I. Subject. Moderate Sedation
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- Virgil Dawson
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1 I. Subject II. III. Moderate Sedation Purpose To establish criteria for the monitoring and management of patients receiving moderate throughout the hospital Definitions A. Definitions of three levels of include the following: 1. Minimal (anxiolysis) A drug-induced state which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected. 2. Moderate /analgesia ( conscious ) 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 is. Cardiovascular function is usually maintained. 3. Deep /analgesia A drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous may be in. Cardiovascular function is usually maintained. B. American Society of Anesthesiology Physical Status Class 1. ASA-1: A patient with no organic, physiologic, biochemical, systemic, or psychiatric disturbance (i.e., an otherwise healthy patient) 2. ASA-2: A patient with mild systemic disease that results in no functional limitation (e.g., hypertension, diabetes, chronic bronchitis, mild to moderate obesity, extremes of age) 3. ASA 3: A patient with severe systemic disease that results in functional limitation (e.g., poorly controlled hypertension, diabetes mellitus with vascular complications, morbid obesity, angina pectoris, prior myocardial infarction, pulmonary disease that limits activity) 4. ASA-4: A patient with severe systemic disease that is a constant threat to life (e.g., congestive heart failure, unstable angina pectoris, advanced pulmonary, renal, or hepatic dysfunction)
2 IV. Policy A. Qualifications and Training for Administering and Monitoring Moderate Sedation 1. Practitioners administering moderate must be credentialed with appropriate clinical privileges by demonstrating knowledge of the management of patients at whatever level of is achieved, either intentionally or unintentionally. 2. Practitioners who have appropriate credentials and are permitted to administer moderate are qualified to rescue patients from moderate and are competent to manage a compromised airway and to provide oxygenation and. 3. Practitioners who have appropriate credentials and are permitted to administer deep are qualified to rescue patients from general anesthesia and are competent to manage an unstable cardiovascular system as well as a compromised airway and in oxygenation and. 4. Physician credentialing may be accomplished by reading the policy on moderate and by successfully passing the written examination on the proper use of moderate 5. All patients undergoing moderate must be monitored by a health professional with appropriate training and a current ACLS card. 6. All healthcare professionals responsible for managing the care of patients receiving IV moderate will complete and maintain competency in the skill. 7. This policy does not apply to the management of ventilated patients B. General Information 1. Selection and pre- evaluation of the patient who is to undergo moderate, is the responsibility of the physician performing the procedure. The physician must be present for the procedure or immediately available (on the immediate unit and not otherwise involved in another procedure). 2. Physicians are encouraged to notify Anesthesia for evaluation of patients that have been assessed with an ASA-4 or Mallampati Class 4. Airway History Considerations: a. History of difficult intubation b. History of head or neck radiation c. History of airway tumor d. History of prior tracheostomy e. History of sleep apnea
3 Airway Assessment (Mallampati score): Mallampati score is based on visualization of uvula and soft palate when the patient fully opens the mouth and extends the tongue. A Mallampati score of 4 is associated with difficult intubation and sleep apnea. Consider consultation with anesthesiology if any of the above airway history is positive or the patient has a class 4 Mallampati score. Mallampati Scoring Class 1: Full visibility of tonsils, uvula and soft palate Class 2: Visibility of hard and soft palate, upper portion of tonsils, and uvula Class 3: Soft and hard palate and base of the uvula are visible Class 4: Only hard palate is visible 3. All patients undergoing moderate should have intravenous access established 4. Moderate may be administered in areas where appropriately trained staff and equipment are available within the hospital. 5. All patients undergoing moderate will be observed and assessed for reactions to medication and for behavioral and psychological changes utilizing the Aldrete assessment scoring system. 6. The patient s response to care provided throughout the supported procedure is documented in the patient s record. 7. After meeting discharge criteria, patients will be released to a responsible person and receive follow-up instructions. If a patient's Aldrete score is 8 or below the physician must be notified and the patient cannot be discharged. C. Monitoring 1. Level of consciousness (LOC) Moline - Roberts Pharmacologic Sedation Scale 9/08 The purpose of this scale is to aid the decision-making process regarding administration of opioids and sedatives. Do not use this scale for any patient with neurological impairment which prevents normal response to a stimulus or ability to follow commands. At all times, the individual s
4 physiologic status and unique response to opioids/sedatives must be included in the decision process. Presen tation Audi tory Stim ulus Tact ile Stim ulus Resp onse Sed ation ACTI ON for Attentiv e Pain Manage ment ACTION for Moderate Sedation/An algesia Awake, aware, alert Restful, drowsy, dozing, lightly sleeping None None Spontan eous, sustained interaction Soft voice or Ambient noise Soft to normal voice None or light touch, rubbing or tapping Light touch, rubbing or tapping Sustains interaction Limited or brief interaction 1 None to Minimal 2 Anxioly sis 3 Modera te Sedation May increase opioid dose if pain rating greater than goal May increase opioid dose if pain rating greater than goal Conside r if evaluation of pain plan is appropriate May provide May provide if level greater than 2 is desired May provide if level greater than 3 is desired Airway and may be impaired Normal to loud voice Loud voice Light touch, rubbing or tapping Intens e to noxious Follows simple commands Purpose ful response or nonpurposeful movement 4 Modera te Sedation 5 Deep Evaluat e pain plan Exceptio n: patient in critical care environment Decrea se or stop opioids/seda tives Monitor airway and, support if needed Consid er reversal, RAT or Code Blue Excepti on: patient in critical care environment Titrate medication to prevent deeper No further Monitor airway and, support as needed Consider reversal, RAT, Code Blue Airway and likely impaired Loud voice Noxiou s No response, unarousable 6 Genera l Anesthesia Stop opioids/seda tives Continu ally monitor airway and, support if needed No further Continually monitor airway and Provide reversal Consider RAT, Code Blue
5 Provide reversal Initiate RAT or Code Blue Excepti on: patient in critical care environment Copyright 2008 Poudre Valley Health System Patients responses to verbal commands during a procedure performed with /analgesia serve as a guide to their LOC An appropriate LOC implies that patients will be able to control their own airways and take deep breaths as necessary LOC should be assessed at 1-minute intervals during the onset of and whenever medications are being titrated 2. Pulmonary Ventilatory function may be monitored through observation of spontaneous respiratory activity or continuous auscultation of breath sounds 3. Oxygenation Pulse oximetry should be used on a continuous basis in order to provide the earliest warning of hypoxemia 4. Hemodynamics Blood pressure (BP) and heart rate (HR) should be measured at frequent intervals especially during the onset of / analgesia Baseline BP and HR should be obtained and recorded prior to the initiation of During the onset of, BP and HR should be read at 1- or 2- minute intervals During the procedure, after a stable level of moderate has been established, BP and HR readings should be taken every 5-10 minutes BP and HR should be recorded at the end of the procedure and again prior to discharge 5. ECG monitoring EKG is monitored in patients with significant cardiovascular disease or when dysrhythmias are anticipated or detected.
6 D. Pharmacologic Agents 1. All personnel involved in the administration of intravenous moderate should be familiar with the dosages and side effects of the sedatives, opioids, and reversal agents used. 2. Intravenous drugs initial doses: Midazolam: mg Diazepam: mg Fentanyl: mcg Morphine: 1-2 mg Flumazenil: 0.2 mg slow push Naloxone: mg Exact dosing will be dependent upon patient's weight and use at the discretion of the supervising physician. 3. Supplemental oxygen Supplemental oxygen via nasal cannula or face mask, should be administered to all patients undergoing moderate E. Emergency Equipment 1. Size- and age-appropriate airway equipment should be immediately available. 2. Size- and age-appropriate intravenous equipment should be immediately available. 3. A cardiac defibrillator should be immediately available 4. Suction equipment should be immediately available F. Documentation Requirements 1. Risks of moderate and options are documented as part of informed consent 2. History and Physical as required by the Medical Staff Rules and Regulations 3. Symptoms and indications for performing the described procedure 4. Allergies 5. Mental status assessment 6. Heart and lung auscultory examination 7. ASA Physical Status and Mallampati score 8. Current medications 9. Informed consent
7 10. Patient education re: the proposed procedure 11. Pre-procedure vital signs (BP, HR, RR, temperature, SpO 2 ) 12. Physician post-procedure note V. References Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.
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