Minimal Sedation (Anxiolysis)

These guidelines are designed to be applicable to procedures performed in a variety of settings by practitioners who are not specialists in anesthesiology.The purpose of these is to allow clinicians to provide their patients with the benefits of sedation /analgesia, while minimizing associated risks.These guidelines are intended to be general in their application and broad in scope.

• These guidelines are designed to be applicable to procedures performed in a variety of settings by practitioners who are not specialists in anesthesiology.The purpose of these is to allow clinicians to provide their patients with the benefits of sedation /analgesia, while minimizing associated risks.These guidelines are intended to be general in their application and broad in scope.

Minimal Sedation (Anxiolysis)

• Minimal Sedation (Anxiolysis)

• - is 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.

Moderate Sedation/Analgesia (Conscious Sedation)

• Moderate Sedation/Analgesia (Conscious Sedation)

• - is a drug induced depression of consciousness during which patients respond purposefully* to 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 maintained.

Deep Sedation/Analgesia

• Deep Sedation/Analgesia

• - is drug induced loss of consciousness during which patients cannot be easily aroused but respond purposefully* following repeated stimulation. The ability to independently maintain ventilatory function is often impaired.Patients may require assistance in maintaining a patent airway and positive pressure ventilation may be required. Cardiovascular function may be impaired.

General 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 is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required. Cardiovascular function may be impaired.

Protective airway reflexes-includes the ability of an individual to counteract noxious events, especially to defend breathing passages against foreign material.

• Protective airway reflexes-includes the ability of an individual to counteract noxious events, especially to defend breathing passages against foreign material.

• Reflex withdrawal from a painful stimulus is NOT considered a purposeful response

• Sedation is a continuum, it is not always possible to predict how an individual will respond.

• Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended.

Radiology Department

• Radiology Department

• Medical Special Procedures

• Dental Clinic

• Emergency Department

• Progressive Care Units

• Procedure Unit E-Yellow

History/ Physical exam

• History/ Physical exam

• Airway evaluation

• Abnormalities of the major organ systems

• Previous adverse experience with sedation

• Drug allergies, current meds.,potential interaction

• Focused physical exam- vital signs, auscultation of heart and lungs, evaluation of the airway

• NPO status

• Lab data

Class I- normal, healthy

• Class I- normal, healthy

• Class II- mild systemic disease

• Class III- severe systemic disease, e.g. HTN COPD,

• Class IV-severe systemic disease that is a constant threat to life, e.g. unstable angina

• Class V- moribund patient not expected to live with or without the procedure

ASA class III or higher

• ASA class III or higher

• Airway abnormalities

• Morbid obesity

• Sleep apnea

• Previously failed sedation

• Major allergy or anaphylactic reaction

Informed consent

• Informed consent

• Pre op fasting

• Clear liquids 2h
• Breast milk 4h
• Infant formula 6h
• Milk 6h
• Light meal 6h

Self inflating bag and mask

• Self inflating bag and mask

• Oxygen – 2 outlets

• Suction ( working )

• Pulse oximeter, ECG monitor, BP. Monitor

• ? Capnometer

• Pharmacologic antagonists

• Emergency equipment – airway kit (age appropriate) crash cart, defibrillator

Pre-procedure

• Pre-procedure

• -V.S., SpO2

• Procedure

• -Continuous SpO2, E.C.G.

• -V.S. q 5 min.

• -L.O.C. q 5 min.(level of consciousness)

• Post Procedure

• -Continuous SpO2, V.S. q 5 min. for 15 min., then q 15 min. until discharge criteria met

The minimal number of available personnel should be two:

• The minimal number of available personnel should be two:

• The operator (performs procedure)

• The monitor (administers drugs, monitors airway and vital signs.

• The second individual may assist with minor interruptible tasks.

• Both personnel must be credentialed in Moderate Sedation/ Analgesia

Personnel who can administer Moderate Sedation/ Analgesia or monitor a patient, include:

• Personnel who can administer Moderate Sedation/ Analgesia or monitor a patient, include:

• - A physician, or dentist who has been credentialed

• Under the supervision of the above, the following persons may administer M.S.

• - CRNA, or a student CRNA,

• - resident physician or resident dentist

• -registered nurse, under special situations.

Individuals responsible for patients should understand the pharmacology of agents used for sedation and antagonists for opiates and benzodiazepines.

• Individuals responsible for patients should understand the pharmacology of agents used for sedation and antagonists for opiates and benzodiazepines.

• Individuals monitoring patients should be able to recognize associated complications.

• One individual capable of estabilishing a patent airway and positive pressure ventilation should be present.

• All personnel must be ACLS certified.

Patients will be discharged according to the Aldrete score. The patients must have a score of ten.

• Patients will be discharged according to the Aldrete score. The patients must have a score of ten.

• Aldrete score is printed at the end of the Moderate sedation/Analgesia record

• Patients who receive reversal agents need to remain in the procedure area for at least one hour after the last dose.

Meperidine (Demerol)

• Meperidine (Demerol)

• Morphine

• Fentanyl (Sublimaze)

• Ketamine

• Diazepam (Valium)

• Midazolam (Versed)

• Droperidol (Inapsine)

• Phenobarbital

Drugs EXCLUDED for M.S./ Analgesia by non-anesthesia staff are:

• Drugs EXCLUDED for M.S./ Analgesia by non-anesthesia staff are:

• Sodium Thiopental

• Propofol

• Brevital (metho hexital)

• Etomidate

• Sufentanil

• Remifentanil

IV.drugs should be given in small, incremental doses, titrated to end points of analgesia/sedation.

• IV.drugs should be given in small, incremental doses, titrated to end points of analgesia/sedation.

• Allow time for onset before repeating

• Benzo. and opiates have synergistic effects

• Non IV routes, eg. Oral,rectal,im.,tm.-allow adequate time for absorption. Repeat doses not recommended(unpredictable absorption)

Effects of Benzodiazepine and Opiate are additive (synergistic)

• Effects of Benzodiazepine and Opiate are additive (synergistic)

• For example, 2 mg. Midazolam or 10 mg. Morphine equals no apnea

• 1 mg Midazolam plus 5 mg morphine equals apnea

Low cardiac output equals slow onset

• Low cardiac output equals slow onset

• Consider the age of the brain

• Consider the physical condition of the patient

• What effect is desired?

• Is post-procedure pain control needed?

• When in trouble, back out

• Titrate drugs to effect, wait for onset.

Specific antagonists, naloxone/flumazenil should be available

• Specific antagonists, naloxone/flumazenil should be available

• May be administered if apnea or hypoxemia develops, but routine use is strongly discouraged.

• Patients need to be observed longer in recovery (at least 2 hrs.) if reversal agents are used.

Dose-dependent binding to opioid receptors (especially mu) leads to:

• Dose-dependent binding to opioid receptors (especially mu) leads to:

• Analgesia
• Sedation
• Respiratory Depression

• Side effects:

• Nausea/vomiting
• Miosis
• Decreased Peristalsis

Average Dose: 5-15 mg

• Average Dose: 5-15 mg

• Incremental Dose: 2.5 mg

• Time Between Doses: 5-10 min

• Onset Time: 5-10 min

• Duration of Effect: 3-4 hrs

• Paradoxical Reaction

• Pruritis

• Anaphylactoid Reaction

• Active Metabolites

Average Dose: 50-150 mg

• Average Dose: 50-150 mg

• Incremental Dose: 25 mg

• Time Between Doses: 5 min

• Onset Time: 3-5 min

• Duration of Effect: 2-3 hrs

• Caution: Not used with MAO Inhibitors, Antidepressants, Antiparkinsonian drugs

• Remember “Libby Zion”

• Active Metabolite can accumulate with renal dysfunction

Enhance GABA transmission in CNS

• Enhance GABA transmission in CNS

• Most are lipid soluble only (except midazolam)

• Effects:

• Amnesia
• Anticonvulsant
• Anxiolytic
• Behavioral disinhibition
• Muscle relaxant

Average Dose: 5-20 mg

• Average Dose: 5-20 mg

• Incremental Dose: 2.5 mg

• Time Between Doses: 2-3 min

• Onset Time: 1-2 min

• Duration of Effect: 0.5-2 hrs

• Several active metabolites prolong effects

• Elimination t1/2 15-21 hrs

Average Dose: 1-5 mg

• Average Dose: 1-5 mg

• Incremental Dose: 0.5-1 mg

• Time Between Doses: 3-5 min

• Onset Time: 3-5 min

• Duration of Effect: 0.5-2 hrs

• Water and lipid soluble

• Active metabolites, which are less potent

• Elimination t½; 2-4 hrs

Sedating antihistamine with anticholinergic properties

• Sedating antihistamine with anticholinergic properties

• PO/IV/IM

• Maximum sedative effect 1-3 hrs, duration; 4-7 hrs

• Elimination t1/2: 2-8 hrs

Average Dose: 0.025-0.15 mg

• Average Dose: 0.025-0.15 mg

• Incremental Dose: 0.025 mg

• Time Between Doses: 2-3 min

• Onset Time: 1-2 min

• Duration of Effect: 0.5- 1 hrs

• Elimination t1/2: 3.1-6.6 hrs

• May cause muscle rigidity

Reversal of opiates

• Reversal of opiates

• Side effects:

• Pain
• Hypertension
• Tachycardia
• Ventricular dsyrhythmias
• Pulmonary Edema
• Re-narcotization –Delayed respiratory depression

Average Dose: 0.4 mg

• Average Dose: 0.4 mg

• Incremental Dose: 0.04 mg

• Time Between Doses: 2-3 min

• Onset Time: 1-2 min

• Duration of Effect: 0.5-1 hrs

Average Dose: 1 mg

• Average Dose: 1 mg

• Incremental Dose: 0.2 mg

• Time Between Doses: 1 min

• Onset Time: 1-2 min

• Duration of Effect: 0.5-1.5 hrs

• Resedation

• Seizures

All departments are responsible for PI activities related to moderate sedation

• All departments are responsible for PI activities related to moderate sedation

• Data collection monthly, quarterly reporting of complications on 6 PI indicators

• All complications must be reported to Department of Anesthesiology PI representative A copy of the record needs to be sent to Dr. A Patel

• Moderate sedation data is presented at the Invasive Procedure Committee and Hospital PI committee

Respiratory complications- need for oral airway, bag mask ventilation, intubation etc.

• Respiratory complications- need for oral airway, bag mask ventilation, intubation etc.

• Cardiovascular complications- hypotension, arrythmias, etc.

• Use of reversal drugs

• Admission to hospital,if outpatient

• Pre sedation evaluation done

• Discharge criteria documented