conscious sedation during procesures like bronchoscopy

1. DR. MUSTAFA ALRABAYAH
ANESTHESIA DEPARTMENT
JUH 2019
CONSCIOUS SEDATION

2. Definition
 Combinations of pharmacological agents
administered by one or more routes to produce a
minimally depressed level of consciousness and
satisfactory analgesia while retaining the ability to
independently and continuously maintain an airway,
protective reflexes and respond to physical
stimulation and verbal commands.
 Almost all therapeutic and diagnostic procedures
performed will require some combinations between
analgesia and sedation

3. Indications
 Uncooperative patients
 Children
 Patients with special needs who have difficulty
understanding orders or unable to stand still for a
long time
 Phobia
 Patients with extensive procedures
 Medical condition of the patient whose physiologic
state will be more safely controlled in a sedated or
anesthetized state.

4. Environment for office-based anesthesia
 The American Society of Anesthesiology (ASA) has
proposed guidelines for office-based anesthesia for
ambulatory surgery.
 Environmentally, there should be a reliable source of
oxygen, suction, resuscitation equipment, and available
emergency drugs.
 There should be an appropriate anesthesia apparatus or
equipment with necessary monitoring
 Monitoring resources should include the competent
responsible personnel, noninvasive blood pressure
monitor, pulse oximeter, electrocardiography, and
stethoscope and capnograph

5. Environment for office-based anesthesia
 If anesthesia is to be provided for pediatric patients,
the required equipment should be suitable for
children of all ages.
 For life-threatening situations, an emergency cart,
defibrillator, and advanced airway management tool
should be on hand.
 Full cooperation between the supervising doctor,
assistants, and anesthesiologist is needed.
 Teamwork is the key to achieve safe and successful
procedure under sedation or general anesthesia.

6. Environment for office-based anesthesia
 All “conscious sedation” areas (OR and non-OR)
must have processes (pre-sedation assessment,
intra- procedure monitoring, discharge criteria),
facilities, equipment, and personnel similar to those
utilized for MAC delivered by qualified anesthesia
providers in the OR.

7. Patient Evaluation
The goals of the medical assessment include
comprehensive review of the past medical history,
previous surgical history, and review of current
and past medications.
 Abnormalities of the major organ systems
 Previous adverse experience with sedation/ analgesia as
well as regional and general anesthesia
 Drug allergies, current medications, and potential drug
interactions
 Time and nature of last oral intake
 History of tobacco, alcohol, or substance use or abuse.

8. Patient Evaluation
Patients presenting for sedation/analgesia should
undergo a focused physical examination, including
 Vital signs,
 Auscultation of the heart and lungs, and
 Evaluation of the airway.
Preprocedure laboratory testing should be guided by the
patient’s underlying medical condition and the likelihood that
the results will affect the management of sedation/analgesia.
These evaluations should be confirmed immediately before
sedation is initiated.

9. Patient Evaluation

10. Patient Evaluation
 Patients with ASA class III should be evaluated by
the anesthesiologist responsible for the decision
 Patients with ASA class IV and V are not
recommended for sedation or general anesthesia in
the office.

11. Patient Evaluation
 Note for preop assessment and orders.
 Discharge instructions and orders

12. Patient Evaluation
Airway Assessment Procedures for Sedation
and Analgesia
 Positive pressure ventilation, with or without
tracheal intubation, may be necessary if respiratory
compromise develops during sedation–analgesia.
 This may be more difficult in patients with atypical
airway anatomy

13. Patient Evaluation
Some factors that may be associated with difficulty in airway
management are:
History
 Previous problems with anesthesia or sedation
 Stridor, snoring, or sleep apnea
 Advanced rheumatoid arthritis
 Chromosomal abnormality (e.g., trisomy 21)
Physical Examination
 Significant obesity (especially involving the neck and facial structures)
 Short neck, limited neck extension, decreased hyoid–mental distance ( 3 cm in
an adult), neck mass
 trauma, tracheal deviation, dysmorphic facial features (e.g., Pierre-Robin
syndrome)
 Small mouth opening ( 3 cm in an adult); edentulous; protruding incisors; high
arched palate; macroglossia; tonsillar hypertrophy;
 Micrognathia, retrognathia

14. Mallampati classification

15. Fasting
 Patients should strictly follow fasting rules to
decrease the risk of aspiration.

16. Consent
 Appropriate preprocedure counseling of patients
regarding risks, benefits, and alternatives to sedation
and analgesia should be discussed with the patient
and family and informed consent should be signed.

17. Contraindication
 Non fasting patient
 Physical class III –IV or greater
 Lack of support staff, drugs, monitoring or
equipment
 Lack of experience/approved on part of clinician
 Patient not ready ,no consent

18. General anesthesia
 General anesthesia services are generally available for in
hospitals or surgical centers only.
 General anesthesia is the most effective modality for
ensuring that the provider will be able to complete
procedures on a patient who has difficulty accepting
treatment.
 However, it is also the most complex to arrange; in some
circumstances is the most expensive of the modalities
listed; and has the greatest risk of side effects.

19. Sedation
 As with general anesthesia, sedation is generally
available for treatment in hospitals or surgical
centers or office based.
 Some Drs are trained and equipped to provide
sedation services in their offices.
 This procedure generally has a lower risk or side
effects than general anesthesia.

20. Behavioral support
 Behavior support describes a range of nonpharmacologic
techniques that can be used to help people treatment.
 Techniques for limiting mobility using physical means to
help an individual hold still during procedure.
 Behavioral and psychological interventions can lessen
individuals’ anxiety and increase their ability to tolerate
care in an office setting.
 Techniques such as these may reduce or eliminate the
need for sedation or anesthesia

21. Depth of anesthesia

22. Key Definitions
 Anxiolysis: diminution or elimination of anxiety
 Analgesia: diminution or elimination of pain
 Amnesia: diminution or elimination of memory

23. Depth of anesthesia
Minimal sedation (anxiolysis) is as follows:
 Response to verbal stimulation is normal.
 Cognitive function and coordination may be
impaired.
 Ventilatory and cardiovascular functions are
unaffected.

24. Depth of anesthesia
Moderate sedation/analgesia (formerly called
conscious sedation) is as follows:
 Depression of consciousness is drug-induced.
 Patient responds purposefully to verbal commands.
 Airway is patent, and spontaneous ventilation is
adequate.
 Cardiovascular function is usually unaffected

25. Depth of anesthesia
Deep sedation/analgesia is as follows:
 Depression of consciousness is drug-induced.
 Patient is not easily aroused but responds purposefully
following repeated or painful stimulation.
 Independent maintenance of ventilatory function may be
impaired.
 Patient may require assistance in maintaining a patent
airway.
 Spontaneous ventilation may be inadequate.
 Cardiovascular function is usually maintained.

26. Depth of anesthesia
General anesthesia is as follows:
 Loss of consciousness is drug-induced, where the patient
is not able to be aroused, even by painful stimulation.
 Patient's ability to maintain ventilatory function
independently is impaired.
 Patient requires assistance to maintain patent airway,
and positive pressure ventilation may be required
because of depressed spontaneous ventilation or drug-
induced depression of neuromuscular function.
 Cardiovascular function may be impaired.

27. Depth of anesthesia

28. Depth of anesthesia

29. Depth of anesthesia

30. Conscious Sedation
Safe conscious sedation can provide by following
situation :
 Fit patient selection
 Adequate preoperative assessment
 Adequate preparation
 (Familiarity with Ready & Functioning Equipment &
Medications)
 Functional monitoring
 Adequate IV access
 Experienced personnel (Doctor and Nurse)
 Recovery room( staff -monitoring-discharge criteria )

31. Procedural Sedation
Optimal conscious sedation/analgesia is achieved
when the patient:
 Maintains consciousness
 Independently maintains his/her airway
 Retains protective reflexes (swallow and gag)
 Responds to physical and verbal commands
 Is not anxious or afraid
 Experiences acceptable pain relief
 Has minimal changes in vital signs
 Is cooperative during the procedure
 Has mild amnesia for the procedure
 Recovers to preprocedure status safely

32. Analgesia
The decision to provide analgesia during a
procedure will be based on:
 The knowledge of the likelihood that the procedure is
painful.
 Patient’s age.
 Anxiety level.
 Previous experience with a painful procedure may
contribute to high or low levels of anxiety about the
procedure.

33. Procedural Sedation
Inhalational anesthetics:
 Nitrous Oxide: Referred to as laughing gas or sweet air
 Administered via face mask, this mild sedative is ideal for
patients who can remain still during appointments yet
need the extra help to stay relaxed.
 Typically recommended for children, this sedative can
help alleviate some of the anxiety younger patients
experience without the patient losing consciousness.
 It offers a good analgesic effect too.

34. Procedural Sedation
Oral Sedation:
 Administered as either a pill or syrup, this form of
conscious sedation provides a stronger alternative to
nitrous oxide.
 While the medication may cause patients to forget their
details of their procedure, many remain responsive to
simple commands.
 Oral sedation is highly recommended for anxious
patients.

35. Procedural Sedation
IV Sedation:
 In cases where patients require complex procedures
or have a disability that limits their ability to
understand direction and be treated safely,
intravenous sedation may be the best course of
treatment.
 Administered via IV, this option allows patients to
enter a state of deep relaxation.

36. General Anesthesia
 When oral and IV sedation are not sufficient to keep
patients calm for procedure, general anesthesia is also an
option.
 Administered by an experienced anesthesiologist, the
medication puts patients into a deep sleep.
 The patient’s vitals are closely monitored throughout the
duration of their procedure, ensuring their safety from
start to finish.
 All general anesthesia treatments are performed at a
hospital.

37. Complications of IV sedation
 Airway Disaster 20%
Aspiration • Respiratory Depression
 Cardiovascular Complications
 Paradoxical Response to sedation
 Medication Related Events
 Inadequate Sedation / Movement
 Nausea and Vomiting
 Patient Dissatisfaction
 Agitation in 28.6%
 Sleepiness in 28.6%
 Drowsiness in 14.3%
 Pain in 14.3%

38. Complications of IV sedation
Possible Solutions ?
 Provider Education and Training
 Patient Selection
 Adherence to dosing recommendations
 Improved Monitoring
 Increased VIGILANCE

39. Equipment
 Fully equipped crash cart, including emergency and
resuscitative drugs, airway and ventilatory equipment, and
defibrillator in all locations where conscious
sedation/analgesia is administered.
 Electrocardiogram (ECG) monitor with display
 Noninvasive blood pressure (BP) monitor
 Oximetry monitor
 Stethoscope
 100% oxygen source and administration supplies
 Airways and positive pressure breathing device in room
 Suction source and supplies
 IV supplies
 Sedative, analgesic, and reversal agents

40. Equipment
Intravenous equipment
 Gloves
 Tourniquets
 Alcohol wipes
 Sterile gauze pads
 Intravenous catheters [24-22-gauge]
 Intravenous tubing [pediatric “microdrip” (60 drops/ml)]
 Intravenous fluid
 Appropriately sized syringes
 Tape

41. Equipment
Basic airway management equipment
 Source of compressed oxygen (tank with regulator or
pipeline
 Supply with flowmeter
 Source of suction
 Suction catheters [pediatric suction catheters]
 Face masks [infant/child]
 Self-inflating breathing bag-valve set
 Oral and nasal airways
 Lubricant

42. Equipment
Advanced airway management equipment
(for practitioners with intubation skills)
 Laryngeal mask airways
 Laryngoscope handles
 Endotracheal tubes

43. Equipment
Pharmacologic Antagonists
 Naloxone
 Flumazenil
 Emergency medications
 Epinephrine
 Ephedrine
 Vasopressin
 Atropine
 Nitroglycerin (tablets or spray)
 Amiodarone
 Lidocaine
 Glucose, 50% [10 or 25%]
 Hydrocortisone, methylprednisolone, or dexamethasone

44. Equipment

45. Equipment

46. Equipment

47. Equipment

48. Equipment

49. Equipment

50. Equipment

51. Preparation Phase
 Insure all supplies and equipment to be used for the
administration and monitoring of conscious
sedation/analgesia and emergency management are
fully stocked and functional.
 Review patient’s history and physical information
and any risk factors of conscious sedation/analgesia.
 Determine current medications patient is taking;
existence of allergies; adverse experience with
anesthesia
 Last oral intake
 Insure written consent is obtained

52. Preparation Phase
 Patient education includes discussing the
following important points:
 Purpose and goal of conscious sedation/analgesia
 Procedure for administering conscious sedation/analgesia
 Sensations patient may experience
 Assessment and monitoring
 Pain assessment, use of pain rating scale
 Side effects and complications and their treatment
 Patient’s and family’s roles
 Post recovery expectations and instructions

53. Preparation Phase
 Attach monitoring equipment to patient (ECG, BP,
oximetry).
 Obtain and document baseline data on patient: heart
rate and rhythm; respiratory status, including
oxygen requirements, depth of respirations, breath
sounds, and oxygen saturation; blood pressure; skin
condition; level of sedation and mental status; ability
to ambulate; weakness and/or sensory loss in
extremities (if indicated); and description and
intensity of any current painful condition.
 Insert IV line

54. Monitoring
 Level of Consciousness.
 Pulmonary Ventilation.
 Oxygenation.
 Hemodynamics.
 Blood pressure
Once sedation started, recording vital signs every 5
min. until the end of the procedure.

55. Monitoring
Availability of an Individual Responsible for
Patient Monitoring
 A designated individual, other than the practitioner
performing the procedure, should be present to
monitor the patient throughout procedures
performed with sedation/analgesia.

56. Administration Phase
 Conduct a “time out” to verify patient and the
procedure with assistant present (two-person rule).
 GOAL DIRECTED PROTOCOL
 PATIENT-TARGETED PROTOCOL

57. Administration Phase
 Administer pharmacological agents under direct
supervision of responsible physician.
 Continuously observe and document patient
responses to conscious sedation/analgesia
 ECG, BP, and oxygen saturation every five minutes
 Auscultation of breath sounds and observation of
respiratory depth and rate every five minutes
 Level of sedation and mental status every five
minutes
 Pain rating every 10 minutes

58. Recovery Phase
 Continue mechanical monitoring: ECG, BP, oxygen
saturation.
 Assess and document vital signs, skin condition,
level of sedation and mental status, and pain every 15
minutes for at least 60 minutes after the last sedative
or analgesic drug dose is given and until discharge
criteria is met.
 Maintain IV access for at least 60 minutes after last
sedative and analgesic drug dose is given and until
discharge criteria are met.
 Review discharge instructions.

59. Recovery Phase
Patients who have received conscious sedation/analgesia may be
discharged 60 minutes after the last dose of sedative or analgesic drug
is administered if all of the established discharge criteria are met.
 Patient is as alert and orient as baseline
 Presence of protective reflexes (swallow and gag)
 Stable vital signs consistent with baseline for 30 minutes after last drug dose
 Oxygen saturation on room air at least 95% or at baseline for 30 minutes after
last drug dose
 Cardiac rhythm consistent with baseline
 BP and heart rate within 20% of baseline or within normal limits
 Pain rating < or = to baseline
 Patient is able to ambulate with minimal assistance.
 Responsible adult is present to drive patient home and remain with patient the
length of two half-lives of the drugs administered for conscious
sedation/analgesia

60. Conscious Sedation
 Practitioners must be skilled in providing procedural
sedation, must be
 Proficient in airway management
 BLS, ACLS and cardiovascular support
 Must possess the skills required to rescue a patient from sedation
deeper than intended.
 Have privileges granted to perform conscious sedation
 Training in:
 Oxygen delivery systems
 Basic cardiovascular physiology
 Pharmacology of sedatives and reversal agents
 Understanding and knowledge of required and emergency equipment
 KNOW HOW TO CALL FOR HELP !

61. Conscious Sedation
 It is recommended that a trained anesthesia
provider be consulted prior to administering
conscious sedation/analgesia if:
 Liver or kidney disease
 Respiratory compromise
 Unstable arrhythmias
 Young children, infants, neonates
 Frail, debilitated elderly (ASA class ≥ III)
 Possible or confirmed pregnancy, nursing mothers
 H/o drug abuse
 Severe Obesity

62. Conscious Sedation
Procedural Sedation is extremely Safe and
Effective when performed on well selected,
adequately informed patients, by
appropriately trained, credentialed, and well
supported providers.

63. QUESTIONS !!