|Checklist for Sedated Procedures|
by Tom Trimble, RN
N.B.: This document is intended as a memory aid for Qualified staff in preparing for a sedated procedure. It is not a substitute for training or credentialing to provide sedation. Its goal is to promote consistency and compliance with requirements of policy and safety.
Anticipation: Caution Pt. NPO; Ascertain weight; verify meds., allergies, comorbid history, potential airway problems/anesthetic history; Confirm patient will not drive home; Notify Physician
Planning:Confirm plan to perform sedation; Confirm Airway Plan and Manager (Deep Sedation requires worse case scenario qualified Intubator (ED faculty, designated ED attendings, Anesthesiology only); Confirm adequacy of staff & conditions for proposed procedure; Resuscitation equipment & Code Cart at hand. NPO x 6 hrs (solids) x 2 hrs (clear liquids in modest amount) if in doubt, reassess plan!
Alternative Plans:Admit patient (short stay) for O.R. or other procedure room. Discharge patient for return as elective procedure (e.g., Ambulatory Surgery). Return to ED after full NPO time period.
Short painful procedures requiring
"relaxation" or amnesia (joint and fracture reductions, cardioversion):
IV Propofol (Diprivan™) or IV Methohexital (Brevital) & analgesic; adding "hematoma block" with fracture reductions. Longer procedures with unawareness/amnesia (e.g., pediatric wound repair):
IM Methohexital (Brevital) or Ketamine (Ketalar). Short procedures requiring dissociation, amnesia, analgesia, and lower risk of airway loss:
IV Ketamine (Ketalar). Longer procedures requiring titrated analgesia/sedation with patient cooperation or not needing unawareness:
IV morphine/fentanyl & midazolam/diazepam.
Monitoring:Continuous Pulse Oximetry; Vital Signs (automatic=OK) within 15 minutes before procedure, 5 minutes after drug, q 15 minutes thereafter until recovered. EKG monitor if cardiac history or over 50 years of age (run rhythm strip). Pain Scale rating assessed.
Drug Preparation: Draw drugs (label if >1 agent); Naloxone/Flumazenil in room, if appropriate to agents used.
Patient Preparation: Monitors as above; IV access (available in room if IM sedation only): N.S. (18ga. desirable); allay anxiety; Oxygen for all patients (titrate sPo2 to 95% or greater). Suction/resuscitative equipment functional.
Recovery: Observe & record: LOC/GCS, VS/SpO2, q 15 minutes until baseline; Must be able to lift head/take deep breath to command. Wakefulness should be without verbal slurring or confusion (or to baseline).
Beware: Be wary of potential re-sedation after procedure as stimulus of pain and anxiety removed, especially with multiple agents or doses rapidly absorbed.
Discharge Criteria: Alert or baseline (exhausted children past bedtime may be drowsy if undisturbed but rousable and otherwise stable); able to take po fluids, able to ambulate at baseline; able to void; verbalization at baseline; understands cautions (to baseline). Pain Scale Assessment.
Documentation: Complete Conscious Sedation Record; Revert to regular Nurses Notes after Recovery; Log ALL cases in Sedation Log; Procedure Note by physician; QA Voice Line/ Incident Report of indicated cases.
"Checklist for Sedated Procedures"
is a webarticle presented by:
Emergency Nursing World ! [http://ENW.org]
©Tom Trimble, RN [Tom@ENW.org]
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