2. OBJECTIVES
• Understand levels of (nurse monitored)
sedation
• Know who can give sedation
• Know how to find out
• Know what your responsibilities are
• Know what equipment is needed
• RN responsibility
• Know where to get help
3. Levels of Sedation/Analgesia
(Nurse Monitored)
• Minimal Sedation (Anxiolysis)
– First or lowest level of sedation.
– 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.
4. • Moderate Sedation/Analgesia
(Conscious Sedation)
– 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.
Levels of Sedation/Analgesia
(continued)
5. • Deep Sedation/Analgesia
A drug-induced depression of consciousness during
which patients cannot be easily aroused but respond
purposefully following repeated or painful
stimulation. Reflex withdrawal from a painful
stimulus is not considered to be a purposeful response.
The ability to independently maintain ventilatory
function may be impaired.
Patients may require assistance in order to maintain a
patent airway.
Spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.
Levels of Sedation/Analgesia
(continued)
6. • Anesthesia
– Is the last, or deepest level of sedation.
– Must be provided by an anesthesia
provider (CRNA or anesthesiologist).
– Consists of general, spinal or major
regional anesthesia.
Levels of Sedation/Analgesia
(continued)
7. Sedation-to-anesthesia is a
continuum
Per JCAHO: Any medication which is used for the purpose
of inducing moderate sedation, or any medication, which
when used results in a level of moderate sedation would
be subject to the standards for moderate or deep sedation.
• Because the response to procedures and medications is
not always predictable, it is not always possible to
predict how an individual patient will respond
• Patient safety should guide the decision to consider if it
is sedation or not
8. Who can give sedation?
• “Individuals administering moderate or deep
sedation and anesthesia are qualified and have
the appropriate credentials to manage patients
at whatever level of sedation or anesthesia is
achieved, either intentionally or
unintentionally.” JCAHO Standard PC 13.20
• “Each patient’s moderate or deep sedation care
shall be planned by a qualified individual”
• Physicians must be credentialed by the hospital
& Medical Staff to give moderate or deep
sedation
9. Provider Qualifications
The individuals providing moderate or deep sedation and
anesthesia have at a minimum had competency-based
education, training, and experience in the following:
– Evaluation of patients prior to the sedation
– Methods and techniques required to rescue those patients
who unavoidably slip into a deeper level of sedation or
anesthesia
– Re-evaluation of the patient IMMEDIATELY before the
use of sedation
– Planning for the appropriate level of post-procedure
care.
– Administration of pharmacological agents predictably
achieve the desired level of sedation
10. How do I find out?
• A list of credentialed physicians is
available in the medical staff office and
from the PCC. Should also be available in
the unit’s Sedation binder.
11. Before the Procedure
• Physician plans level of sedation
• Physician documents H & P (on the chart)
• Informed consent obtained
• Post procedure care & assessment is planned for
• Re-assessment is done just prior to procedure, with
appropriate documentation of:
– H & P update
– Airway assessment
– Planned sedation level
– Physical (heart & lungs) & mental status assessed
– Informed Consent verification
• Adherence to the Universal Protocol
12. RN qualifications to monitor
Patient during Sedation
• Must maintain yearly airway & CPR
competency
• Must be familiar with monitoring equipment
• Must be familiar with the basic pharmacology
of the agents to be used
• Must follow “Medication Safety” and
“Medications, Approved List for
Administering Intravenous” policies
13. • Make sure to refer to the Policy “Medications,
Approved List for Administering Intravenous”
• Physician MUST be present when sedation is
given
• FENTANYL & VERSED REQUIRE
SPECIFIC EDUCATION/COMPETENCY
before it can be given by an RN
• Fentanyl can only be given in Critical Care and
Surgical settings
• Brevital & Propofol can be given ONLY by the
Physician
Specific Medication
Considerations
14. What equipment do I need?
• Oxygen
• Suction
• Ambu-bag
• Code cart and defibrillator
• Reversal agents romazicon or narcan
• Monitoring devices oximeter, B/P cuff,
cardiac monitor if required by patient condition
15. Pre-Procedure RN Responsibilities
• Assessment: VS, LOC, understanding of procedure
that H & P is available
• Ensure immediate availability of emergency
equipment & meds
• Ensure that post-procedure recovery has been
planned for
• Patient/family education
• Verify last oral intake
• Assure vascular access
• Know the drugs and
policies!
• Complete Universal Protocol checklist, including
consent verification
16. Intra-Procedure RN Responsibilities
• Do “time out” just prior to procedure
• Have no other responsibilities other than monitoring
the patient
• Administer meds within hospital policy
recommendations, in small, incremental doses,
titrated to effect.
• Administer Oxygen as needed/ordered
• VS, LOC every 5 min. Use Modified Ramsey Scale
• Document response to meds, complications,
interventions, etc.
17. Post-Procedure RN Responsibilities
• Directly monitor the patient until “discharge” criteria met (see
policy)
– Easily aroused & oriented (or at baseline)
– Can cough & swallow
– VS stable & O2 sat >92% on room air or O2 ordered,
Aldrete score > 8
– It has been >30 min since last dose of sedating medication
– It has been >45 minutes since given narcan or romazicon (or
2 hours if romazicon was given for valium, ativan or >10 mg
versed)
• Document assessment and discharge instructions if applicable
• Make sure that physician documents orders for all medications
given
18. Documentation
• Use sedation analgesia (or unit
specific) flow sheet
– Pre-procedure assessment & care
– Intra-procedure VS, LOC, pain,
medications
– Post-procedure Aldrete score,
discharge/safety instruction
• Universal Protocol Checklist
• Complete Audit Tool and give to
manager after any adverse event.
19. Champlain Valley Physicians Hospital Medical Center
PROCEDURAL SEDATION FLOWSHEET – NON-SURGICAL SETTING
Date:________________________________ Procedure:_________________________________________________
Physician performing sedation:____________________ Physician performing procedure:________________________
Nursing Pre-Procedure Care/Assessment Physician Drug Orders
Time Drug/Dose/RoutePatient weight: kgs
Last meal/drink: ___________hours ago
Allergies/Sensitivities:______________________________________
“Time Out” verification immediately pre-procedure Time/Initials
Correct patient identity _________
Agreement on procedure _________
Correct side & site (MD to initial same, unless N/A) _________
Correct patient position _________
Availability of special equipment _________
(See Procedural Sedation Checklist)
(Record Vital Signs (SpO2 , Pulse, Resp, BP) and LOC (Modified Ramsey Scale, see back) 5 minutes after administering IV drug, and every 5
minutes up to 30 after last dose given or until all vital signs and LOC are back to baseline)
Intra-Procedure Nursing Documentation of Care
Time Drug: Dose/Route/Administered By SpO2 P R BP LOC*
O2
LPM
Comments
Baseline data immediately pre-procedure:
Post-Procedure Nursing Documentation of Care
Vital signs and LOC (*Modified Ramsey Scale) at end procedure and end sedation protocol are documented above
See Additional Nurses Notes on T Sheet (ECC only)
Discharged and/or Protocol dc’ed @ (time)
PATIENT:
Aldrete Score: (must be > 8)
Able to dress/ambulate consistent w/age (ECC)
PATIENT LABEL
RN signature: ____________________________MD signature: ___
Form # 100S1 revised 7/07
New
Flow
Sheet
Time
Out
Section
Physican
Order
Section
(can be used as
orders if doc
signs bottom)
20. Joint Commission Requirements
Monitoring of Adverse Events Related to Sedation
(PI 01.01.01 EP 6 and LD 04.04.04 EP 2)
Sedation provided by a non-Anesthesiologist is considered a
high risk procedure, because an Anesthesiologist is not
present if the patient loses their airway.
All adverse events related to sedation must be reviewed.
Upon an adverse event occurring, the RN in the procedural
area will document the adverse event, report the adverse
event to their immediate supervisor, and complete their
department-specific QA Monitoring Tool.
21. What are Adverse Events?
• Initiation of bag valve mask
• Reversal agents administered in a rescue
attempt
• Patient turned over to anesthesia staff
• Unplanned intubation
• Unplanned admission related to the use of
sedation
22. HELP!
• Policy
– “Moderate or Deep
Sedation/Analgesia
Administered /Directed by
Non-Anesthesiologists”
• PCC
• Unit reference binder
• Unit Management,
Clinical Education
Managers
• IV Therapy/Resource
Nurse
23. References
• CVPH Medical Staff Policy: Sedation/Analgesia for
Diagnostic or Therapeutic Procedures
• CVPH Administrative Policy: Moderate or Deep
Sedation/Analgesia Administered/Directed by a
Non-Anesthesiologist
• CVPH Policy: Medications, Approved List for
Administering Intravenous
• CVPH Policy: Obtaining Informed
Consent
• JCAHO Standards 2012
• CBO Credentialing Program, ASPAN 2002
