Principles for Sedated Procedures
by Tom Trimble, RN
Anxiety Reduction: Insofar as possible, eliminate patient anxiety before beginning
the procedure. A patient's understanding of the intended procedure, that every
effort will be made to eliminate discomfort and memory of noxious stimuli, and that he need
not remember any part that he doesn't wish to, will go far to make the procedure
smoother and to lower the dose of sedative agents needed.
Anesthesia": Remember to choose your words carefully. (The patient is
listening!) Avoid "loaded" words such as "pain".
Choose words that allow you to make useful distinctions: "First, we'll use some numbing
medicine to eliminate "sharp" sensations and lessen discomfort.
You may be aware of some deeper sensations, such as pressure or tugging, but you don't
have to let those bother you! I think that you'll be pleasantly surprised
when it is over. And, that you'll have little reason to think about it. In
fact, while we're taking care of this, if you don't want to ---you don't even
have to be here! If you would rather be somewhere else, like on that perfect
vacation when you win the Lottery . . . you can go there in your mind's eye,
and enjoy it as much as you wish! Everything will have been done when it's over,
and you will have had a wonderful daydream. You are entitled to enjoy
Ensure that the patient is comfortably supported and positioned.
Nothing should interfere with him relaxing limply and loosely upon the bed.
Full use should be made of local and regional anesthesia with good coverage
of the operative area. This lessens the dose requirement for sedative agents.
Communication: The team and the environment should be conducive to
relaxation. Disquieting distractions should be avoided. Actions should be
smooth and unhurried. Voices should be soft background sounds (no conspiratorial
whispers; no unnecessary chit-chat). One person should have primary
responsibility for communicating with the patient, guiding his imagery, etc. Silly
jokes from others that "Now, you're making ME sleepy . . ." tend to break the
mood; other team members should be reminded beforehand that they do not need to pay
attention or respond to the relaxing suggestions given to the patient nor should they
distract from them.
Timing is everything:
Do not be rushed into beginning before medications have had full
effect. There is danger here. Inadequate preparations leads to calls for more
drug, more struggle, more drug; than either the procedure will fail or an excessively
sedated patient occurs, or both. Do not expect the "amnestic effect" to
cover all errors.
Pain Relief &
Correct Agent: Expect pain to increase during the procedure. Give
an adequate analgesia dose beforehand . Do not use a purely sedating or amnestic
agent alone as it does not have those properties .
Use Deep Sedation if
necessary: Short, sharp, uncomfortable procedures, e.g.
reductions of joints and malaligned fractures, or cardioversions, may require Deep
Sedation to accomplish a fast smooth result. Don't try to
"sneak-up" on an adequate sedation with small and piddling doses of analgesia
and sedatives! Do it right the first time. Less danger occurs in
the well-prepared short deep procedure which is quickly over, than in a longer ineffective
and tortured procedure.
Longer procedures, e.g. complicated wound repair, will do well with
"Conscious Sedation" unless absolute motionlessness (e.g. eyelid
repair) will be required, in which case admission for general anesthetic may be indicated.
Reduction in dosage should be made for patients in whom the "C.L.O.C.K"
Cardiac disease ---more easily stressed or decompensated, especially if hypotensive or hypoxemic.
Liver disease ---decreased clearance of drugs.
Old age ---unpredictable, potentially exquisite response to drugs.
Central Nervous System disease or polypharmacy ---unpredictable, potentially exquisite response to drugs; additive or potentiating effects of other medications.
Kidney disease ---decreased clearance of drugs.
N.B.: The scoring systems for level of sedation and post-anesthesia recovery usually seen here are removed for revision.
"ENW: Principles for Sedated Procedures" [http://ENW.org/SedationPrinciples.htm]
is a WebArticle presented by
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© Tom Trimble, RN [Tom@ENW.org]
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