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Pre sedation phase

Informed Consent, Levels of Sedation, Getting Started, Equipment Needs, Standard Monitoring, Timeout

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Pre sedation phase

  1. 1. Wesam Farid Mousa Assist prof Anesthesia & ICU Dammam University , KSA Informed Consent, Levels of Sedation, Getting Started, Equipment Needs, Standard Monitoring, Timeout
  2. 2. Needed from all patients undergoing procedural sedation Consent will be obtained by the physician: Consent is a process not a signature - Options for care - Explanation of risks
  3. 3. Understanding the various depths of sedation is essential to provide safe and effective sedation The American Society of Anesthesiologists (ASA) has defined the various sedation depths, as follows:
  4. 4. Patency of the Airway Response to tactile stimulation and verbal commands Co-ordination Cognitive function Ventilatory function Cardiovascular function
  5. 5. The patient retains ability to independently and continually maintain an airway and respond normally to tactile stimulation and verbal command. Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected.
  6. 6. The key word here is the ability of the patient to remain in a conscious state. Even though there may be a modest impairment of cognitive ability, they can still respond to you in a normal manner For example, I can ask them a question or lightly tap them on the shoulder and they can respond Swallowing reflexes are intact and they have no problem breathing on their own
  7. 7. The individual who is minimally sedated is still able to function in a somewhat normal fashion. Maybe we can say the patient is awake but drowsy
  8. 8. Patients at this level of sedation would be given a drug in an amount equal to or less than the minimal recommended dose (MRD)
  9. 9. Patency of the Airway Response to tactile stimulation and verbal commands Co-ordination Cognitive function Ventilatory function Cardiovascular function
  10. 10. The patient’s retains ability to independently and continually maintain an airway and respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Their cognitive function and co-ordination are noticeably influenced. Ventilatory and Cardiovascular function are usually maintained.
  11. 11. The key word here is purposeful. This person may be asleep, but he can be easily aroused. The patient can respond in a purposeful manner to verbal commands or light tactile stimulation. I can still ask the patient a question or tap them on the shoulder and they can respond, but it is purposeful. What does purposeful mean? He can respond, but has to think about what he is saying. ‫متأني‬ dedicated
  12. 12. This person would be obviously sedated, but still able to function. They should not be allowed to drive home. They would endanger themselves and others.
  13. 13. All swallowing reflexes are intact and they have no trouble breathing on their own. For those who have had received a colonoscopy, with moderate sedation. They would probably describe it as a pleasant experience, in which they remembered very little, if anything.
  14. 14. The starting dose would be the MRD increased in increments
  15. 15. Patency of the Airway Response to tactile stimulation and verbal commands Co-ordination Cognitive function Ventilatory function Cardiovascular function
  16. 16. The patient may lose the ability to maintain an airway and breath on their own. The patient is unable to respond purposefully to physical stimulation or verbal command. You have to shake him or arouse him with a painful stimulus to awaken him. They are asleep but difficult to arouse Their cognitive function and co-ordination are no longer preserved. Ventilatory and Cardiovascular function are usually maintained.
  17. 17. There is partial or complete loss of protective reflexes particularly the swallowing reflex. If they were to regurgitate, they could very well asphyxiate on their own vomit.
  18. 18. Patency of the Airway Response to tactile stimulation and verbal commands Co-ordination Cognitive function Ventilatory function Cardiovascular function
  19. 19. this is an induced state of unconsciousness that's accompanied by partial or complete loss of protective reflexes, including the inability to continually maintain an airway independently or respond purposefully to verbal commands or physical stimulus.
  20. 20. The key word here is unconsciousness. The patient cannot be aroused by shaking or painful stimulation. You can cut a patient with a scalpel and they will not respond.
  21. 21. Protective reflexes such as swallowing are obviously impaired and the patient may not be able to breathe on their own.
  22. 22. Key words: Minimal sedation: Normally Moderate sedation: Purposefully Deep sedation: Asleep General Anesthesia: Unconsciousness
  23. 23.  Dynamic Sedation Level The patient’s level of sedation may be dynamic. Patients may suddenly or gradually experience an increased or decreased level of sedation than intended.
  24. 24. The response to procedural sedation medications is directly related to the type of drug administered, the dose, and the individual’s own response.
  25. 25. Over-sedated risk of ventilatory and cardiovascular impairment and loss of protective reflexes Under-sedated • anxiety and agitation • awareness and recall Without a means to objectively titrate the level of sedation, patients may be:
  26. 26. Incidence of Inappropriate Sedation Over-sedation On Target Under-sedation 54% 15.4% 30.6% Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110. Olson D et al. NTI Proceedings. 2003; CS82:196. 10% 20% 70% Kaplan L. and Bailey H. 2000 Olson D. et al. 2003
  27. 27. Components of Comfort Analgesia Muscle Relaxation Consciousness/Sedation COMFORT Autonomic & Somatic Response + Pain Scales Movement + Nerve Stimulator Vital Signs + Sedation Scales + BIS Monitoring
  28. 28.  Ramsay Scale The goal of moderate (conscious) sedation is to have the patient at level 2 or 3 on the scale
  29. 29.  Richmond Agitation and Sedation Scale
  30. 30. Bispectral Index (BIS) A practical, processed EEG parameter that measures the direct effects of sedatives on the brain Frontal montage Numerical scale correla that is patient independent and it is drug independent. It requires no calibration for either the patient or the drugs that are being used. Provides objective information about an individual patient’s response to sedation
  31. 31. BIS Display / BIS Sensor BIS Display BIS Sensor
  32. 32. BIS Range Guidelines Titration of sedatives to BIS ranges should be dependent upon the individual goals for sedation that have been established for each patient. These goals and associated BIS ranges may vary over time, in the context of patient status and treatment plan.
  33. 33. BIS in Deep Sedation Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67. • Titration to maximal Ramsay Score of 6 (unarousable) • Blinded BIS monitoring Results: • Ramsay Score remains the same, with significant decrease of BIS values over time. • Data suggest possible accumulation of sedatives and inherent risks of over-sedation. 0 10 20 30 40 50 60 70 80 90 100 Day 1 Day 3 Day 5 BISValue BIS RamsayScore* 68 45 31 6 6 6 2 3 4 5 6 * Mondello et al. Minerva Anestesiology. 2002;68(102):37-43. Ramsay
  34. 34. BIS in Deep Sedation Riker. AJRCCM 1999 De Deyne. Int Care Med 1998 Unarousable 0 10 20 30 40 50 60 70 80 90 100 BispectralIndex(BIS) SAS 1 Ramsay 6 • Titration to unarousable state by subjective scale • Blinded BIS monitoring Results: • Patients were unarousable at maximal sedation score. • All patients appeared similar clinically, but displayed wide variation in sedation level as measured objectively with BIS monitoring. SAS=sedation agitation scale
  35. 35. The bispectral index (BIS) Although the latest recommendations from the ACEP state that “There is insufficient evidence to advocate the routine use of BIS in procedural sedation and analgesia", future studies will likely assess its utility
  36. 36. The two basic requirements for all procedural sedation are The continuous monitoring of vital signs by a combination of clinical methods and monitoring devices The continuous presence of a qualified person who is responsible for patient monitoring and not involved in any other procedures
  37. 37. Equipment Needs, Standard Monitoring
  38. 38. Be Prepared! Nothing is more expensive than the missed opportunity

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