded)
MEDICATION       ROUTE        DOSE mg/kg            ONSET       DURATION*             COMMENTS
 Sedatives ƒ
Midazolam       Deep IM     0.08 mg/kg-          IM: 15 min.    1-2 hours      •IV maximum
(Versed)                    0.1 mg/km                                          concentration—
                                                                               1 mg/ml
                IV          0.08-0.15 mg/kg      IV: 1-5 min.                  •Decrease dose by 30% if
                            given over 10-20                                   narcotics and other CNS
                            min.                                               depressants are administered
                                                                               concomitantly
                                                                               •Rapid onset; amnesic;
                                                                               Allow 3-5 min between
                                                                               doses to decrease the chance
                                                                               of oversedation.
                                                                               •Maximum IM/IV dose—10
                                                                               mg
                PO          0.4-0.5 mg/kg with   20-30 min      1-2 hrs        •Concomitant use of
                (Syrup)     a maximum oral                                     barbiturates, alcohol or
                            dose of 15 mg                                      other CNS depressants may
                                                                               increase the risk of
                PR          0.3 mg/kg            20-30 min      1-2 hrs        hypoventilation, airway
                                                                               obstruction, desaturation, or
                IN (Nasal   0.2-0.3 mg/kg        5 min          30-60 min      apnea and may contribute to
                Spray)                                                         profound and/or prolonged
                                                                               drug effect.
                                                                               •Contraindicated in patients
                                                                               with a known
                                                                               hypersensitivity to the drug
                                                                               or allergies to cherries or
                                                                               formulation excipients.
                                                                               •Rectal route: Dilute in 5
                                                                               ml NS; administer rectally
                                                                               •Nasal route: Use a 1 ml
                                                                               needleless syringe into the
                                                                               nare over 15 sec; use 5
                                                                               mg/ml concentration; ½
                                                                               dose may be given into each
                                                                               nare




                                                                                   Page 12 of 13
                                   Sonoma Valley Hospital – Medical Staff
                 Self-Study Guide for Procedural Sedation Credentialing
                            **These guidelines are derived from published resources.
                       Doses in excess of these guidelines are at the discretion of the physician.**
                                      PEDIATRIC DRUG DOSAGE GUIDELINES
            Drug Administration guidelines: For pediatrics > 2 years. (Neonates and Adolescents excluded)
     MEDICATION           ROUTE       DOSE mg/kg            ONSET        DURATION*              COMMENTS
     Ketamine            IV        1-2 mg/kg             1 min           10-20 min       Requires IV be in place
     (Ketalar)                                                                           before use in other then
                                                                                         emergent situations in the
                                                                                         Emergency Department.
                                                                                         Must have 1:1 nurse to
                                                                                         patient ratio.

                         IM        2-4 mg/kg             5 min           15-45 min       Requires IV be in place
                                                                                         before use in other then
                                                                                         emergent situations in the
                                                                                         Emergency Department.
                                                                                         Must have 1:1 nurse to
                                                                                         patient ratio

       Analgesics
     Fentanyl            IV, IM    1-3 mcg/kg            IV: immediate   IV: 30-60 min   •Titrate in 1 mcg/kg doses
     (Sublimaze)                   May repeat at 30-                                     •Inject slowly 3-5 min
                                   60 minute intervals   IM: 7-15 min    IM: 1-2 hrs.    Rapid IV infusion may
                                                                                         result in skeletal muscle and
                                                                                         chest wall rigidity leading to
                                                                                         impaired ventilation and
                                                                                         apnea

     Morphine            IV, IM    0.05-0.2 mg/kg        5-15- min       IM: 3-5 hours   •Administer IV for at least 5
     Sulfate                                                             IV: 2-5 hours   min
                                                                                         •Watch out for hypotension,
                                                                                         bradycardia, peripheral
                                                                                         vasodilation, histamine
                                                                                         release

     Hypnotics -
     No reversal agent
     available




                                LEGEND FOR PEDIATRIC MEDICATIONS:
 =   Duration will vary according to dosages IM Intramuscular    PR                          Rectally
IV   Intravenous                             IN Intranasal       SL                          Sublingual
 ƒ   reversible with Romazicon               PO Per mouth/orally
 0   reversible with Naloxone




                                                                                             Page 13 of 13

								
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