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Conscious (iv) sedation

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  • 1. Conscious (IV) Sedation Intravenous sedation is defined as a medically controlled state of depressed consciousness with or without analgesia that: • allows protective reflexes to be maintained, • retains patient’s ability to maintain a continuously independent patent airway, and • permits appropriate response by the patient to verbal command or physical stimulation Intravenous sedation and analgesic agents are to be given in small incremental doses that are titrated to the desired end- points of sedation and analgesia
  • 2. Conscious Sedation (continued) Groups of drugs used for this purpose include:  Sedatives • Benzodiazepines  Hypnotics • Antihistamines  Anti-anxiety • Narcotics The pharmacologic agents’ intended uses are for short-term therapeutic, diagnostic, or surgical procedures Sufficient time must elapse between doses to allow the effect of each dose to be assessed before subsequent drug administration IV Fentanyl is not administered by nurses at WCMC
  • 3. Conscious Sedation (Competency) Physicians and CRNA’s managing the care of patients receiving intravenous sedation for a procedure must be competent to manage complications related to the administration of Intravenous sedation Anesthesiology credentials physicians and CRNA’s Patients receiving sedation and analgesia for a procedure (such as endoscopy, cardioversion, heart cath, placement of chest tube, etc.) are given the medication and monitored by a registered nurse (RN) who has demonstrated current competency in the administration of Intravenous sedation
  • 4. Conscious Sedation (Competency)Current competency for RNs includes: Knowledge of anatomy and physiology Successful completion of ACLS and BLS courses Knowledge and skills to assess, diagnose, and intervene in the event of complications or undesired outcomes, and ability to institute intervention in compliance with orders (including standing orders); Administration of sedation and analgesic agents: to include physiological and desired effects, medication uses, dosages, routes and speed of administration, contraindications, recognition and management of adverse or side effects, and use of drug antagonists
  • 5. Conscious Sedation (Competency)The RN must:  Understand the principles of oxygen delivery, respiratory physiology, oxygen transport and uptake, & demonstrate ability to use oxygen delivery devices;  Demonstrate the knowledge of legal ramifications of intravenous sedation and analgesia and/or monitoring patients receiving sedation and analgesia, including the RN’s responsibility and liability in the event of an untoward reaction or life-threatening complication;  Assess total patient care requirements during sedation and analgesia and recovery
  • 6. Conscious Sedation (Staffing) Staffing during intravenous and deep sedation for procedures always includes one RN and one MD at a minimum Additional staff is obtained as indicated according to the acuity of the patient procedure and potential response to the medications administered The RN monitoring the patient does not engage in any other tasks that would compromise the ability to assess and monitor, care for patient, intervene as needed, and be in constant attendance
  • 7. Conscious Sedation (continued) Physiologic measurements include, but are not limited to: • Respiratory rate • Oxygen saturation • Blood pressure • Cardiac rate and rhythm • Level of consciousness • Level of sedation The RN administers the prescribed medication under the direct supervision of the physician In the instance a qualified registered nurse is unavailable to administer the agent, the physician is responsible for administering the agent
  • 8. Conscious Sedation (Medications) The pharmacological agents used to produce Intravenous sedation/analgesia during procedures include these selected benzodiazepines and opiates, but are not limited to: • Valium (diazepam) • Versed (midazolam) Benzodiazepines • Ativan (lorazepam) • Morphine • Demerol (meperidine) Opiates These selected medications are dose and patient dependent and are usually titrated to the desired effect
  • 9. Conscious Sedation (Equipment)The following equipment is readily available whenadministering conscious sedation. Supplemental oxygen and accessibility of delivery devices (nasal cannula, venturi mask, non-rebreather mask, bag-valve-mask-device, intubation equipment ) Crash cart with available defibrillator, emergency medications, airway adjuncts, and the ability to provide 100% oxygen Benzodiazepine Antagonist (Romazicon) and Opiate Antagonists (Narcan) readily available Monitors for noninvasive or invasive blood pressure; continuous cardiac rhythm and pulse oximetry
  • 10. Conscious Sedation (Pre-procedure)Before the procedure there is a history and physical completedby the physician. Exception: in emergent situations, an acceptable history and physical for the procedural purpose may be limited to major significant conditions requiring intervention Patients should be NPO 6 hours prior to administration of sedation if procedure is elective Medications may be given with 30ml of water or less if ordered The patient will have continuous intravenous access prior to the administration of any sedation/analgesia agent and until the patient meets discharge criteria
  • 11. Conscious Sedation (Pre-procedure)Nursing assessment is to include, but is not limited to Procedure to be performed Complete vital signs Pulse oximetry Level of consciousness General physical assessment Allergies with reaction Current medication Time of last PO intake (should be fasting at least 6 hours is elective) Past medical history
  • 12. Conscious Sedation (Intra-procedure)Assessment and documentation is to include: Time procedure began and completed Medications along with assessment of effects of medication Cardiac rate and rhythm, respiratory rate, blood pressure, and pulse oximetry must be documented at regular intervals during the procedure (a minimum of every 15 minutes and PRN as the condition requires)
  • 13. Conscious Sedation (Intra-procedure)Monitoring continuously throughout the procedure: Continuous pulse oximetry with visual and auditory displays Level of consciousness (LOC) documented every 15 minutes Use of supplemental oxygen Hypersensitivity reactions* Documentation is required for intervention needed to support any of the above parameters - the physician must be notified of significant deviations, including adverse effects of medication
  • 14. Conscious Sedation (Post-procedure)Assessment and documentation is to include: Activity, oxygenation (to include pulse oximetry), circulatory, and LOC, every 15 minutes until sedation/analgesia score = 9 or above When the sedation/analgesia score is 9 or above, patient may be transferred to another unit unless the patient is to be discharged from the hospital Hence, the patient must be monitored for at least one hour and have a responsible party to drive patient home When an antagonist is administered, the patient must be monitored for two hours from the last dose of the antagonist
  • 15. Conscious Sedation (continued) Additional and more frequent monitoring is dictated by patient condition or at the discretion of the physician, and may be unit-specific Assess and document safety precautions with side rails up and in place Prior to discontinuing post-operative monitoring, the patient’s vital signs must be stable as compared to baseline pre-procedure readings If the patient is to be discharged post procedure written discharge instructions pertaining to post sedation home care are provided

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