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Conscious Sedation Basics and Introduction
The document outlines a mandatory course on conscious sedation, focusing on its terminology, pharmacology, and patient management. It describes the continuum of sedation levels, indications for use, and guidelines for safe practice, particularly in children who require deeper sedation. Key components include appropriate documentation, monitoring, and recovery protocols to ensure patient safety and positive experiences.
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Conscious Sedation Basics and Introduction
- 1. Dr. Hazem Sharaf AnesthesiaConsultant KFH Al-Baha hazemsharaf@yahoo.com 10-May-14 1
- 2. Conscious sedation course 10-May-142 Today’s course is Mandatory for the C.S. privilege & delivers basic knowledge about: 1- Conscious sedation terminology & basics 2- Pharmacology of Sedative Drugs 3- Patient Management under C.S. 4- Hospital sedation policy.
- 3. 10-May-14 3 Egypt B4Revolution
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- 5. Conscious sedationis administering drugs for specific goals: Provision of safe analgesia, anxiolysis, sedation, and amnesia during stressful procedures. Safely decreasing adverse psychological responses associated with stressful procedures. Return of patients to their pre-procedural level of functioning. 10-May-14 5
- 6. Procedural Sedation Continuum Sedation is a continuum of “levels” ranging from minimally impaired consciousness to unconsciousness. The following terminology refers to the different levels of sedation: Minimum Moderate Dissociative Deep G.A. Levels of sedation are considered to be on a continuum because a sedated patient can go in and out of an intended level quite rapidly.
- 7. Minimal Sedation (anxiolysis) Druginduced state during which; patients can respond normally to verbal commands. We almost never do this 10-May-14 7 ASA Continuum of Depth of Sedation. Approved 1999;last amended 2004.
- 8. 10-May-14 8 No matterthe level of sedation you intend, BUT you should be able to rescue patients one level of sedation “deeper” than that which was intended. Minimal Sedation (anxiolysis)
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- 10. Moderate (Conscious) Sedation Drug-induceddepressed consciousness Purposeful response to verbal or tactile stimulation NO interventions necessary to maintain a patent airway Adequate spontaneous ventilation Cardiovascular function maintained 10-May-14 10 ASA Continuum of Depth of Sedation. Approved 1999;last amended 2004.
- 11. It is discouraged touse the term “conscious sedation” when referencing sedation in children.* * American Academy of Pediatrics Committee on Drugs. Moderate (Conscious) Sedation
- 12. Dissociative Sedation =(Ketamine) A bizarre, cataleptic state occurs with both profound analgesia & amnesia while maintaining protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. Due to Ketamine’s markedly different clinical effect, it does not officially fit the ASA sedation continuum. However, it is generally recognized to produce a level of sedation between moderate and deep sedation. Consciousness Unconsciousness Moderate Sedation Deep Sedation General Anesthesia Minimal Sedation Dissociative
- 13. A patient whois appropriately consciously (moderately) sedated: A. Must be able to open his eyes B. Must be able to protect his airway C. Responds to painful stimuli only D. Is comatosed 10-May-14 13
- 14. Deep sedation Drug induceddepression of consciousness during which patients cannot be easily aroused, but respond purposefully to repeated painful stimulation. Patients require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. 10-May-14 14 ASA Continuum of Depth of Sedation. Approved 1999;last amended 2004.
- 15. 10-May-14 15 Planning fordeep sedation requires that the practitioner must be able to rescue a patient slipping into (unintentional) general anesthesia. Deep sedation
- 16. General Anesthesia Drug inducedloss of consciousness during which patients are not arousable, even by painful stimuli. Patients require assistance in maintaining a patent airway & cardiovascular function, and positive pressure ventilation may be required. 10-May-14 16 ASA Continuum of Depth of Sedation. Approved 1999;last amended 2004.
- 17. 10-May-14 17 Credentialing for GAis typically limited to anesthesiologist General Anesthesia
- 18. Moderate Sedation inChildren Children receive sedation more frequently than adults (due to diagnostic procedures that require controlled/no movement). To meet necessary goals, sedation/analgesia usually must be deeper than adults. Children are at higher risk for respiratory depression and life-threatening hypoxia. Children can easily slip from one sedation level to another.
- 19. Which of thefollowing is a normal main determinant of the drive to breathe in humans? A. Anxiety level B. Painful Stimuli C. Partial pressure of CO2 in arterial blood (PaCO2) D. Partial pressure of O2 in arterial blood (PaO2) 10-May-14 19
- 20. Indications Indication Immobility • PainControl • Anti-anxiety Goals Cooperation • Alteration of mood • Analgesia • Autonomic Stability • Amnesia • Rapid, safe return to highest possible health status 10-May-14 20 If patient really needs to be sedated! First Decide:
- 21. Goals of conscioussedation include: A. Anxiolysis B. Analgesia C. Amnesia D. All of the above10-May-14 21
- 22. Strike a Balance MAXIMIZEbenefits while minimizing the associated risks RISK BENEFIT Hypoventilation Apnea Airway obstruction Laryngospasm Cardiac depression Death Minimize pain & discomfort Control movement Minimize psychological trauma/anxiety Maximize amnesia
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- 25. Any Sedation ProtocolMUST Involve: Appropriate number of qualified staff Appropriate equipment & monitoring Appropriate documentation Appropriate reporting of outcomes & adverse effects 10-May-14 25
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- 27. Pre-sedation History &Physical Any airway anomalies? (Nares to Lungs) Patient status > ASA (American Society of Anesthesiologists) classifications 10-May-14 27
- 28. ASA classification ClassI – normal healthy patient Class II – patient with mild to moderate controlled systemic disease Class III - severe systemic disease Class IV – patient with severe systemic disease that is a constant threat to life Class V – moribund patient who is not expected to survive without the procedure Class VI - A brain-dead patient for organ harvest Add e - to any class in case of emergency 10-May-14 28
- 29. 10-May-14 29 NPO guidelines‘ NPOguidelines' NPO guidelines' NPO guidelines'Nil Per Os
- 30. 10-May-14 30 Starved forhow long…? Controversial. Probably not as rigid as anesthetic guidelines for GA... It depends on degree and duration of sedation
- 31. 10-May-14 31 NPO guidelines' NPO6-8 hr. before sedation Clear liquids for 2-3 hr. Clear = you can see writing thru it Children Clear liquid 2-3 hr Breast milk 4 hr Infant formula 6 hr Solid diet 8 hr. These guideline used for patients havig normal gastric emptying time
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- 33. 10-May-14 33 In emergencies, weighthe need for immediacy with the high risk of pulmonary aspiration. Use the lightest effective sedation possible.
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- 37. Equipment & SuppliesS O A P M E Suction – appropriate suction catheters and suction apparatus Oxygen – adequate O2 supply, working flow/delivery devices Airway – appropriate airway equipment (e.g., ET tubes, LMAs, oral and nasal airways, laryngoscope blades, stylets, bag mask) Pharmacy – basic life-saving drugs, & reversal agents Monitors – pulse oximeter, BP monitor, ECG, EtCO2 Equipment – special equipment for particular patient (e.g., crash cart, respiratory box, IV access equipment) MOST IMPORTANT PERSONNEL SKILLED IN ADVANCED LIFE SUPPORT! 38
- 38. 10-May-14 38 ASA addedETCo2 to standard monitoring
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- 40. Appropriate methods fortreating hypotension associated with the administration of conscious sedation include all the following except: A. IV fluid bolus B. Placing the patient in Trendelenburg’s position C. Administration of fentanyl 50 ug IV D. Administration of a mild vasopressor such as ephedrine 10 mg. IV 10-May-14 40
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- 46. Foundation for SafeSedation Patient evaluation Rescue SkillsMonitoring
- 47. Before You Begin… Considerwhether the procedure could be accomplished without sedation by engaging alternative modalities (e.g., Child Life services, distraction techniques, comfort positions, etc.) Select the lowest drug dose with the highest therapeutic index for the procedure Each sedation plan should be tailored to the individual patient’s situation But, do not under-treat patient when sedation/analgesia is appropriate & necessary
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- 50. Prepare for theworst What can go wrong? Unexpected drug reaction or anaphylaxis Vomit and aspirate Obstructed airway (e.g. laryngospasm, tongue) Apnoea, respiratory arrest Profound hypotension Unexpected drug reactions: dystonias Inadequate sedation Unsuccessful procedure… still needs GA
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- 52. 10-May-14 52 *Keep watchingthe patient … during *Keep watching the patient … after *Discharge with a well-advised capable observer
- 53. Recovery & Discharge Therecovery period lasts from the conclusion of the procedure until the patient has returned to baseline. Saturation should be monitored continuously. Vital signs & level of consciousness recorded at regular intervals. Discharge instructions should be clearly written and reviewed with patient/responsible adult.
- 54. Patient Discharge Criteria Returnto baseline verbal skills. Understand and follow directions. Appropriately verbalize. Return to baseline muscle control function. If infant can sit up unattended. Children can walk unattended. Return to baseline mental status. Patient or responsible person with patient can understand discharge instructions. 10-May-14 54
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- 56. PATIENT MONITORING ANDAIRWAY SKILLS ARE THE KEYS TO SAFETY 13
- 57. Reporting the adverseeffects http://www.aesedationreporting.com/login.aspx 10-May-14 57
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- 60. Conclusion Conscious sedation that iscarefully planned and carried out by a well- trained health care team will allow both caregivers and patients to have a positive, good experience rather than a bad memory.
- 61. 10-May-14 61 THANK YOU& Have A Nice Day