SEDATED PROCEDURES
. . . Safely and Effectively
. . .
An Emergency Department
Outline
by Tom Trimble, RN
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DEFINITIONS, PURPOSE, & SCOPE:
DEFINITIONS:
Analgesia---Relief from pain
Anesthesia---A state with five conditions:
1. Analgesia
2. Amnesia
3. Unconsciousness
4. Muscle relaxation
5. Physiologic stability
Local anesthesia---Creating a local area of insensibility to pain by the injection of a local anesthetic
Hypnotic---An agent that promotes the onset of sleep.
Induction agent---A drug that promotes the quick short-lived onset of unconsciousness allowing endotracheal intubation to be performed; there should be unresponsiveness to command and loss of the ciliary reflex
Sedative---An agent that decreases activity, moderates excitability and calms the patient
Conscious sedation---Pharmacologically producing a state of profound sedation while maintaining all protective reflexes
Dissociative sedation---A chemically produced unique state with the following features:
1. Analgesia
2. Amnesia
3. Cooperation
4. Maintenance of all protective reflexes
Unconscious sedation---Sedation associated with loss of protective reflexes
Rapid tranquilization---Chemically sedating severely agitated or violent patient
{from "Analgesia & Sedation" by Paris, Paul M. and Stewart, Ron, in Rosen’s Emergency Medicine}
The purpose of conscious, dissociative, and deep sedation in the emergency department is to humanely facilitate noxious and painful procedures with minimal discomfort and minimal danger to the patient’s physiologic homeostasis.
The scope is to effectively carry out such sedation for brief procedures not requiring the extended time, monitoring, surgical relaxation, and physiologic control typical of general anesthesia in an operating room.
THE USE OF SEDATION IS NOT AN EMERGENCY BUT HAS THE POTENTIAL TO CAUSE EMERGENCIES!
CAVEATS & LEGAL CONSIDERATIONS:
1. Are YOU "prepared" by education, licensure, training, and experience to render conscious sedation? Has your competency been reviewed and approved? Are you authorized to do it? Are you fully familiar with all official Policy & Procedures, Standards or Guidelines, and customary practices effective upon that date?
2. Is the procedure indicated? Is the environment prepared, safe, and conducive to do it?
3. Does the patient meet criteria? Has valid informed consent (after explanation of risks and benefits) been obtained? If relative contraindications are present, have countermeasures been planned and provided?
4. Are you prepared and equipped to deal with any adverse event which may occur ?
5. Will your documentation comply with all applicable standards? Will any necessary additional reports such as Adverse Drug Reaction, Incident Reports, or QA-QI, be prepared also?
ASSESSMENT & PRE-PLANNING FOR CONSCIOUS SEDATION:
Is a sedated procedure likely to be necessary?
Has patient been NPO for 4 hours?
Is the patient's weight known or accurately estimated? Dosage calculations for initial, incremental, or re-dosing known ahead of time.
Are there any removable dentures? Any indicators of potential difficult intubation or of difficult mask-ventilation?: history of difficult intubation; short, thick neck; receding jaw; edentulous; obesity; poorly opening mouth; physical distress;
Pertinent Complicating Medical History or Co-ingestions?
Is adequate large bore IV access in place?: Contralateral, if possible to the side of injury or intended procedure; sufficient volume of fluid available to counter any hypotension; adequate extension tubing; needle-less set-up or stopcock?
When did the patient last void the bladder?
Adequate post-discharge safe transportation and supervision available?
Charge nurse and other staff aware to provide cover and back-up?
Other personnel necessary? e.g. Anesthesiologist? Respiratory Therapist? Additional providers for the procedure or manipulation? Additional nurse to "circulate"?
CONSCIOUS SEDATION "PRE-FLIGHT
CHECKLIST"
{CONTROLLED ENVIRONMENT}
Informed consent obtained?
Physical Preparation of a safe environment?
1. Patient pre-oxygenated with O2 4 lpm nasal prongs x 5 minutes to Sa(tc)O2 =/>95%?
2. Suction equipment set-up, function-tested, and at hand?
3. O2 BVM with correctly sized mask at hand? Anesthesia Bag may be used but self-refilling BVM must also be present.
4. Resuscitation Equipment and Airway adjuncts at hand (OPA, NPA, ETT) Laryngoscopy equipment.
5. Monitoring devices in place and functioning:
Pulse Oximetry (consider adhesive sensor, reinforce prn);
Vital Signs Monitor (DynaMap™ or Sphygmomanometer);
Cardiac Monitor (if +cardiac history, age >50 yrs., or potentially unstable)
6. Anticipated Sedatives and Analgesics, with additional doses available without leaving room. Reversal agents present in cart.
7. Patient emotionally prepared for procedure. Lights dimmed if needed (but adequate for observation).
8. Personnel present, prepared, roles agreed upon, coached as needed. Emergency Department Attending Physician or Anesthesiologist MUST be present for and throughout the procedure! [Only an individual QUALIFIED to carry-out a "worst-case" airway management scenario] Unnecessary family or personnel removed. Necessary family must be cautioned as to expectations, and to leave when signaled.
DURING THE PROCEDURE:
Observe the patient continuously.
Maintain a quiet environment
Remember, the patient is always listening. Amnesia may not occur ---despite the reputation of the drug. Amnesia can be enhanced prior to, during induction, during awakening, and during recovery to alertness, by soothingly telling the patient that he "doesn't need to remember any part of this that he doesn't wish to; that he can remember only to forget and forget to remember."
Talk to the patient frequently and soothingly. "Verbal Anesthesia" works!
If additional equipment is needed, have a runner obtain it. The patient should not be left without someone whose sole duty is to look after him.
Do not persevere in failing efforts. If safe sedation is not adequate to accomplish the procedure, it may be necessary to abort further efforts and admit or have the patient return for general anesthesia in the OR.
Provide for the patient’s safety, warmth, and modesty.
SIGNS OF SEDATION:
The patient may take a few deeper breaths; the speech (e.g. counting backwards) becomes slower, softer, slurred, cognitive errors occur, and speech ceases; the face assumes a more relaxed appearance and facial tone sags, breathing becomes more shallow and slow; if airway is not supported, the lips may splutter and stertor occur with expirations; the patient no longer flutters eyelids when the lashes are gently stroked with a finger; the patient no longer responds to a noxious stimulus. The patient should still maintain his respiration and vital signs should be adequate and stable. Awakening occurs in reverse order. Amnesia is neither immediate nor invariable.
NON-PHARMACOLOGICAL ENHANCEMENT OF SEDATION:
Having the patient understand, from his own point of view, what the procedure is and why it is desirable, the anticipated sequence of events, what he is likely to feel and experience during induction and wakening, to realize that any emergency is prepared for and that he will not be alone at any time.
Talk to the patient during preparation and induction. Have others in the room remain quiet (it is easier to focus upon a single empathetic voice). The patient should never hear "OOPS!", or any gossip, clinical chatter, or joking. The patient is always listening.
If adverse events occur, repeatedly and confidently point out to the patient his positive responses, "I see you doing so much better, your pulse is strong and firm, your breathing is easier and more relaxed, your color is so much better, you must be feeling better now than you were, keep it up! You’re doing so well!"
If sedation lightens or the patient responds by struggling to stay awake, tell him, soothingly, "That’s right, everything is o.k., you can go back to sleep, now!
Amnesia can be enhanced by saying "You don’t have to remember any more of this than you wish to."
Learning can be enhanced by telling the patient "You will want to carefully remember and do all the suggestions for getting better that the doctors and nurses give you."
RECOVERY FROM SEDATION:
Provide a calm and unthreatening environment.
Reassure and re-orient the patient frequently.
Be wary of re-sedation ensuing after the successful completion of the procedure has relieved the patient of his pain and anxiety when heavy doses of analgesic and sedations have not yet worn off.
Provide follow-up procedures as needed e.g. post-reduction films, etc.
Monitor and document LOC, VS, course of events.
DISCHARGE:
Patient achieves pre-procedure mental status and vital signs.
Patient is able to drink and tolerate fluids, to urinate, to ambulate satisfactorily.
Has sufficient supplies and medicine to care for self, understands instructions.
Has someone to drive and to supervise patient.
POST-DISCHARGE & DOCUMENTATION:
Return room to reusable and re-stocked condition.
Waste controlled drugs in compliance with policies.
Assure all charting, reports, other documentation is complete.
Responsible physician must complete ED Critical Care Note.
Charge patient appropriately for procedures, supplies, services.
Important Additional Readings:
ENA's
Position Statement on Conscious Sedation
[http://www.ena.org/about/position/conscioussedation.asp]
ANA's Position
Statement on RN's Administering Sedation
[http://www.nursingworld.org/readroom/position/joint/jtsedate.htm]
Practice
Guidelines for Sedation and Analgesia by Nonanesthesiologists - from American
Society of Anesthesiologists
[http://www.asahq.org/publicationsAndServices/sedation1017.pdf]
Sedation
of Patients in Intensive Care Unit
- from Anesthesiology - Medstudents of The
Federal University of Rio de Janeiro
[http://www.medstudents.com.br/anest/anest4.htm]
Practice Guidelines for Management of the Difficult Airway: An Updated
Report by the American Society of Anesthesiologists Task Force on Management
of the Difficult Airway
[http://www.anesthesiology.org/pt/re/anes/fulltext.00000542-200305000-00032.htm;jsessionid=Cl0UbU0lS2SMOQ1nVxuoPSpV1EgiY6CgpoRpRieKfcWsxyqSZfZQ!-1715133107!-949856031!9001!-1?&fullimage=true]
pdf format [http://www.anesthesiology.org/pt/re/anes/pdfhandler.00000542-200305000-00032.pdf;jsessionid=Cl0UbU0lS2SMOQ1nVxuoPSpV1EgiY6CgpoRpRieKfcWsxyqSZfZQ!-1715133107!-949856031!9001!-1]
"Sedated Procedures Safely and Effectively - An Emergency Department
Outline"
[http://ENW.org/SedationGuidelines.htm]
is a webarticle presented by:
Emergency Nursing World ! [http://ENW.org]
©Tom Trimble, RN
[Tom@ENW.org]
Our
DISCLAIMER
completely and specifically applies to each and every part of this article.
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