Prof.Med. Nabil H. MohyeddinBoard certifiedIntensive care &AnesthesiologyRostock University Academic College, Berlin, Germany,MEEQAT GENERAL HOSPITAL ,MADINA, KSA

1. Prof.Med. Nabil H. MohyeddinProf.Med. Nabil H. Mohyeddin
Board certifiedBoard certified
Intensive care &AnesthesiologyIntensive care &Anesthesiology
Rostock UniversityRostock University
Academic College, Berlin, GermanyAcademic College, Berlin, Germany
E-mail: nhm1955@hotmail.comE-mail: nhm1955@hotmail.com
Conscious sedationConscious sedation

2. ObjectivesObjectives
&&
Sedation DefinitionsSedation Definitions

3. GoalsGoals
• To provide safe sedation/analgesiaTo provide safe sedation/analgesia
((Guard patient safety)Guard patient safety)
• To decrease adverse psychologicalTo decrease adverse psychological
responsesresponses
• To facilitate procedural ease through:To facilitate procedural ease through:
1.1. Minimize pain of procedure.Minimize pain of procedure.
2.2. Minimize fear and anxiety.Minimize fear and anxiety.
3.3. Control behavior.Control behavior.
4.4. Provide amnesia.Provide amnesia.

4. Minimal Sedation (AnxiolysisMinimal Sedation (Anxiolysis((
• A drug-induced state during whichA drug-induced state during which
patients respond normally to verbalpatients respond normally to verbal
commands. Although cognitivecommands. Although cognitive
function and coordination may befunction and coordination may be
impaired, ventilatory andimpaired, ventilatory and
cardiovascular functions arecardiovascular functions are
unaffected.unaffected.

5. Moderate SedationModerate Sedation
• A drug induced depression ofA drug induced depression of
consciousness during which patientsconsciousness during which patients
cannot be easily arouse, but respondcannot be easily arouse, but respond
purposefully following repeated orpurposefully following repeated or
painful stimulation. No interventionspainful stimulation. No interventions
are required to maintain a patentare required to maintain a patent
airway, and spontaneous ventilation isairway, and spontaneous ventilation is
adequate. Cardiovascular function isadequate. Cardiovascular function is
usually maintained.usually maintained.

6. Deep SedationDeep Sedation
• A drug-induced depression of consciousnessA drug-induced depression of consciousness
during which patients cannot be easilyduring which patients cannot be easily
aroused, but respond purposefully followingaroused, but respond purposefully following
repeated or painful stimulation. The ability torepeated or painful stimulation. The ability to
independently maintain ventilatory functionindependently maintain ventilatory function
may be impaired. Patient may requiremay be impaired. Patient may require
assistance in maintaining a patent airway andassistance in maintaining a patent airway and
spontaneous ventilation may be inadequate.spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.Cardiovascular function is usually maintained.

7. Level of
Consciousness Awake
Analgesia
Anxiolysis
Hypnosis
“Conscious
Sedation”
Deep
Sedation
General
Anesthesia
The Spectrum of Sedation
Patients may travel quickly in either direction along this spectrum!
Protective
Reflexes
Potential
Loss
Potential
Loss
Present Total LossPresent
ED/Transport Mgmt

10. PharmacologyPharmacology
ofof
SedativesSedatives

11. Common Medications forCommon Medications for
Sedation & AnalgesiaSedation & Analgesia
•BenzodiazepinesBenzodiazepines
•OpioidsOpioids
•Sedative-hypnoticsSedative-hypnotics
•NeurolepticsNeuroleptics
•Anaesthetic agentsAnaesthetic agents

12. Common Medications forCommon Medications for
SedationSedation & Analgesia& Analgesia
•Desired actions of drugs used for sedation:Desired actions of drugs used for sedation:
• Short duration of actionShort duration of action
• Lack of cumulative effectsLack of cumulative effects
• Promote rapid recoveryPromote rapid recovery
• Minimal side-effectsMinimal side-effects
• Residual analgesiaResidual analgesia
•UnfortunatelyUnfortunately, no single pharmacological, no single pharmacological
agent satisfies all requirements.agent satisfies all requirements.
• Generally have to combine medications.Generally have to combine medications.

13. List of TermsList of Terms
• Because of the wide rangeBecause of the wide range
of settings in which thisof settings in which this
presentation will bepresentation will be
viewed, a list of genericviewed, a list of generic
and proprietary drugand proprietary drug
names is presented.names is presented.
Please refer to this slide asPlease refer to this slide as
necessary throughout thenecessary throughout the
presentation.presentation.
• Alprazolam = XanaxAlprazolam = Xanax
• Diazepam = ValiumDiazepam = Valium
– Lorazepam = AtivanLorazepam = Ativan
• Midazolam = VersedMidazolam = Versed
• Propofol = DiprivanPropofol = Diprivan
• Ketamine= ketalarKetamine= ketalar
• FentanylFentanyl
• Mepiridine = pethidineMepiridine = pethidine
• Naloxone = NarcanNaloxone = Narcan
• Flumazinil = RomaziconFlumazinil = Romazicon
– Methohexital = BrevitalMethohexital = Brevital
• Sodium Thiopental =Sodium Thiopental =
Sodium PentothalSodium Pentothal

14. BenzodiazepinesBenzodiazepines
•Actions:Actions:
• Potentiate the effects of the neuroinhibitorPotentiate the effects of the neuroinhibitor
GABA.This creates anticonvulsant, amnesic andGABA.This creates anticonvulsant, amnesic and
sedative effects.sedative effects.
• Mimic inhibitory actions of Glycine. CausingMimic inhibitory actions of Glycine. Causing
muscle relaxation and anxiolysis.muscle relaxation and anxiolysis.
•Benzodiazepines affect the limbic system,Benzodiazepines affect the limbic system,
thalamus and hypothalamus.thalamus and hypothalamus.

15. BenzodiazepinesBenzodiazepines
• Indicated for:Indicated for:
• AnxietyAnxiety
• InsomniaInsomnia
• SeizuresSeizures
• Muscle relaxationMuscle relaxation
• Induction of general anaesthesiaInduction of general anaesthesia
• Preoperative sedationPreoperative sedation
• Conscious sedationConscious sedation
• Alcohol withdrawalAlcohol withdrawal
• Most commonly used types:Most commonly used types:
• Diazepam, Lorazepam andDiazepam, Lorazepam and MidazolamMidazolam

16. BenzodiazepinesBenzodiazepines
• Benzodiazepines have no analgesic properties.Benzodiazepines have no analgesic properties.
• Combining sedatives and opoids creates aCombining sedatives and opoids creates a
synergistic action.synergistic action.
• Recommended to reduce dose ofRecommended to reduce dose of
benzodiazepine and opiod by 1/3 when givingbenzodiazepine and opiod by 1/3 when giving
concurrently.concurrently.

17. Watch OutWatch Out!!
•Contraindications:Contraindications:
•Acute narrow angle glaucomaAcute narrow angle glaucoma
•Untreated open angle glaucomaUntreated open angle glaucoma
•ShockShock
•ComaComa
•Acute alcohol intoxicationAcute alcohol intoxication
•Children<6 months oldChildren<6 months old

18. Benzodiazepines : Adverse effectsBenzodiazepines : Adverse effects
• Respiratory:Respiratory:
• Respiratory depression,apnoea,respiratory arrestRespiratory depression,apnoea,respiratory arrest
(especially Midazolam)(especially Midazolam)
• CV:CV:
• Diazepam-SVR and CODiazepam-SVR and CO
• Midazolam-hypotension and bradycardiaMidazolam-hypotension and bradycardia
• CNS:CNS:
• Diazepam-drowsiness, confusion,slurred speech,Diazepam-drowsiness, confusion,slurred speech,
syncopesyncope
• Midazolam-agitation, hyperactivity, involuntaryMidazolam-agitation, hyperactivity, involuntary
movement, combativenessmovement, combativeness

19. Midazolam (VersedMidazolam (Versed((
• Rapid onset.Rapid onset.
• Short duration 20 - 30 minutes.Short duration 20 - 30 minutes.
• DoseDose
• IV 0.1mg/kg max. 5mg., onset 2 - 3 min.IV 0.1mg/kg max. 5mg., onset 2 - 3 min.
• Oral 0.5mg/kg, onset 20 - 25 min.Oral 0.5mg/kg, onset 20 - 25 min.
• Intranasal 0.4mg/kg, onset 15 - 20 min.Intranasal 0.4mg/kg, onset 15 - 20 min.
• Rectal 0.5mg/kg, onset 5 - 10 min.Rectal 0.5mg/kg, onset 5 - 10 min.

20. OpioidsOpioids
• The opioids provide analgesia andThe opioids provide analgesia and
some sedation, as well assome sedation, as well as
alterations of mood and perceptionalterations of mood and perception
of surroundings. They may alsoof surroundings. They may also
depress cough reflexes.depress cough reflexes.
• Examples includeExamples include
– morphinemorphine
– hydromorphonehydromorphone
– meperidinemeperidine
– fentanylfentanyl depicted at rightdepicted at right
• Some opioids like meperidine andSome opioids like meperidine and
fentanyl are synthetic substances,fentanyl are synthetic substances,
while others are natural.while others are natural.

21. Mepiridine (pethidineMepiridine (pethidine((
• MeperidineMeperidine should be used cautiously inshould be used cautiously in
patients with renal/hepatic disease, those atpatients with renal/hepatic disease, those at
risk for seizure due to accumulation of itsrisk for seizure due to accumulation of its
active metabolite, normeperidine, and inactive metabolite, normeperidine, and in
those with little cardiac reserve.those with little cardiac reserve.
• 0.5-2 mg/kg iv bolus, may repeat as0.5-2 mg/kg iv bolus, may repeat as
necessary.necessary.
• Not used in pediatric patients.Not used in pediatric patients.

22. FentanylFentanyl
• FentanylFentanyl may cause chest wall and glotticmay cause chest wall and glottic
rigidity, particularly when administeredrigidity, particularly when administered
rapidly. This may make manualrapidly. This may make manual
ventilation very difficult.ventilation very difficult.
• Route: IVRoute: IV
• Onset: 1-3 minOnset: 1-3 min
• Duration: 30-60 minDuration: 30-60 min
• Adult dose: 25-50 mcg/doseAdult dose: 25-50 mcg/dose

23. • Propofol is widelyPropofol is widely
distributed in the bodydistributed in the body
and is eliminated viaand is eliminated via
hepatic & pulmonaryhepatic & pulmonary
systems.systems.
• No dosage adjustmentsNo dosage adjustments
necessary in patientsnecessary in patients
with hepatic/renalwith hepatic/renal
disease.disease.
• To preventTo prevent
hypotension considerhypotension consider
reduced doses in thereduced doses in the
elderly, hypovolemic,elderly, hypovolemic,
or patients receivingor patients receiving
otherother
narcotics/sedatives.narcotics/sedatives.
• Supports rapidSupports rapid
bacterial growth;bacterial growth;
discard 6 hrs afterdiscard 6 hrs after
opening.opening.

24. Propofol (DiprivanPropofol (Diprivan((
• Experience in emergency departmentExperience in emergency department
limited.limited.
• Short acting, nonopioid sedative hypnotic.Short acting, nonopioid sedative hypnotic.
• Dose, 1 - 2 mg/kg IV over 1 - 2 min followedDose, 1 - 2 mg/kg IV over 1 - 2 min followed
by infusion of 6mg/kg/hour.by infusion of 6mg/kg/hour.
• Duration, 8 - 10 min.Duration, 8 - 10 min.
• Side effectsSide effects
• Deeper sedation.Deeper sedation.
• Cardiorespiratory depression. (hypotension 3-10%)Cardiorespiratory depression. (hypotension 3-10%)
• Pain at injection site.Pain at injection site.
• Contraindicated in patients with hypersensitivity toContraindicated in patients with hypersensitivity to
eggseggs..

25. KetamineKetamine
•SedativeSedative
•AmnesiaAmnesia
•Powerful analgesicPowerful analgesic
•General anaesthesiaGeneral anaesthesia

26. Ketamine: Adverse effectsKetamine: Adverse effects
•CNS:CNS: muscle tone, emergence reaction:e.gmuscle tone, emergence reaction:e.g
hallucinations, delirium, tremors, increasehallucinations, delirium, tremors, increase
intracranial pressureintracranial pressure
•CV:CV: increase BP, tachycardia, decrease BPincrease BP, tachycardia, decrease BP
in hypovolaemic patientsin hypovolaemic patients
•Respiratory:Respiratory: copious secretions (pre-treatcopious secretions (pre-treat
with atropine)with atropine)

27. Ketamine:Ketamine:
ContraContra-indications-indications
•Hypertension, heart failure, recentHypertension, heart failure, recent
MI, history of cardiovascular diseaseMI, history of cardiovascular disease
•Increased intracranial pressureIncreased intracranial pressure
•Increased intraocular pressureIncreased intraocular pressure
•Acute psychiatric illnessAcute psychiatric illness
•ThyrotoxicosisThyrotoxicosis

28. BarbituratesBarbiturates
• Barbituates includeBarbituates include
sodium pentothal andsodium pentothal and
methohexital.methohexital.
• Barbiturates provideBarbiturates provide
sedation but nosedation but no
analgesia.analgesia.

29. Reversal AgentsReversal Agents
• Naloxone:Naloxone:
– Dose for reversal. IV or IM or SC.Dose for reversal. IV or IM or SC.
• Titrate 0.01 - 0.1 mg/kg to desired effect.( 1-Titrate 0.01 - 0.1 mg/kg to desired effect.( 1-
2 mcg/kg over less than 30 seconds to2 mcg/kg over less than 30 seconds to
reverse sedation.reverse sedation.
• May need multiple doses.( repeat every 2-3May need multiple doses.( repeat every 2-3
min. )min. )
• Onset of action 1 - 2 min.Onset of action 1 - 2 min.
• Duration of action 20 - 60 min.Duration of action 20 - 60 min.

30. • Flumazenil (Anxat)Flumazenil (Anxat)
– Dose IV or IMDose IV or IM
• Pediatrics 0.01 - 0.2 mg/kg (max.Pediatrics 0.01 - 0.2 mg/kg (max.
0.2mg) May be repeated. Half dose q 10.2mg) May be repeated. Half dose q 1
min.min.
• Adults 0.2 mg bolus to total 1mg. MayAdults 0.2 mg bolus to total 1mg. May
repeat q 10 min.repeat q 10 min.
• Onset of action 1 - 5 min.Onset of action 1 - 5 min.
• Duration of action 20 - 60 min.Duration of action 20 - 60 min.

31. Reversal AgentsReversal Agents-,

32. Indications of consciousIndications of conscious
sedationsedation::
– Fracture, dislocation reduction.Fracture, dislocation reduction.
– F.B. removalF.B. removal
– Laceration repairLaceration repair
– EndoscopyEndoscopy
– Pediatric Gyne .ExamPediatric Gyne .Exam
– Invasive procedure.Invasive procedure.
– OthersOthers

33. High risk patientsHigh risk patients
• The elderlyThe elderly
• Hepatic disordersHepatic disorders
• Renal disordersRenal disorders
• Respiratory disordersRespiratory disorders
• Cardiac disordersCardiac disorders
• Drug abusersDrug abusers
• Obese patientsObese patients

34. MonitoringMonitoring
• Vigilant monitoring is theVigilant monitoring is the
key to prevention of overdosekey to prevention of overdose
and other potentialand other potential
complicationscomplications

35. Complication ofComplication of
SedationSedation

36. • Sedation failure:Sedation failure:
– Could be due to unsuitability of theCould be due to unsuitability of the
patient , orpatient , or
– Problems with medicationsProblems with medications
• Excessive sedation:Excessive sedation:
– Can be avoided by:Can be avoided by:
• Monitoring level ofMonitoring level of
consciousness(i.e Ramsey score)consciousness(i.e Ramsey score)
• Titration of medicationsTitration of medications

37. Respiratory depression &Respiratory depression &
hypoventilationhypoventilation
• Detected by:Detected by:
• Decrease in oxygen saturationDecrease in oxygen saturation
• Decrease in rate and depth of respirationsDecrease in rate and depth of respirations
• Treatment:Treatment:
• Stimulate patientStimulate patient
• Open airwayOpen airway
• Give oxygenGive oxygen
• If the above steps are unsuccessful,ventilate withIf the above steps are unsuccessful,ventilate with
ambu-bag. If the condition does not improve orambu-bag. If the condition does not improve or
the patient stops breathing, intubate.the patient stops breathing, intubate.

38. Cardiac complications &Cardiac complications &
hypotensionhypotension
• Cardiac arrythmias:Cardiac arrythmias:
• Must be recognized and treated quickly forMust be recognized and treated quickly for
positive patient outcomespositive patient outcomes
• Hemodynamic instability, causedHemodynamic instability, caused
by a variety of factors:by a variety of factors:
• HypovolaemiaHypovolaemia
• Myocardial ischaemiaMyocardial ischaemia
• MedicationsMedications
• AcidosisAcidosis
• Parasympathetic stimulationParasympathetic stimulation

39. Cardiac complications &Cardiac complications &
hypotensionhypotension
• Treatment:Treatment:
• IV fluidsIV fluids
• OxygenOxygen
• Vasopressors or specificVasopressors or specific
agonists(avoid if possible)agonists(avoid if possible)

40. In conclusionIn conclusion
• If patient and medicationIf patient and medication
selection is appropriate and theselection is appropriate and the
patient is monitored adequately,patient is monitored adequately,
then the incidence ofthen the incidence of
complications due tocomplications due to
sedation/analgesia will be verysedation/analgesia will be very
low.low.

41. Staff Qualification &Staff Qualification &
PrivilegingPrivileging

42. Sedation policies & procedureSedation policies & procedure
identifyidentify::
• Special qualifications orSpecial qualifications or
skills of staff involved inskills of staff involved in
sedation processsedation process

44. Sedation ProviderSedation Provider
• Any physician who is privileged.Any physician who is privileged.
• Anesthesiologists by nature of theirAnesthesiologists by nature of their
specialty.specialty.
• Physician or dentist who isPhysician or dentist who is
credentialed or privileged.credentialed or privileged.

45. The Sedation Provider should beThe Sedation Provider should be
competent incompetent in::
• Techniques of various modes of sedationTechniques of various modes of sedation
• Appropriate monitoringAppropriate monitoring
• Response to complicationsResponse to complications
• Use of reversal agentsUse of reversal agents
• At least basic life supportAt least basic life support

46. Privileging of non-Privileging of non-
AnesthesiologistsAnesthesiologists
• Valid BLS Certification.Valid BLS Certification.
• Documented attendance and successfulDocumented attendance and successful
completion of an approvedcompletion of an approved
Sedation/Analgesia Course.Sedation/Analgesia Course.
• Training curriculum clearly indicating thatTraining curriculum clearly indicating that
competency in providing Sedation/Analgesiacompetency in providing Sedation/Analgesia
is part of the qualification process for his/heris part of the qualification process for his/her
degree.degree.

47. Privileging of non-Privileging of non-
AnesthesiologistsAnesthesiologists
• Certificates of experience from his/herCertificates of experience from his/her
Chairman or previous employerChairman or previous employer
documenting that provision ofdocumenting that provision of
Sedation/Analgesia is part of his/herSedation/Analgesia is part of his/her
clinical practice for a minimum of 5yrs.clinical practice for a minimum of 5yrs.
• Attending and passing the BasicAttending and passing the Basic
Competency Course provided by theCompetency Course provided by the
Hospital Sedation Committee.Hospital Sedation Committee.

48. Privileging of non-Privileging of non-
AnesthesiologistsAnesthesiologists
• Re-evaluation of Privileging on individualRe-evaluation of Privileging on individual
basis is mandated if:basis is mandated if:
• Invalid BLS.Invalid BLS.
• Less than 10 sedation/procedures per year.Less than 10 sedation/procedures per year.
• Failure to pass the basic competency courseFailure to pass the basic competency course
provided by the Hospital Sedationprovided by the Hospital Sedation
Committee.Committee.

49. Responsibilities of SedationResponsibilities of Sedation
ProviderProvider
• Obtain ConsentObtain Consent
• Evaluate patient prior to procedureEvaluate patient prior to procedure
• Document the assessmentDocument the assessment
• Refer to Anesthesia Department if neededRefer to Anesthesia Department if needed
• Prescribe or administer medications as per his/herPrescribe or administer medications as per his/her
privilegeprivilege
• Ensure monitoring of patient’s progressEnsure monitoring of patient’s progress
• Present in procedure area throughout the entirePresent in procedure area throughout the entire
procedure and remain on the premises of recovery areaprocedure and remain on the premises of recovery area
during recovery.during recovery.
• Ensure appropriate discharge of patient.Ensure appropriate discharge of patient.

50. Competencies required for RegisteredCompetencies required for Registered
NurseNurse
• The nurse is competent in patientThe nurse is competent in patient
monitoring, drug administration, andmonitoring, drug administration, and
protocols for dealing with emergencyprotocols for dealing with emergency
situationssituations
• The nurse will have NO otherThe nurse will have NO other
responsibilities that would leave theresponsibilities that would leave the
patient unattended or compromisepatient unattended or compromise
continuous monitoring.continuous monitoring.

51. Competencies required for RegisteredCompetencies required for Registered
NurseNurse
• The Nurse is able to demonstrate theThe Nurse is able to demonstrate the
required knowledge of Pharmacology, andrequired knowledge of Pharmacology, and
complications related to medications.complications related to medications.
• Demonstrate monitoring requirementsDemonstrate monitoring requirements
during sedation and recovery.during sedation and recovery.
• Understand the principles of oxygen delivery,Understand the principles of oxygen delivery,
respiratory physiology, transport and uptake,respiratory physiology, transport and uptake,
and demonstrate the ability to use oxygenand demonstrate the ability to use oxygen
delivery devices.delivery devices.

52. Competencies required for RegisteredCompetencies required for Registered
NurseNurse
• Anticipate and recognize potentialAnticipate and recognize potential
complications of sedation in relation to thecomplications of sedation in relation to the
type of medication being administered.type of medication being administered.
• Possess the requisite knowledge and skillsPossess the requisite knowledge and skills
to assess, diagnose and intervene in theto assess, diagnose and intervene in the
event of complications or undesiredevent of complications or undesired
outcomes and to institute nursingoutcomes and to institute nursing
interventions in compliance with orders.interventions in compliance with orders.

53. Competencies required forCompetencies required for
Registered NurseRegistered Nurse
• Demonstrate skill in airway management andDemonstrate skill in airway management and
resuscitation principles.resuscitation principles.
• The Nursing Education Department willThe Nursing Education Department will
maintain an educational/competencymaintain an educational/competency
validation mechanism that includesvalidation mechanism that includes
demonstration of the knowledge, skill anddemonstration of the knowledge, skill and
abilities related to the management of patientsabilities related to the management of patients
receiving sedation/analgesia.receiving sedation/analgesia.

54. Privileging for RegisteredPrivileging for Registered
NurseNurse
• The Registered Nurse needs to have aThe Registered Nurse needs to have a
valid:valid:
• BLS certificateBLS certificate
• IV Cannulation workshopIV Cannulation workshop
• ECG workshopECG workshop
• Sedation and Analgesia workshopSedation and Analgesia workshop

55. The Registered Nurse is ResponsibleThe Registered Nurse is Responsible
forfor::
• Providing uninterruptedProviding uninterrupted
monitoring of the patient’smonitoring of the patient’s
physiological parametersphysiological parameters
• Assisting in supportive orAssisting in supportive or
resuscitation measures.resuscitation measures.

56. DocumentationDocumentation

57. Responsibilities of SedationResponsibilities of Sedation
ProviderProvider
• Obtain Consent (new requirement)Obtain Consent (new requirement)
• Evaluate patient prior to procedureEvaluate patient prior to procedure
• Document the assessmentDocument the assessment
• Refer to Anesthesia if neededRefer to Anesthesia if needed
• Prescribe or administer medications as perPrescribe or administer medications as per
his/her privilegehis/her privilege
• Ensure monitoring of patient’s progressEnsure monitoring of patient’s progress
• Present in procedure area throughout the entirePresent in procedure area throughout the entire
procedure and remain on the premises of recoveryprocedure and remain on the premises of recovery
area during recovery.area during recovery.
• Ensure appropriate discharge of patient.Ensure appropriate discharge of patient.

58. DocumentationDocumentation
• ASA ClassificationASA Classification
• Airway classificationAirway classification
• Physical examinationPhysical examination
• Lab resultsLab results

59. ASA Classification of Physical StatusASA Classification of Physical Status
• Class I Class I
– The patient has no organic,The patient has no organic,
physiological, biochemical orphysiological, biochemical or
psychiatric disturbance. Thepsychiatric disturbance. The
pathological process for which surgerypathological process for which surgery
is to be performed is localized and doesis to be performed is localized and does
not entail a systemic disturbance.not entail a systemic disturbance.
Examples: a fit patient with an inguinalExamples: a fit patient with an inguinal
hernia, a fibroid uterus in an otherwisehernia, a fibroid uterus in an otherwise
healthy woman. healthy woman.

60. • Class IIClass II
– Mild to moderate systemic disturbanceMild to moderate systemic disturbance
caused either by the condition to becaused either by the condition to be
treated surgically or by othertreated surgically or by other
pathophysiological process. Examples:pathophysiological process. Examples:
Non-limiting organic heart disease, mildNon-limiting organic heart disease, mild
diabetes, essential hypertension ordiabetes, essential hypertension or
anaemia (i.e. controlled systemic disease).anaemia (i.e. controlled systemic disease).
Extreme obesity and chronic bronchitisExtreme obesity and chronic bronchitis
may be included in this category. may be included in this category.
ASA Classification of Physical StatusASA Classification of Physical Status

61. • Class IIIClass III
– Severe systemic disturbance or diseaseSevere systemic disturbance or disease
whatever cause, even though it may not bewhatever cause, even though it may not be
possible to define the degree of disabilitypossible to define the degree of disability
with finality. Examples: Severe limitingwith finality. Examples: Severe limiting
organic heart disease, severe diabetes withorganic heart disease, severe diabetes with
vascular complications, moderate to servervascular complications, moderate to server
degrees of pulmonary insufficiency, anginadegrees of pulmonary insufficiency, angina
pectoris or healed myocardial infarctionpectoris or healed myocardial infarction
(i.e. controlled systemic disease).(i.e. controlled systemic disease).
ASA Classification of Physical StatusASA Classification of Physical Status

62. • Class IVClass IV
– Severe systemic disorders that areSevere systemic disorders that are
already life threatening, not alwaysalready life threatening, not always
correctable by operation. Examples:correctable by operation. Examples:
Patient with organic heart diseasePatient with organic heart disease
showing marked signs of cardiacshowing marked signs of cardiac
insufficiency, persistent angina, orinsufficiency, persistent angina, or
active myocarditis, advanced degrees ofactive myocarditis, advanced degrees of
pulmonary hepatic, renal or endocrinepulmonary hepatic, renal or endocrine
insufficiency.insufficiency.
ASA Classification of Physical StatusASA Classification of Physical Status

63. • Class V Class V
– The moribund patient who has little chanceThe moribund patient who has little chance
of survival but is submitted to operation inof survival but is submitted to operation in
desperation. Examples: Burst of aorticdesperation. Examples: Burst of aortic
aneurysm with profound shock, majoraneurysm with profound shock, major
cerebral trauma with rapidly increasingcerebral trauma with rapidly increasing
intracranial pressure, massive pulmonaryintracranial pressure, massive pulmonary
embolus. Most of these patients requireembolus. Most of these patients require
operations as a resuscitative measure. (i.e.operations as a resuscitative measure. (i.e.
patients who are not expected to live morepatients who are not expected to live more
than 24 hours). than 24 hours).
ASA Classification of Physical StatusASA Classification of Physical Status

64. • Class E Class E
– Any emergency procedure, is labelled EAny emergency procedure, is labelled E
in addition to one of the above classesin addition to one of the above classes
according to patient’s condition, e.g. II Eaccording to patient’s condition, e.g. II E
or I E.or I E.
ASA Classification of Physical StatusASA Classification of Physical Status

65. Anesthesia ConsultationAnesthesia Consultation
• Adult patient ASA III or above.Adult patient ASA III or above.
• Pediatric patient ASA IV or above.Pediatric patient ASA IV or above.
• Patients with complex airway problems.Patients with complex airway problems.
• Previous failure of sedation / analgesia.Previous failure of sedation / analgesia.
• Patient ASA I or above undergoing a diagnosticPatient ASA I or above undergoing a diagnostic
and / or therapeutic procedure(s) performed by aand / or therapeutic procedure(s) performed by a
physician / dentist who is not privileged to performphysician / dentist who is not privileged to perform
sedation / analgesia.sedation / analgesia.

67. HOWHOW
TO IMPLEMENTTO IMPLEMENT
THE STANDARDSTHE STANDARDS??

68. The BeginningThe Beginning
• Formulate a Task force for evaluation.Formulate a Task force for evaluation.
• Review the policy.Review the policy.
• Identify and Inspect the sedation areas.Identify and Inspect the sedation areas.
• Review the process of conduct of sedation,Review the process of conduct of sedation,
monitoring, record keeping.monitoring, record keeping.
• Review of departments policies.Review of departments policies.

69. GoalGoal
• Formulation of Hospital Policy.Formulation of Hospital Policy.
• Formulation of unified recordFormulation of unified record
keeping.keeping.
• Formulation of a sedationFormulation of a sedation
committee.committee.
• Define the charges of theDefine the charges of the
committee.committee.

70. Committee MembersCommittee Members
• Chairman: AnesthesiologistChairman: Anesthesiologist
• Members:Members:
• Physician Representative from major clinicalPhysician Representative from major clinical
departments.departments.
• Nursing representative from Nursing educationNursing representative from Nursing education
department.department.
• QM representative.QM representative.
• Clinical pharmacistClinical pharmacist..
• Admin AssisstantAdmin Assisstant

71. Committee ChargesCommittee Charges
• Survey & Certify Location(s) within the hospital meetingSurvey & Certify Location(s) within the hospital meeting
the criteria of your policy.the criteria of your policy.
• Review & update the policy.Review & update the policy.
• Conduct and prepare a sedation/analgesia course forConduct and prepare a sedation/analgesia course for
physician and nurses.physician and nurses.
• Certify physicians requesting sedation privileges.Certify physicians requesting sedation privileges.
• Certify nurses to monitor patients during sedation.Certify nurses to monitor patients during sedation.
• Monitor the practice and come up with recommendationMonitor the practice and come up with recommendation
to improve the quality of care.to improve the quality of care.

72. Committee ChargesCommittee Charges
• Receive quarterly reports and statistics from variousReceive quarterly reports and statistics from various
clinical departments in relation to the practice ofclinical departments in relation to the practice of
sedation.sedation.
• Receive and review quality indicator forms forwardedReceive and review quality indicator forms forwarded
from various departments in relation to the practice offrom various departments in relation to the practice of
sedation.sedation.
• Submit a quarterly report to the hospital Q.I committee.Submit a quarterly report to the hospital Q.I committee.
• Forward an annual report to medical director about theForward an annual report to medical director about the
practice of sedation/analgesia.practice of sedation/analgesia.

74. AuditAudit
&&
Quality ImprovementsQuality Improvements

75. HowHow
do we auditdo we audit
our practiceour practice??

76. Quality IndicatorsQuality Indicators
Used for monitoring of sedation/analgesiaUsed for monitoring of sedation/analgesia
performanceperformance
Completed by Sedation Assistant at the endCompleted by Sedation Assistant at the end
of procedureof procedure
Sent to Quality Management DepartmentSent to Quality Management Department
for review and analysisfor review and analysis

77. whywhy
do we needdo we need
to audit our practiceto audit our practice??

78. Adverse events or patterns of adverseAdverse events or patterns of adverse
events during moderate or deep sedationevents during moderate or deep sedation
are analyzed.are analyzed.
Use information from data analysis toUse information from data analysis to
identify improvements or reduce (oridentify improvements or reduce (or
prevent) adverse events.prevent) adverse events.

79. Hospital SedationHospital Sedation
CommitteeCommittee

80. RationaleRationale
• Maintain the quality of care.Maintain the quality of care.
• Maintain patient safety.Maintain patient safety.
• Central committee responsibleCentral committee responsible
about the practice of sedation.about the practice of sedation.

81. Hospital Sedation CommitteeHospital Sedation Committee
• A committee that is called andA committee that is called and
approved by the Hospital Director, orapproved by the Hospital Director, or
equivalent, to be responsible aboutequivalent, to be responsible about
the practice of sedation/analgesia bythe practice of sedation/analgesia by
non anaesthesiologist.non anaesthesiologist.

82. Committee MembersCommittee Members::
• Chairman:Chairman: chair of the Anesthesiology Department, or anchair of the Anesthesiology Department, or an
Anesthesiologist Nominated by the chair of the AnesthesiaAnesthesiologist Nominated by the chair of the Anesthesia
Department.Department.
• Nursing division representative:Nursing division representative: Director of Nursing Education.Director of Nursing Education.
• Quality management representative:Quality management representative: quality managementquality management
specialist.specialist.
• Department of Medicine representative:Department of Medicine representative: Chair or any physicianChair or any physician
nominated by the chair of the department.nominated by the chair of the department.
• Department of Surgery representative:Department of Surgery representative: Chair or any physicianChair or any physician
nominated by the chair of the department.nominated by the chair of the department.
• Department of Paediatrics/Paediatric Oncology representative.Department of Paediatrics/Paediatric Oncology representative.
• Department ofDepartment of EmergencyEmergency & family medicine representative:& family medicine representative:
Chair or any physician nominated by the chair of theChair or any physician nominated by the chair of the
department.department.
• Administrative AssistantAdministrative Assistant..

83. Committee ChargesCommittee Charges
• Survey and certify location(s) within the institute meeting the criteria ofSurvey and certify location(s) within the institute meeting the criteria of
the hospital policy.the hospital policy.
• Review and update that policy.Review and update that policy.
• Conduct and prepare a sedation/analgesia course for physicians andConduct and prepare a sedation/analgesia course for physicians and
nurses.nurses.
• Certifications of physicians requesting the privilege to administerCertifications of physicians requesting the privilege to administer
sedation.sedation.
• Certifications of nurses to monitor patients during sedation.Certifications of nurses to monitor patients during sedation.
• Monitor the practice of sedation/analgesia in the hospital and come upMonitor the practice of sedation/analgesia in the hospital and come up
with recommendation to improve the quality of care as deemed necessary.with recommendation to improve the quality of care as deemed necessary.
• Receive quarterly reports and statistics forwarded from various clinicalReceive quarterly reports and statistics forwarded from various clinical
departments in relation to the practice of sedation/analgesia.departments in relation to the practice of sedation/analgesia.
• Receive and review quality indicator forms forwarded from variousReceive and review quality indicator forms forwarded from various
departments in relation to the practice of sedation/analgesia.departments in relation to the practice of sedation/analgesia.
• Forward an annual report to the Hospital Director, or equivalence aboutForward an annual report to the Hospital Director, or equivalence about
the practice of sedation/analgesia.the practice of sedation/analgesia.
• To conduct research in the field of sedation/analgesia for the purpose ofTo conduct research in the field of sedation/analgesia for the purpose of
improvement of the quality of care.improvement of the quality of care.

84. •overover