Sedation monitoring and post sedation recovery and discharge

1. Sedation Monitoring and Post-sedation
Recovery and Discharge

2. Key Principles of Procedural Sedation
and Analgesia
• Determine appropriate level of sedation
desired
• Have appropriate monitoring and rescue
equipment
• Administer analgesic before sedative
• Titrate agents to desired level of sedation
• Observe and monitor until recovery to
baseline mental status

3. Equipment and Supplies
Recommendations
• Intravenous equipment
• Basic & advance airway management
equipment
• Pharmacologic antagonist
• Emergency medication

4. Procedural Sedation Monitoring
• Interactive monitoring
• Mechanical monitoring

5. Procedural Sedation Monitoring
• Interactive monitoring:
Direct observation of patient to access
- Depth of sedation
- Respiratory function & Hemodynamics
Unobstructed view of the
patient’s face, mouth,
chest wall

6. In patients undergoing procedural sedation and
analgesia in the emergency department,
what is the minimum number of personnel
necessary to manage complications?

7. • Mostly, one clinician performs the
procedure while another (usually a
nurse) observe and continuously
monitor the patient
Level C recommendations
Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department
Ann Emerg Med. 2014;63:247-258.

8. Monitoring Depth of sedation
• Check response to verbal commands
• If verbal response is not possible, “thumbs up”
• Deep sedation: response to a more profound
stimulus
• Response limited to reflex withdrawal from a
painful stimulus is not considered a
purposeful response

9. Scale monitoring depth of sedation
Moderate sedation: Do not exceed level 4
Deep sedation score: Level 5

10. Regular patient monitoring is more important
than the application of scales

11. Bispectral Index monitoring
• uses processed electroencephalogram signals
to measure the depth of sedation
• 100 = complete alertness,
• 0 = no cortical activity at all
• 40 - 60 is believed to be consistent with GA

12. Monitoring
• Interactive monitoring
• Mechanical monitoring

13. Mechanical Monitoring
• Arterial oxygenation
• Ventilation
• Vital sign
• ECG monitoring

14. Arterial oxygenation
• Pulse oxymetry is not a substitute for
monitoring ventilation
• Hypoventilation or apnea develop before
oxygen saturation decreases especially
“Patient who receive supplemental oxygen”

15. Ventilation
• Capnography
• ETco2 correlates with arterial Pco2
• ETco2 > 50 mmHg or ↑>10 mmHg
indicates hypoventilation

17. In patients undergoing procedural sedation and
analgesia in the emergency department,
Does the routine use of capnography
reduce the incidence of adverse
respiratory events?

18. Level B recommendation
• Capnography* may be used as an adjunct to
pulse oximetry and clinical assessment to
detect hypoventilation and apnea earlier than
pulse oximetry and/or clinical assessment
alone in patients undergoing procedural
sedation and analgesia in the ED.
• Capnography includes all forms of quantitative
exhaled carbon dioxide analysis.

19. Vital Signs
• Before the procedure
• After each dose of sedative
• Regular intervals during the procedure
• During initial of recovery period
• Before discharge

20. Recommendations
Level of
Sedation
LOC Heart Rate Respiratory
Rate
BP O2
Saturation
Capno
graphy
Minimal Observe
frequently
q 15 min q 15 min q 15 min
and after
sedative
boluses
Continuously -
Moderate
or
Dissociative
Observe
constantly
Continuously Continuous
direct
observation
q 5 min
& after
sedative
boluses
Continuously Consider
continuously
Deep Observe
constantly
Continuously Continuous
direct
observation
q 5 min
& after
sedative
boluses
Continuously Recommend
continuously
If recording is performed automatically,
Device alarms should be set to alert

21. Cardiac monitoring
Recommended for:
• Preexisting cardiac disease
• Dysrhythmias
• During procedures in which the cardiac
rhythm is of interest

22. Post-Sedation Recovery
• Recovery and discharge under supervision of
operating practitioner or a licensed physician.
• A nurse or other individual should monitor
until appropriate discharge criteria are
satisfied
• Preparation for management of complications.

23. Observation Duration
• In most cases, prolong observation beyond 30
min is unlikely to be necessary
• Longer duration in patients who receive
reversal agents

24. Discharge Criteria
• Low risk procedure that additional monitoring is
un necessary.
• Symptoms should be well-controlled.
• Stable V/S and respiratory and cardiac function
• Alert and oriented or returned to baseline
• A reliable person who can provide support and
supervision at least a few hours.
• Scoring systems may assist in documentation.
• Patient instruction

26. 10/12 points required
before discharge

28. Pediatric Discharge Criteria
• Young infants or children who are
handicapped should return to the level of
responsiveness observed before sedation
• Because of the significant risk of apnea after
sedation, term infants with postconceptual
ages (PCA) ≤45 weeks and former premature
infants with PCA <60 weeks should undergo
prolonged observation of respiratory status
prior to discharge

29. Minimum Duration of Observation for
Infants
• All infants with PCA ≤45 weeks – 12 hours
• Pre-term infants with PCA 46 to 60 weeks and
significant comorbidities – 12 hours
• Healthy pre-term infants with PCA 46 to 60
weeks – 6 hours (12 hours if given opioids or
other medications with significant respiratory
depressant effects)

30. • Patients, who develop apnea during
observation, warrant prolonged observation
until they are free of apnea for at least 12
hours.
• In some patients with frequent apneic
episodes, caffeine administration may be
appropriate.

32. Any
Questions?
??

33. THANK YOU