CONSCIOUS SEDATION

               Please fill out the attached form only if requesting conscious
      sedation privileges. Return only the form; the Policies & Procedures are
                                  for your information.

                          - -    --   ------
                           LSU         HEALTH CARE SERVICES DIVISION
                                     EARL K. LONG MEDICAL CENTER

                                         Conscious Sedation
                 Application for Privileges for the Non-Anesthesiologist Physician


SERVICE:      _     General Surgery          _        Orthopedics     _     Pediatrics             Other

                    Internal Medicine                Radiology        _     Emergency Medicine

                                                 Conscious Sedation

               Newborn          Infant              Child           Adolescent    Adult            Mature Elder
               (1 month)        (1 mon.-I yr.)      (1-8)           (9-17)        (18-64)          (65-over)

I hereby request for each procedural privilege indicated above.

Signature of Applicant                       Printed Name                                   Date

I hereby apply for each procedural privilege, indicated above for this staff physician/resident in my
service, and attest that they are qualified and competent to perform each procedure.

Signature of Chief of Service                Printed Name                                   Date

I hereby certify that I have reviewed each procedural privilege request as supported by documentation of
training and experience, and clinical competence and feel this physician is.qualified to perform conscious
sedation under the direction of their service chief.

Chief of Anesthesiology                      Printed Name                                Date

     Recommendations for Safe Administration of Sedation and Analgesia (Conscious Sedation)

                Documentation of annual review by the non-Anesthesiologist Physician

 Name:                                              Date:

Instructions: After reviewing the EKL Procedural Sedation policy, and the booklet entitled,
Recommendations for Safe Administration of sedation and Analgesia (Conscious Sedation)*,
please answer the following questions. One answer is correct for each question.

1.       Conscious sedation is a state of minimally depressed consciousness induced by the
         administration of pharmacologic agents that allows the patient to retain his or her ability
         to maintain patent airway independently and continuously, and respond appropriately to
         physical stimulation and verbal commands during diagnostic and therapeutic procedures.
         The most important thing to remember is that during conscious sedation, the patient:

         a)     May not remember anything about the procedure.
         b)     May have partial or complete loss of protective reflexes.
         c)     May also receive topical anesthesia.
         d)     Will be able to remain still for extended periods of time.

2.       The pre-procedure patient evaluation and documentation prior to conscious sedation
         should consist of:

         a)     Current History & Physical
         b)     Focused Physical exam, including cardiac, respiratory, and airway examination
         c)     Explanation of the risks, benefits, and alternatives to conscious sedation to the
                patient and/or family members.
         d)     All of the above.

3.       Except for emergency procedures, to decrease the risk of pulmonary aspiration, the adult
         patient should be NPO for solids and non-clear liquids:

         a)     For 2-3 hours before the procedure.
         b)     For 6-8 hours prior to the procedure.
         c)     For 8-10 hours prior to procedure.
         d)     Only in cases of delayed gastric emptying.

4.       With the administration of conscious sedation, the patient:

         a)     Shows a delayed response to verbal commands, and speech is slowed or slurred.
         b)     Only responds to painful stimuli.
         c)     Responds to light tactile stimuli.
         d)     a and c

                                -                       --
 *Adapted from the American Society of Anesthesiologist Guidelines on Sedation and Analgesia
 by Non-Anesthesiologist Booklets provided by Roche Laboratories.

 5.    Monitoring of pulmonary ventilation provides the earliest indication of inadequate air
       exchange, which may lead to alveolar hypoventilation and hypoxemia. Ventilatory
       function can be monitored during conscious sedation by:

       a)        Observation or auscultation of spontaneous respiratory activity.
       b)        Pulse oximetry.
       c)        Observation of skin color.
       d)        All of the above.

 6.    Because medications administered during conscious sedation may depress cardiac
       function, impair the ability of the autonomic nervous system and the sympathetic nervous
       system to compensate for hemodynamic changes:

       a)     Conscious sedation is not recommended for patients with cardiac disease.
       b)     IV fluids should .be infused rapidly during the procedure.
       c)     The patient's blood pressure and heart rate are evaluated at frequent intervals.
       d)     Patients should be administered a short-acting vasoconstrictor.

7.     Other than the individual performing the procedure, there should be

       a)    Personnel trained in the complications of conscious sedation available to
             continuously monitor the patient.
       b)    An anesthesiologist or CRNA present.
       c)    Another physician with training in conscious sedation available to monitor
             the patient.
       d)    None of the above.

8.     T     F         When sedatives and opiods are combined, their respiratory depressant
                       effects are potentiated.

9.     T     F         It may take several minutes for a sedative/analgesic to reach its peak effect.

10..   T     F        Flumazenil (Romazicon) reverses the sedative and respiratory d~pressive
                      effects of narcotics.

11.    T     F        Patients receiving reversal agents should be observed for up to two hours
                      after the last dose of an antagonist.

12.    T     F        Personnel present during conscious sedation should have BLS training,
                      with personnel trained in ACLS ready available.
13.    T     F        A crash cart with age and size appropriate equipment should be
                      immediately available during conscious sedation.

14.    T     F        Supplemental oxygen decreases the likelihood of hypoxia during

                                                           - -    -
              conscious sedation.

15.   T   F   Medications are chosen for conscious sedation by considering the desired
              effect needed (sedation, amnesia, analgesia) and titrated to each individual.

16.   T   F   When used in combination, the doses of sedatives and opioids should be

17.   T   F
              All atients receiving conscious sedation must have a atent IV accesfl'
              an    access.
              wit Vthe exception of Ketamine, which may be           dminlstered     M without
18.   T   F   All patients discharged after conscious sedation should be given written
              discharge instructions.

19.   T   F   Outpatients can drive themselves home after conscious sedation if they stay
              in the recovery area for at least two hours and meet discharge criteria.

20.   T   F   Patients who are uncooperative during procedures, can be given as many
              additional doses as needed until the desired effect is reached.

21.   T   F   Anesthesia personnel should be consulted when patients with significant
              underlying diseases require sedation/analgesia.

22.   T   F   Flumazenil (Romazicon) reverses the respiratory effects of propofol

23.   T   F   Agitation may be an indication of hypoxia.

                 - - ---                     --
                        Conscious Sedation Recommendations:

.   The only persons who may be considered for conscious sedation privileges will be
    physicians and CRNAs.
.   All persons wishing to have conscious sedation privileges must be certified by EKL.
.   Certification consists of approval of the department chief and passing of the conscious
    sedation test at least Qnce.
.   The department chief may require more ftequent passing of the exam.
.   The conscious sedation test is developed by the D~partment of Anesthesiology and
    administered by                . Passage ofthe exam will be noted in the person's file.
.   During conscious sedation at least one person who is certified to administer conscious
    sedation will be physically present in the room.
.   In an emergency situation, the attending physician (who is, himself, certified) may
    allow a resident to administer conscious sedation without having someone who is
    certified present.
.   Ketamine used as conscious sedation may be administered llvfwithout an intravenous
.   Conscious sedation is part of a continuum beginning with small doses of drug leading
    to relaxation and minimal pain relief all the way to general anesthesia. Our definition
    for these rules is that conscious sedation is the administration of drugs prior to or
    during a procedure as opposed to giving the same drugs for pain management where
    no procedure is being contemplated.
SUBJECT: Sedation                                 DEPARTMENT: Nursing

                                                  Policy Number: 06-14-051

EFFECTIVE DATE: 08/07         I   REVISION DATE: 08/07,         ORIGIN DATE: 05/00
REF#                                                              Pa!!e: 1 of 4

REVIEWE                              2008        2009         2010          2011          2012


  A. To provide guidelines for the management of patients receiving IV sedation.
  B. To define physical status classification of the American Society of Anesthesiologist (ASA)
  C. To define the discharge criteria and/or Aldrete Scoring System to be used in evaluating
     patient's condition prior to discharge.


  A. Minimal sedation (anxiolvsis) a drug-induced state during which patients respond normally
     to verbal commands. Although cognitive function and coordination may be impaired,
     ventilatory and cardiovascular functions are unaffected.
  B. Moderate sedation/analgesia ("conscious sedation") A drug-induced depression of
     consciousnessduring which patients respond purposefullyto verbal commands, either alone
     or accompanied by light tactile stimulation. No interventions are required to maintain a
     patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually
  C. Deep sedation/analgesia: A drug-induced depressionof consciousnessduring which patients
     cannot be easily aroused but respond purposefullyfollowing repeated or painful stimulation.
     The ability to independently maintain ventilatory function maybe impaired. Patients may
     require assistance in maintaining a patent airway and spontaneous ventilation may be
     inadequate. Cardiovascular function is usually maintained.
  D. Anesthesia Consists of general anesthesia and spinal or major regional anesthesia. It does
     not include local anesthesia. General anesthesia is a drug-induced loss of consciousness
     during which patients are not arousable, even by painful stimulation. The ability to
     independently maintain ventilatory function is often impaired. Patients often require
     assistance in maintaining a patent airway and positive pressure ventilation may be required
     because of depressed spontaneous ventilation or drug-induceddepression of neuromuscular
     function. Cardiovascular function may be impaired.

  A. An informed consent is required for the appropriate level of sedation.
  B. A physician/oral surgeon must be present or immediately availableduringthe administration
     of Sedation.
  C. Sedation may be administered IV, 1Mor PO.
  D. Resources shall be available including, but not limited to, resuscitation equipment and
  E. Monitoring parameters should include:
      1. Respiratory rate
     2. Oxygen saturation
     3. Blood pressure
     4. Cardiac rate and rhythm
     5. Level of consciousness
     6. Skin condition
     7. Pain level
  F. The responsibility of monitoring and/or administering Moderate Sedation shall be according
     to currently recognized standards of practice, manufacturer's guidelines and ASA
     Classification System.
             STATUS         DEFINITION
             I              No organic, physiologic, biochemical, or psychiatric disorder
             II             Patient with mild to moderate systemic disease
             III            Patient with a severe systemic disease that affect ADL's.
             IV             Severe disease/Lifethreatening
            V               Critical patient that is not expected to live 24 hours

      1. Moderate Sedation may be initiated by privileged: (Clinical privileges may be verified
         by accessing Internet Explorer, Favorites, iPrivilege)
             a. Physicians (ASA 1-4) ASA > 3 requires Anesthesia consult
             b. Oral Surgeons (ASA 1-4)> 3 requires Anesthesia consult
             c. Anesthesiologist (ASA 1-5)
             d. Anesthetist (ASA 1-5)
      2. Deep Sedation may be initiated in a safe environment as deteIT11inedy Anesthesia:
             a. Anesthesiologist
             b. CRNA
             c. Physician with deep sedation privileges
   G. Registered Nurses:
      1. Must participate in thehospital'seducationallcredentialingmechanismin orderto provide
         evidence of competency in administration of moderate sedation and the monitoring of
         deep sedation
             a. Competencies will be measured initially and thereafter on an annual basis
             b. Current certification in ACLS, PALS or NALS required based on patient age.
      2. Will have no additional responsibilities when administering/monitoring sedation
      3. May administer/monitor moderate sedation to patients with ASA 1-5 under the direction
         of a physician, oral surgeon or anesthesiologist

    4. May not administer medications prohibited by licensure (deep sedation)
    5. May monitor patients under deep sedation
            a. Adult patients ASA 1-3
            b. Pediatric patient ASA 1-2
H. Moderate Sedationmay be initiated in the following areas
    1. Operating Suite
   2. Recovery Room
   3. Oral Surgery
   4. EmergencyRoom
   5. Radiology
   6. Adult ICU
   7. NICU
   8. CardiologyLab
I. Patients receiving sedation shall be monitored in a controlled environment until deemed
   ready for discharge.
   1. Discharge criteria and/or Aldrete Scoring System will be used to evaluate the patient's
       physical condition on admission, post procedure and prior to dischargeprior to discharge
       and/or when any change occurs in any of the categories during the patient's recovery.
       Patients shall be classed with a discharge score of 8+, SP02 of 94% or return to base
       line on room air, 1 hour post sedation and capable of assuming limited activities or on
       documented orders from a physician.
J. Patients must have a discharge sponsor available to provide transportation to home/facility.
A. Obtain a nursing assessment which includes information that is obtained from:
    1. Interview with patient, patient's family and/or relatives
    2. Pre-procedureassessment should include but not be limited to:
           a. Minimum requirements for history and physical assessment per physician
           b. Current Medications
           c. Drug allergies/sensitivities
           d. Concurrent medical problems (i.e. hypertension, diabetes, cardiopulmonary
               disease, kidney problems, respiratory problems, problems with previous
           e. Diagnosis
           f. Baseline vital signs, including weight and age per RN
           g. Levelof consciousness per RN
           h. Emotional state
           i. All females of child bearing age must have a UPT test performed within the past
               24 hours
           j. NPO status when medically appropriate: 2 hours clear liquids, 6 hours solid food
B. ASA Classification(Physician must determine ASA classificationbased upon pre-procedure
C. Consult with Anesthesiapersonnel whenpatients are identifiedas needingmore extensiveand
   intensive monitoring.
D. Obtain and secure a patent IV access line as ordered by physician

  E. Perfornl Time Out
  F. Prepare and administer IV sedation according to physician orders and manufacturer's
     guidelines per RN, CRNA
  G. Administer 02 per nasal cannula or mask when medically appropriate per RN
  H. Document all pertinent infornlationin theMedicalRecord, Moderate/DeepsedationRecordat
     3 to 15 minute intervals and at any significant event per RN.
      1. Vital Signs including pain level
      2. Dosage of all drugs and agents used
      3. Level of consciousness
      4. Any intervention and the patient's response
      5. Any untoward or significant patient reaction and intervention
      6. Types and amount of fluids administered
      7. Status of patient at conclusion of procedure
  1. Evaluate post procedure status of patient and document the following.
      1. Vital Signs, SP02 and level of consciousnessat a minimum of 5 minutes for the first 15
          minutes and then every 15minutes for a total of 45 minutes after last dose of sedation (a
          total 60 minutes post sedation)
      2. Intravenous fluids administered including blood and blood products
      3. All drugs administered
      4. Unusual events or post procedure complications and the management of those events
      5. Physical assessment
  J. Document information/events during the discharge process
      1. Discharge instructions, verbal and printed
      2. Patients and/or sponsor's understanding of discharge instructions
      3. Patient's condition upon discharge
      4. Name of patent's discharge sponsor
      5. Time of discharge and mode of transportation to curbside

Louisiana State Board of Nursing: Declaratory Statement 3/16/2005
Louisiana State Board of Nursing: Spring 2004 Examiner
Louisiana State Board of Nursing: September 1990Examiner.
Nursing Care for the Patient Receiving Conscious Sedation During Gastrointestinal Endoscope
Procedures, Society of GastroenterologyNurses and Associates. Winter 1991
Position Statement: Society of GastroenterologyNurses and Associates Inc. August 1991.
AORN: Recommended Practice Monitoring the Patient receiving IV Conscious Sedation.


                                                                                                      Patient Evaluation


                                                            Support Equipment and Emergency Training                                                                                            .

                                                                                             Clinical Pharmacology

                                                                                                        Recovery Care

The following content contained within is based upon the evidence-based American'
Society of Anesthesiologists Guidelines on Sedation and Analgesia by Non-
Anesthesiologists. {Thecompleteguidelinesmay be obtained by calling your Roche..
representative at I-800-LAROCHE

-Tbe guidelines have been endorsed by the governing board of the American Society for Gastrointestinal


 ~                    C/O MERCY HOSPITAL 1400 LOCUST STREET PITTSBURGH, PA 15219
                                                                                                                                ...I!lII!IIIJ!J!lIIIL!!JIJ!IILIII.lIII!I .I   .11l1ll1.1I1J1I1I1II    II   I III III I 111I111111
Adapted &om the American Society of Ancathcsiologi5ts                                                                                                                    Made POSIible through a grant 1iom:
Guidelines.on Sedation and analgesia by Non-Ancsthcsiologi5ts
                                                                                                                                                                   . RocheLaboratories
                                                                                                                                                                     to AMcmbcr of the Roche Group
                                                                                                                                                                         Roche Laboratories Ine.
                                                                                                                                                                         340 Kingsland SIrcct
                                                                                                                                                                         NutlCY.New Jc:ncy 07110-1199

        Patient Evaluation

        Patient Consent

    . Risks, benefits, expectations,and alternatives

    . Major organ systems

             - Pre-existing cardiac or pulmonarydisease may require reduced dosage because
             sedative and analgesicmedicationstend to cause cardiovascular and respiratory

            - Hepatic and renal abnormalitiesmay impair drug metabolismand excretion resulting in
            longer duration.of drug action.

  Current medications
  Drug allergies
. AJcohol, tobacco, illicit substance use

            - Alcohol and/or other substance abuse may increase required effective dosage of
            sedatives and/or analgesics.

            - Smoking increases risk of airwayirritability,bronchospasm, or cough during sedation.

.       Pre"ious experience with sedation/analgesia

            -Prior adverse reactions to sedation or anesthesia may increase risk of complications
            during subsequent sedation/analgesia.

Focused Physical Examination

.       Cardiac
.       Respiratory
.       Airway

    Example of Airway Assessment Proceduresfor Sedation and Analgesia:

    Positive pressure ventilation, with or without endotracheal intubation, may be necessary
    ifrespiratory compromise develops during sedation/analgesia. This may be more difficUlt
    in patients with atypical airway anatomy. Also, some airway abnormalities may increase
    the likelihood of airway obstruction during spontaneous ventilation. Factors that may be
    associated with difficulty in airway management are:


                                      -   -      -   ---
      Previous problems with anesthesia or sedation

      Stridor, snoring, or sleep apnea

     Dysmorphicfacialfeatllres (e.g. Pierre-Robin syndrome, trisomy 21)

     Advanced rheumatoid arthritis

     Physical examination


     Significant obesity (especially involving the neck andfacial structures)

     Head and neck

     Short neck, limited neck extension, decreased hyoid-mental distance «3 cm in an adult),
     neck mass, cervical spine disease or trauma, tracheal deviation


     Small opening «3 em in an adult); edentulous, protruding incisors; loose or capped
     teeth; high arched palate; macroglossia; tonsillar hypertrophy; nonvisible uvula


    Micrognathia, retrognathia, trismus,significant malocclusion

.    Sedative and analgesic medications tend to impair airway reflexes in proportion to the
degree of sedation achieved. Patients may be at increased risk of aspirating gastric contents
should regurgitation occur.                   .
. For electiveprocedures, this risk may be minimizedby allowingsufficienttime for gastric
emptying before the procedUrebegins.
. In emergent situations or with impairedgastric emptying (bowel obstruction, pregnancy,
opioids, pain), pulmonary aspiration risk should be considered in determiningtiming of the
procedure and target level of sedation.

    Example of Fasting Protocol for Sedation and Analgesia for Elective Procedures:

    Gastric emptying may be influenced by manyfactors, including anxiety, pain, abnormal
    autonomicfunction (e.g., diabetes),pregnancy, and mechanical obstruction. Therefore,
    the suggestions listed do not guarantee that complete gastric emptying has occurred
    Unless contraindicated,pediatric patients should be offered clear liquids until 2-3 h
    before sedation to minimize the risk of dehydration.
                                                                                                                 Solids and Nonclear Liquids'" Clear Liquids
      Adults                                                                                                     6-8 h or none after midnigh~                                                                           2-3 h
      Children older than 36 months                                                                              6-8 h                                                                                                  2-3 h
      Children aged 6-36 months      6h                                                                                                                                                                                 2-3 h
      Children younger than 6 months 4-6 h                                                                                                                                                                              2h

     * This includes milk, fonnula, and breast milk (high fat content may delay gastric emptying).
     1 There are no data to establish whether a 6-8 h fast is equivalent to an overnight fast before

                                     Patient Evaluation                                 IMonitoring ISupport    Equipment and Emergency Training                                                                                                I
                                                                                           Clinical Pharmacology IRecoverv Care

                 <     ANESTHESIA                                  PATIENT                  SAFETY                     FOUNDATION

                       CIO MERCYHQSPITAL                                                    1400 LOCUST STREET PITTSBURGH, PA 15219

Adapted1iomthe AmericanSocietyof Anesthesiologista                                                                                                                                            Made Possiblethrougha grant nom:
                                                                                                                                                                                              Roche Lab 0 '1at o'Ues
Guidelines        on Sedation             and analgesia              by Non-Anesthesiologists
                                                                                                                                                                                       . 10   A Member of the Roche Group
                                                                                                                                                                                              Roche Laboratories                   Inc.
                                                                                                                                                                                              340 Kingsland Street
                                                                                                                                                                                              Nutley, New Jersey 071 IIJ. U99

    Le-vei of C{)naci~H~~neS$

Patients' responses to verbal commands during a procedure perfonned with sedation/analgesia
serve as a guide to their level of consciousness.An apprqpriate level of consciousness implies
that patients will be able to control their own airways and take deep breaths as necessary.

.  Level of consciousnessshould be assessed frequently(l-minute intervals) during the onset
of sedation and whenever medications are being titrated.
. Once an appropriate safe level of sedation is established,patients may be aroused less
frequently if this is necessary to avoid interferingwith the diagnostic or therapeutic procedure.

         - With administration of sedative/analgesic medications, patients' responses to verbal
         commands are delayed and are frequently slowed or slurred.

        - Light, tactile stimulation may be required to get patients' attention.

        - Once aroused, they respond appropriatelyto verbal commands.

        - In cases where verbal response is not possible, seek other indications of consciousness
        in response to verbal or tactile stimulation.     .

Patients whose only response to verbal commandis reflexwithdrawal from painful stimuli are
deeply sedated, approaching a state of general anesthesia,and special care must be taken to
ensure the patency of the airway, adequacy of pulmonaryventilation, and hemodynamic
stability. This is deep sedation, not conscious sedation.

Sedative and analgesicmedications significantlydepress ventilatory drive and decrease airway
patency. Pulmonaryventilation should be monitored to provide the earliest indication of
inadequate air exchange. ~

. Ventilatory functionusually can be monitored by observation of spontaneous respiratory
activity or continuous auscultation of breath sounds.                     .

. In situations where patients are physicallyseparated from the care
giver, automated apnea monitoring (detection of exhaledcarbon .
dioxide, nasal thermistor, etc.) is desirable.

                 Pulse oximetry should be used on a continuousbasis to
                 provide the earliest warning of hypoxemia. .
                 .   There may be a delay of a minute or more between the onset of apnea and the
                 first decrease in oximeter reading, particularlyif the patient is breathing

                                    ---                   - - - ---    -
                Pulse oximetry should never replace evaluation of the patient.
               If the monitor indicates low oxygen saturation, check thepatient first to ensure
               adequate ventilation and oxygenation. If the patient responds appropriately and
               appears to be ventilating adequately, consideration can be given to possible
    monitoring errors. Equipment failure is a diagnosis of exclusion.


    Medications administered during sedation/analgesiamay directly depress cardiac function. In
    addition, they may impair the abilityof the autonomic nervous system to compensate for
    hemodynamicchanges.                                                             .:.~.

    . Blood pressure and heart rate should be monitored at fi-equentintervals,
    especiallyduring the onset of sedation/analgesia.
    . If recognized early, hypotension may be treated by elevation of the legs,
    administrationof intravenous fluids, and, in some cases, administrationof a short acting

          - Obtain a baseline blood pressure and pulse reading prior to initiation of sedation.

          - Obtain frequent readings (1-2 minute intervals) during the onset of sedation.

         - Obtain readings regUiarly (5-10 minute intervals) during the procedure.

         - Obtain readings at the end of the procedure and prior to discharge.

    Continuous EKG Monitoring

Patients may be at increased risk for developing cardiac dysrhythmiasduring sedation and
analgesia.Continuous electrocardiograph monitoring enables the practitioner to rapidly detect
and.diagnose dysrhythmias, so that any necessary intervention can be undertaken in a timely

This is especially important in the following situations:

.  Patients with underlying cardiovascular disease
.  Patients who are suspected of having dysrhythmiasbecause of
irregular rhythm noted on the pulse oximeter or detected during
auscultation of heart sounds
. Procedures with increased risk of dysrhythmia(those involving
gastrointestinal distention or cardiovascularmanipulations such as angioplasty and endocardial

                Patient Evaluation IMonitoring: ISupport Eauipment and Emergencv Training:   I
                                    Clinical Pharmacology IRecovery Care

                                  - --       -- - -
Support Equipment and EmergencyTraining
.  Supplemental oxygen administrationreduces the risk of hypoxemiaand provides an
additional margin of safety.
. Age- and size-appropriate emergencyequipment shouldbe immediatelyavailable,
including a defibrillatorfor patientswith cardiovascular disease.
. A person trained in basic life support and aIrway managementshould be present and
available to initiate resuscitation if respiratory and/or cardiovasculardepression occurs.
. An individualwith advanced life support skills should be immediatelyavailable.

                                                   Emergency Algorithim
                                                                      .. ...................

                 Apply S-Uppl~m,gntaI Q)cygen.
                      Chl1c!<    alr     ,ray !C)flo~t"J::.
                      Chock bre<l!h sounds.

                                       :.r .

                         Probfem resolved.

          ,"                                                                                                                     !I-lo
    Continue     suppferrnmtal             -='       Cmrtlflue       sLJppf<:mtmta!                      {1.ppl:iposi!";e pressure
 .            D~ygen.         .                                   oK}'gen.                             \:<tntHation wrth m~klb3g.
Monitor   yjt<:1 signs/\/'efltilaticm.           Monitor      1o!italsignsiventilatiQn~                    Consider intub.>ti-::m.

                                                      A$$e5Sventilatory adeqll1n:y. leve! o!
                                                   cQfmcrous.'1~ vital signs:. skin color, lung
                                                    sounds, ainnay rejJ;:,)(~. puis;:.cxlmctf>/.

               Patient Evaluation                IMonitorine:ISUDDortEauiDment                 and Emergencv Trainine      I
                                                  Clinical PharmacologY IRecoverv

       CUnicaJ Pharmacology

    . Combinations of sedatives and analgesicdrugs may increase the likelihood of adverse
    outcomes, including ventilatory depression and hypoxemia.

              - The te~dency for synergism between sedatives and analgesicsreinforces the need to
              appropriately reduce the dose of each component as well as the need to continually
              monitor respiratory function.

   . Sedative and analgesic agents should be administered individuallyto achieve the desired
   effect rather than in fixed combinations.
   . Intravenous sedatives/analgesicdrugs should be given in smallincremental doses titrated to
  desiredendpoints.                                                                         .

  . It is important to allow adequate time for peak drug effects to occur before administration of
  subsequent doses.

  Reversal Agents

 . Specific antagonists are availablefor opioids (i.e., naloxone) and benzodiazepines (e.g.,

Flumazenil reverses the sedative and respiratory depressant effectsofbenzodiazepines.

.      Dose: 0.2 mg IV; if desired effect is not achieved, an additionaldose may be administered.
.      It generally does not cause hypertensionor tachycardia.
.      Seizures may occur in patients who are receiving benzodiazepinesfor seizure control.

Naloxone effectivelyreverses opioid-inducedrespiratory depression;however, analgesia is also

. Dose: 0.5 -1. 0 JlglkgIV;.,\fdesired effectis not achieved, an additional dose may be
administered.                             .

Both flumazenil and naloxone have shorter durations of action than the benzodiazepines and
opioids which they antagonize. Patients must be observedfor an appropriate period of time
(up to 2 hours) after the last dose of an antagonist to ensure that respiratory depression does
not recur.

                      Patient Evaluation IMonitoring                              ISupport EquiDment and Emergencv Training I
                                                          Clinical Pharmacolor!V IRecoverv Care

. I.    .        IIJII...1.   1 III.   111I1 11I1   III             .
                                                          LI .111I11. I   ...1.   I.. II I. .1II11.1.1!11111 ..1...1. .1. 1 II. !l!1II11I1I .   . .I!II!I   ..   . II 11111..                            ..
                                                                                                                                                                                ... 1 I III 111.:111111.111.   111

Adapted 1iom the American Society of Anesthesiologists                                                                                      Mlde Possible through a grant from:

Guidelineson Sedationand analgesiaby Non-Anesthesiologists                                                              ~
                                                                                                                                            A Memberof the Roche Group
                       n         ._.   ..._.__
                                                               .              ...-..---

Recovery Care
. Patients must be monitored during recovery to ensure that any adverse events are
rapidly recognized and treated.
. Vital signs should be recorded at regular intervals and pulse oximetry should be
continued until the patient is no longer at risk of hypoxemia.
. Monitoring should include observationby a person trained in recognition of post-
procedure/post-sedation complications.
. Appropriate discharge criteria shouldbe met prior to discharge.

 Example of Recovery and Discharge Criteria after Sedation and Analgesia:
 Each patient carefacility in which sedation/analgesia is administered should
 develop recovery ans discharge criteria that are suitable for its specific patients
 and procedures. Some of the basicprinciples that might be incorporated in
 these criteria are enumerated

 General Principles

 1. All patients receiving sedation/analgesia should be monitored until
 appropriate discharge criteria are satisfied The duration of monitoring must be
 individualized depending on the level of sedation achieved, overall condition of
 thepatient, and nature of the interventionfor which sedation/analgesia was

 2. The recovery are should be ec QJJipped ith with appropriate monitoring and
 resuscitation equipment.

3. A nurse or other trained individual should be in attendance until discharge
criteria are fulfilled An individual capable of establishing a patient airway and
providing positive pressure ventilation should be immediately available.

4. Level od consciousness and vital signs (includingjrequency and depth of
respiration in the absence of stimulation) should be recorded at regular
intervals during recovery. The responsiblepractitioner should be notified if vital
signsfall outside of the limitspreviously establishedfor each patient.

Guidelines for Discharge

1. Patients should     be alert and oriented; infants and patients whose mental
status was initially    abnormal should have returned to their baseline.
Practitioners must     be aware that pediatric patients are at risk for airway
abstruction should     the head fall foward while the child is secured in a car seat.

2. Vital signs should be stable and within acceptable limits.

3. Sufficient time (up to 2 h) should have elapsed after last administration of
reversal agents (naloxone,f/umazeil) to ensure thatpatients do not become
resedated after reversal effects have abated

4. Outpatients should be discharged in thepresence of a responsible adult who
           wul/ accompany them home and be able to report any post-procedure

          5. Outpatients should be provided with written instructions regarding post-
          procedure diet, medications, and activities, and a phone number to use in case
          of emergency.

                      Patient Evaluation IMonitorine: ISupport Equipment and Emere:encv Training                            I
                                                  Clinical Phannacologv   IRecoverv       Care                        .


Adapted Jrom the American Society of Anesthesiologista                                           Made Possible   through a grant from:
Guidelines on Sedation and analgesia by Non-Anesthesiologista
                                                                                      f    .     RocheLaboratories
                                                                                            e A Member of the Roche Group

                                                                                                 Roche Laboratories Inc.
                                                                                                 340 KiDpland Street
                                                                                                 Nut1ey. New Jeney 07110-1199

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