This document provides information about procedural sedation, including the different levels of sedation from minimal to general anesthesia. It discusses who is allowed to administer various levels of sedation according to Oklahoma regulations. The responsibilities of sedation nurses during the pre-procedure, intra-procedure, and post-procedure periods are outlined. Common sedation medications like Versed, Fentanyl, Demerol and Diprivan are described along with their properties, dosages and side effects. The synergistic effects of combining sedation medications are noted as increasing risks. Finally, patient factors that could increase sedation risks are listed.

1. Procedural Sedation
By Sandy McLellan, RN, CGRN
Norman Endoscopy Center

2. primun non nocere
First, Do No Harm

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OBJECTIVES
Understand levels of procedural sedation
Know who can administer sedation
Know what your responsibilities are
Know what equipment is needed
Responsibilities in the procedure room
Know the properties of the medications given
for sedation
• Understand synergistic effects of medications
• Patient populations who may be at greater risk
for complications

4. These patients and their safety
are in our hands
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We must screen
We must monitor
We must have procedures in place to correct
We must be prudent in our sedation and
zealous in our monitoring

5. Levels of Sedation
• Minimal Sedation (anxiolysis)
– First or lower level of sedation
– A drug-induced state during which patients respond
normally to verbal commands
– Although cognitive function and coordination
function may be impaired, ventilatory
and cardiovascular functions are
unaffected

6. Moderate Sedation / Analgesia
• Also called 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.

7. Deep Sedation / Analgesia
• A drug-induced depression of consciousness
during which patients cannot be easily
aroused by repeated or painful stimulation.
Reflex withdrawal from a painful stimulus is
not considered to be 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

8. General Anesthesia
• Deepest level of sedation
• A drug-induced depressed level of consciousness
where patients are NOT arousable, even with
painful stimuli
• Airway often requires intervention and
spontaneous ventilation is often inadequate.
• Cardiovascular function may be impaired.

9. Continuum of Depth of Sedation
Minimal
Sedation
(“Anxiolysis”)
Moderate Sedation /
Analgesia
(“Conscious Sedate”)
Deep Sedation /
Analgesia
General
Anesthesia
Responsiveness
Norman response
to verbal
stimulation
Purposeful* response to
verbal or tactile
stimulation
Purposeful*
response following
repeated or painful
stimuli
Unarouseable, even
with painful
stimulation
Airway
Unaffected
No intervention
required
Intervention may
be required
Intervention often
required
Spontaneous
Ventilation
Unaffected
Adequate
May be inadequate
Frequently
inadequate
Cardiovascular
Function
Unaffected
Usually maintained
Usually maintained
May be impaired
*Reflex withdrawal from a painful stimuli is NOT considered a purposeful response
Sedation is a continuum and a patient can easily sleep into a deeper level of
sedation. Therefore, the person administering sedation should know how to
rescue the patient who slips into a deeper level.

10. Who Can Administer Sedation?
• Oklahoma Board of Nursing regulates which
nurses can administer sedation in the state of
Oklahoma
– An LPN cannot administer sedation medications but
can monitor a patient who has been sedated
– An trained RN can administer minimal and moderate
sedation under the direction of a licensed physician.
Must maintain current BLS and ACLS certification.
They should not administer deep sedation and the
OBN clearly states that they cannot administer
anesthesia
– Anesthesia can only been administered by licensed
CRNA

12. What are the responsibilities of
sedation nurse?
• Assessment: VS, LOC, understanding of procedure
• Review patient medical history and medication
list, ensure patient is a candidate for procedure
• Ensure immediate availability of emergency
equipment & medications
• Educate patient of recovery process and home
care
• Verify last oral intake
• Assure vascular access
• Know the properties of medications that will be
given

13. Intra-Procedure Sedation Nurse
Responsibilities
• Do “time out” just prior to procedure. Utilize Safe
Surgery Checklist to ensure necessary checks have
occurred
• Have no other responsibilities other than monitoring
the patient
• Administer meds by following procedure policy
recommendations, in small, incremental doses, titrate
to effect
• Administer Oxygen as needed/ordered
• VS, LOC at least every 5 minutes
• Document response to
meds, complications, interventions, etc.

14. Post-procedure Sedation Nurse
Responsibilities
• Ensure all procedural documentation is
completed
• Take patient to recovery room, when stable
• Document patient assessment upon arrival to
recovery room
• Give report to nurse assuming patient’s care

15. What Equipment Do I Need?
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Oxygen
Suction
Ambu-bag
Airways
Crash cart with AED
Sedation medications
Reversal agents
Monitoring devices
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Pulse oximeter
B/P cuff
Cardiac monitor
CO2 monitor (with anesthesia)

16. Medications used for Sedation
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Versed (midazolam)
Fentanyl (sublimaze)
Demerol (meperidine)
Diprivan (propofol)

18. Versed (midazolam)
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Water soluable
Amnesic effect
Reduces anxiety
No analgesic properties
Painless on injection
Respiratory depression
Initial dose 1 – 2 mg
Onset of action (1 – 2
minutes)
• Peaks 3-4 minutes
• Short acting (duration of
15-80 minutes)
• Resedation is unlikely
• Reversal agent is
Romazicon (flumazenil)

19. Fentanyl (sublimaze)
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Initial dose 50–100mcg
Onset of action 1–2 minutes
Peaks 3–5 minutes
Duration of effect 30-60
minutes
• Analgesic; no amnesic
properties
• Respiratory depressant;
may cause episodes of
apnea
• The respiratory depression
may last longer than the
analgesic effects.
• Overdose or rapid
administration can lead to
respiratory
depression, apnea, rigidity
and bradycardia; if these
remain
untreated, respiratory
arrest, circulatory
depression or cardiac arrest
• Reversal agent: Narcan
(naloxone)

20. Demerol (meperidine)
• Analgesic property for
moderate to severe pain
• Initial dose: 25-50 mg
• Additional doses: 25mg
every 2-5 minutes titrated
to effect
• Onset: 3-6 minutes
• Peak: 6-7 minutes
• Duration: 60-180 min.
• Reversal agent: Narcan
(naloxone)
• Depresses cough reflex
• Can cause respiratory
depression and CNS
depression
• Contraindicated for people
who take MAO inhibitors
• Often causes nausea and
vomiting in patients
• Overdose or rapid
administration can lead to
respiratory
depression, apnea, rigidity
and bradycardia; if these
remain
untreated, respiratory
arrest, circulatory
depression or cardiac arrest

21. Diprivan (propofol)
• Loss of consciousness usually occurs
within Peaks in 90 seconds
• Given in procedure atmosphere (short
duration), the effects usually wear off
in 10 to 15 minutes
• No analgesic properties
• No amnesia properties
• Respiratory depressant, frequently
causes apneic episodes that last over
60 seconds.
• Unless totally unconscious they do
not lose their hearing.
• The most significant adverse effect of
propofol is hemodynamic
destabilization. Propofol can
substantially reduce cardiac output
• Expect a drop in BP of 20%
after initial dose from baseline
• SpO2 will drop initially and
then recover
• Can only be administered by
licensed anesthesia person
• There is no reversal agent

22. SYNERGISTIC EFFECTS
of medications

23. Synergistic effects
• Combining a sedative such as a
benzodiazepine, an opioid or a anesthetic, can
potentiate the effects of the medications and can
increase the likelihood of adverse
outcomes, including ventilatory depression and
resultant hypoxemia
• The administration of one of the above drugs can
reduce the amount of the second in a different
class that is needed to achieve the desired level
of sedation.
• Keep in mind that medications taken at home can
also potentiate the effects of medications given
during the procedure (i.e. narcotics, CNS
depressants)

24. Sedation can be risky with certain
patient populations

25. Patient Factors Affecting
Response to Sedation
• The following factors are among those placing
the patient at greater risk for complications:
Morbidity
Organ System Abnormalities
Difficult airways
Sleep apnea; obesity; short neck; reduced mouth
opening; large tongue; anatomical abnormalities
Risk of aspiration
Acute upper gastrointestinal bleeding; gastric
outlet obstruction; delayed gastric emptying;
achalasia
Reduced tolerance /
Tobacco, alcohol, or substance abuse; previous
paradoxical reactions to adverse experience with sedation;
standard sedative
neuropsychiatric disorders; allergies; drug
reactions

26. If all else fails…….
Try this
method

27. Or This..
Or this

28. Sources
• Use of Sedative Medications in the Intensive Care
Unit, Stanley A. Nasraway Jr., MD., FCCM, Department of
Surgery, Tufts-New England Medical Center, Tufts University
School of Medicine, Boston, Massachusetts
• SGNA, www.sedation.org
• Oklahoma Board of Nursing
• AGA Institute Review of Endoscopic Sedation