Conscious sedation

Prof.Med. Nabil H. Mohyeddin

Board certified
Intensive care &Anesthesiology
Rostock University
Academic College, Berlin, Germany
E-mail: nhm1955@hotmail.com
Objectives & Sedation
Definitions
 Goals
• To provide safe
sedation/analgesia (Guard patient
• safety)
To decrease adverse
psychological responses
• To facilitate procedural ease
through:
1. Minimize pain of procedure.
2. Minimize fear and anxiety.
3. Control behavior.
 (Minimal Sedation (Anxiolysis

• A drug-induced state during which

patients respond normally to verbal
commands. Although cognitive
function and coordination may be
impaired, ventilatory and
cardiovascular functions are
unaffected.
 Moderate Sedation

• A drug induced depression of

consciousness during which patients
cannot be easily arouse, but respond
purposefully following repeated or
painful stimulation. No
interventions are required to
maintain a patent airway, and
spontaneous ventilation is adequate.
Cardiovascular function is usually
maintained.
 Deep Sedation

• A drug-induced depression of consciousness

during which patients cannot be easily
aroused, but respond purposefully following
repeated or painful stimulation. The ability to
independently maintain ventilatory function
may be impaired. Patient may require
assistance in maintaining a patent airway and
spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.
 The Spectrum of Sedation
Patients may travel quickly in either direction along this spectrum!

Level of Analgesia “Conscious Deep

Awake Anxiolysis General
Consciousness Anesthesia
Hypnosis Sedation” Sedation

Protective Potential Potential

Present Present Total Loss
Reflexes Loss Loss

ED/Transport Mgmt
Pharmacology
of Sedatives
 Common Medications for
Sedation & Analgesia
•Benzodiazepines
•Opioids
•Sedative-hypnotics
•Neuroleptics
•Anaesthetic agents
 Common Medications for
Sedation & Analgesia
• Desired actions of drugs used for
sedation:
• Short duration of action
• Lack of cumulative effects
• Promote rapid recovery
• Minimal side-effects
• Residual analgesia
• Unfortunately, no single pharmacological
agent satisfies all requirements. Generally
have to combine medications.
 List of Terms
• Because of the wide range
of settings in which this
presentation will be
viewed, a list of generic
and proprietary drug
names is presented.
Please refer to this slide as
necessary throughout the
presentation.
• Alprazolam = Xanax
• Diazepam = Valium
– Lorazepam = Ativan
• Midazolam = Versed
• Propofol = Diprivan
• Ketamine= ketalar
• Fentanyl
• Mepiridine = pethidine
• Naloxone = Narcan
• Flumazinil = Romazicon
– Methohexital = Brevital
•
Sodium Thiopental =
Sodium Pentothal
 Benzodiazepines
• AAcctions:
• Potentiate the effects of the neuroinhibitor
GABA.This creates anticonvulsant, amnesic and
sedative effects.
• Mimic inhibitory actions of Glycine. Causing
muscle relaxation and anxiolysis.
• Benzodiazepines affect the limbic system,
thalamus and hypothalamus.
 Benzodiazepines
• Indicated for:
• Anxiety
• Insomnia
• Seizures
• Muscle relaxation
• Induction of general anaesthesia
• Preoperative sedation
• Conscious sedation
• Alcohol withdrawal
• Most commonly used types:
• Diazepam, Lorazepam and Midazolam
 Benzodiazepines
• Benzodiazepines have no analgesic properties.

• Combining sedatives and opoids creates

a synergistic action.

• Recommended to reduce dose of

benzodiazepine and opiod by 1/3 when giving
concurrently.
 !Watch Out
•Contraindications:
• Acute narrow angle glaucoma
• Untreated open angle glaucoma
• Shock
• Coma
• Acute alcohol intoxication
• Children<6 months old
 Benzodiazepines :
Adverse
effects
• Respiratory:
• Respiratory depression,apnoea,respiratory arrest
(especially Midazolam)
• CV:
• Diazepam-SVR and CO
• Midazolam-hypotension and bradycardia
• CNS:
• Diazepam-drowsiness, confusion,slurred speech, syncope
• Midazolam-agitation, hyperactivity, involuntary movement,
combativeness
 (Midazolam (Versed

• Rapid onset.
• Short duration 20 - 30 minutes.
• Dose
• IV 0.1mg/kg max. 5mg., onset 2 -
3 min.
• Oral 0.5mg/kg, onset 20 - 25 min.
• Intranasal 0.4mg/kg, onset 15 -
20 min.
• Rectal 0.5mg/kg, onset 5 - 10 min.
 Opioids
• The opioids provide analgesia and
some sedation, as well as
alterations of mood and
perception of surroundings. They
may also depress cough reflexes.
• Examples include
– morphine
– hydromorphone
– meperidine
– fentanyl depicted at right
• Some opioids like meperidine
and fentanyl are synthetic
substances, while others are
natural.
 (Mepiridine (pethidine

• Meperidine should be used cautiously in

patients with renal/hepatic disease, those
at risk for seizure due to accumulation of
its active metabolite, normeperidine, and
in those with little cardiac reserve.
• 0.5-2 mg/kg iv bolus, may repeat
as necessary.
• Not used in pediatric patients.
 Fentanyl
• Fentanyl may cause chest wall and glottic
rigidity, particularly when administered
rapidly. This may make manual
ventilation very difficult.
• Route: IV
• Onset: 1-3 min
• Duration: 30-60 min
• Adult dose: 25-50 mcg/dose
• Propofol is widely • To prevent hypotension
distributed in the body consider reduced doses
and is eliminated via in the elderly,
hepatic & pulmonary hypovolemic, or patients
systems. receiving other
• No dosage adjustments narcotics/sedatives.
necessary in patients with • Supports rapid bacterial
hepatic/renal disease. growth; discard 6 hrs
after opening.
 (Propofol (Diprivan
• Experience in emergency department
limited.
• Short acting, nonopioid sedative
hypnotic.
• Dose, 1 - 2 mg/kg IV over 1 - 2 min
followed by infusion of 6mg/kg/hour.
• Duration, 8 - 10 min.
• Side effects
• Deeper sedation.
• Cardiorespiratory depression. (hypotension
3-10%)
• Pain at injection site.
 Ketamine
•Sedative
•Amnesia
•Powerful analgesic
•General
anaesthesia
 Ketamine: Adverse effects

• CNS: muscle tone, emergence reaction:e.g

hallucinations, delirium, tremors, increase
intracranial pressure
• CV: increase BP, tachycardia, decrease
BP in hypovolaemic patients
• Respiratory: copious secretions (pre-treat
with atropine)
 Ketamine:
Contra-indications
• Hypertension, heart failure, recent
MI, history of cardiovascular
disease
• Increased intracranial pressure
• Increased intraocular pressure
• Acute psychiatric illness
• Thyrotoxicosis
 Barbiturates
• Barbituates include
sodium pentothal and
methohexital.

• Barbiturates provide
sedation but no
analgesia.
 Reversal Agents
• Naloxone:
– Dose for reversal. IV or IM or SC.
• Titrate 0.01 - 0.1 mg/kg to desired effect.( 1-
2 mcg/kg over less than 30 seconds to
reverse sedation.
• May need multiple doses.( repeat every 2-3
min. )
• Onset of action 1 - 2 min.
• Duration of action 20 - 60 min.
• Flumazenil (Anxat)
– Dose IV or IM
• Pediatrics 0.01 - 0.2 mg/kg (max.
0.2mg) May be repeated. Half
dose q 1 min.
• Adults 0.2 mg bolus to total 1mg.
May repeat q 10 min.
• Onset of action 1 - 5 min.
• Duration of action 20 - 60 min.
-,
Reversal Agents
 :Indications of conscious sedation

– Fracture, dislocation reduction.

– F.B. removal
– Laceration repair
– Endoscopy
– Pediatric Gyne .Exam
– Invasive procedure.
– Others
Complication of
Sedation
 High risk patients
• The elderly
• Hepatic disorders
• Renal disorders
• Respiratory disorders
• Cardiac disorders
• Drug abusers
• Obese patients
 Monitoring
• Vigilant monitoring is the
key to prevention of
overdose and other potential
complications
 Sedation
• Sedation failure:
– Could be due to unsuitability of the
patient , or
– Problems with medications
• Excessive sedation
– Can be avoided by:
• Monitoring level of consciousness(i.e Ramsey
score)
• Titration of medications
 Respiratory depression &
hypoventilation
• Detected by:
• Decrease in oxygen saturation
• Decrease in rate and depth of respirations
• Treatment:
• Stimulate patient
• Open airway
• Give oxygen
• If the above steps are unsuccessful,ventilate
with ambu-bag. If the condition does not
improve or the patient stops breathing,
intubate.
 Cardiac complications &
hypotension

• Cardiac arrythmias:
• Must be recognized and treated quickly for
positive patient outcomes
• Hemodynamic instability, caused
by a variety of factors:
• Hypovolaemia
• Myocardial ischaemia
• Medications
• Acidosis
• Parasympathetic stimulation
 Cardiac complications &
hypotension

• Treatment:
• IV fluids
• Oxygen
• Vasopressors or specific
agonists(avoid if possible)
 In conclusion
• If patient and medication
selection is appropriate and the
patient is monitored adequately,
then the incidence of
complications due to
sedation/analgesia will be very
low.
Staff Qualification
& Privileging
Sedation policies & procedure
:identify

• Special qualifications or
skills of staff involved
in sedation process
 Sedation Provider

• Any physician who is privileged.

• Anesthesiologists by nature of
their specialty.
• Physician or dentist who
is credentialed or
privileged.
 The Sedation Provider should be
:competent in

• Techniques of various modes of sedation

• Appropriate monitoring
• Response to complications
• Use of reversal agents
• At least basic life support
 Privileging of non-
Anesthesiologists
• Valid BLS Certification.
• Documente attendanc and successful
d e of an approved
Sedation/Analgesia
completion Course.
• Training curriculum clearly indicating that
competency in providing Sedation/Analgesia
is part of the qualification process for
his/her degree.
 Privileging of non-
Anesthesiologists

• Certificates of experience from his/her Chairman

or previous employer documenting that provision
of Sedation/Analgesia is part of his/her clinical
practice for a minimum of 5yrs.
• Attending and the BasicCompetency
Course provided by the Hospital Sedation
passing
Committee.
 Privileging of non-
Anesthesiologists

• Re-evaluation of Privileging on
individual basis is mandated if:
• Invalid BLS.
• Less than 10 sedation/procedures per year.
• Failure to pass the basic competency course
provided by the Hospital Sedation
CCoommmittee.
 Responsibilities of Sedation
Provider
• Obtain Consent
• Evaluate patient prior to procedure
• Document the assessment
• Refer to Anesthesia Department if
• needed
Prescribe or administer medications as per
• his/her privilege
• Ensure
Present monitoring of patient’s
in procedure progress
area throughout the entire
procedure and remain on the premises of recovery area
during recovery.
• Ensure appropriate discharge of patient.
Competencies required for Registered
Nurse

• The nurse is competent in patient

monitoring, drug administration, and
protocols for dealing with emergency
situations
• The will have NO other
responsibilities
nurse that would leave
patient unattended the compromise
continuous monitoring.or
Competencies required for Registered
Nurse
• The Nurse is able to demonstrate the
required knowledge of Pharmacology, and
complications related to medications.
• Demonstrate monitoring requirements
during sedation and recovery.
• Understand the principles of oxygen delivery,
respiratory physiology, transport and uptake,
and demonstrate the ability to use oxygen
delivery devices.
Competencies required for Registered
Nurse

• Anticipate and recognize potential

complications of sedation in relation to the
type of medication being administered.
• Possess the requisite knowledge and skills
to assess, diagnose and intervene in the
event of complications undesire
outcomes
or and to institute d
interventions in compliance with orders.
nursin
g
 Competencies required for
Registered Nurse

• Demonstrate skill in airway management and

resuscitation principles.
• The Nursing Education Department will maintain
an educational/competency validation mechanism
that includes demonstration of the knowledge, skill
and abilities related to the management of patients
receiving sedation/analgesia.
 Privileging for
Registered Nurse
• The Registered Nurse needs to have
a valid:
• BLS certificate
• IV Cannulation workshop
• ECG workshop
• Sedation and Analgesia
workshop
The Registered Nurse is Responsible
:for

• Providing uninterrupted
monitoring of the patient’s
physiological parameters
• AAsssisting in supportive
or resuscitation
measures.
Documentation
 Responsibilities of Sedation
Provider

• Obtain Consent (new requirement)

• Evaluate patient prior to
• procedure Document the
• assessment
• Refer to Anesthesia if needed
Prescribe or administer medications as per his/her
• privilege
• Ensure monitoring of patient’s progress
Present in procedure area throughout the entire
procedure and remain on the premises of
• recovery area
during recovery.
 Documentation

• ASA Classification
• Airway classification
• Physical examination
• Lab results
 ASA Classification of Physical Status

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

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

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

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

• Class V
– The moribund patient who has little chance of survival
but is submitted to operation in desperation.Examples:
Burst of aortic aneurysm with profound shock, major
cerebral trauma with rapidly increasing intracranial
pressure, massive pulmonary embolus. Most of these
patients require operations as a resuscitative measure.
(i.e. patients who are not expected to live more than 24
hours).
 ASA Classification of Physical Status
• Class E
– Any emergency procedure, is labelled E
in addition to one of the above classes
according to patient’s condition, e.g. II E
or I E.
 Anesthesia Consultation

• Adult patient ASA III or above.

• Pediatric patient ASA IV or above.
• Patients with complex airway
• problems. Previous failure of
• sedation / analgesia.
Patient ASA I or above undergoing a diagnostic
and / or therapeutic procedure(s) performed by a
physician / dentist who is not privileged to
perform sedation / analgesia.
HOW TO IMPLEMENT THE STANDARDS
 The Beginning

• Formulate a Task force for evaluation.

• Review the policy.
• Identify and Inspect the sedation areas.
• Review the process of conduct of
sedation, monitoring, record keeping.
• Review of departments policies.
 Goal
• Formulation of Hospital Policy.
• Formulation of unified record
keeping.
• Formulation of a sedation
committee.
• Define the charges of the
committee.
 Committee Members

• Chairman:
Anesthesiologist
• Members:
• Physician Representative from major
clinical departments.
• Nursing representative from Nursing
education department.
• QM representative.
• Clinical pharmacist.
• Admin Assisstant
 Committee Charges

• Survey & Certify Location(s) within the hospital meeting

the criteria of your policy.
• Review & update the policy.
• Conduct and prepare a sedation/analgesia course for
physician and nurses.
• Certify physicians requesting sedation privileges.
• Certify nurses to monitor patients during sedation.
• Monitor the practice and come up with recommendation
to improve the quality of care.
 Committee Charges

• Receive quarterly reports and statistics from

various clinical departments in relation to the
practice of sedation.
• Receive and review quality indicator forms forwarded
from various departments in relation to the practice
of sedation.
• Submit a quarterly report to the hospital Q.I
• committee.
Forward an annual report to medical director about the
practice of sedation/analgesia.
Audit & Quality Improvements
how do we audit our practice
 Quality Indicators

Used for monitoring of sedation/analgesia

performance
Completed by Sedation Assistant at the end
of procedure
Sent to Quality Management Department
for review and analysis
why do we need to audit our
practice
Adverse events or patterns of adverse
events during moderate or deep
sedation are analyzed.
Use information from data analysis
to identify improvements or reduce
(or prevent) adverse events.
Hospital Sedation
Committee
Rationale

• Maintain the quality of care.

• Maintain patient safety.
• Central committee responsible
about the practice of
sedation.
Hospital Sedation Committee

•A committee that is called

approved
and by the Hospital Director, or
equivalent, to be responsible about
the practice of sedation/analgesia by
non anaesthesiologist.
 :Committee Members
• Chairman: chair of the Anesthesiology Department, or
an Anesthesiologist Nominated by the chair of the Anesthesia
• Department.
• Nursing division representative: Director of Nursing Education.
• Quality management representative: quality management specialist.
Department of Medicine representative: Chair or any
• physician nominated by the chair of the department.
Department of Surgery representative: Chair or any physician nominated
• by the chair of the department.
• Department of Paediatrics/Paediatric Oncology representative.
Department of Emergency & family medicine representative: Chair
• or any physician nominated by the chair of the department.
Administrative Assistant.
 Charges
• Survey and certify location(s) within the institute meeting the criteria of the hospital
policy.
• Review and update that policy.
• Conduct and prepare a sedation/analgesia course for physicians and nurses.
• Certifications of physicians requesting the privilege to administer sedation.
• Certifications of nurses to monitor patients during sedation.
• Monitor the practice of sedation/ analgesia in the hospital and come up
with recommendation to improve the quality of care as deemed necessary.
• Receive quarterly reports and statistics forwarded from various clinical departments in
relation to the practice of sedation/analgesia.
• Receive and review quality indicator forms forwarded from various departments
in relation to the practice of sedation/analgesia.
• Forward an annual report to the Hospital Director, or equivalence about the practice of
sedation/analgesia.
• To conduct research in the field of sedation/analgesia for the purpose of improvement
of the quality of care.
• o v e r