CHAPTER 23. Moderate Sedation/Analgesia
Jan Odom-Forren
OBJECTIVES
At the conclusion of this chapter, the reader will be able to:
1. Define moderate sedation, deep sedation, and general anesthesia.
2. Identify the statutory, regulatory, practice guidelines, and promulgated professional standards of care for nurses administering moderate sedation and analgesia.
3. State the components of presedation patient assessment.
4. List sedative and analgesic medications, dosing guidelines, and nursing considerations associated with their administration.
5. Identify required monitoring parameters for the patient receiving moderate sedation and analgesia.
6. State postsedation monitoring requirements for the patient receiving sedation.
7. Identify risk management strategies used to reduce the incidence of complications associated with the delivery of sedative and analgesic medications.
I. SEDATION
A. Definitions
1. Minimal sedation (anxiolysis)
a. Respond normally to verbal commands.
b. Cognitive function and coordination may be impaired.
c. Ventilatory and cardiovascular functions are unaffected.
2. Moderate sedation and analgesia (formerly referred to as “conscious sedation”)
a. A drug-induced depression of consciousness
b. Patients respond purposefully to verbal commands either alone or accompanied by light tactile stimulation.
c. No interventions required to maintain a patent airway
d. Spontaneous ventilation adequate
e. Cardiovascular function usually maintained
3. Deep sedation and analgesia
a. A drug-induced depression of consciousness
b. Patients cannot be easily aroused.
c. Respond purposefully after repeated or painful stimulation.
d. Independent ability to maintain ventilatory function may be impaired.
e. May require assistance in maintaining a patent airway
f. Spontaneous ventilation may be inadequate.
g. Cardiovascular function usually maintained
4. Anesthesia
a. Consists of general anesthesia and spinal or major regional anesthesia
b. Does not include local anesthesia
c. General anesthesia is a drug-induced loss of consciousness.
(1) Patients not arousable, even with painful stimulation
(2) Ability to independently maintain ventilatory function often impaired
d. Often require assistance in maintaining a patent airway
e. Positive pressure ventilation may be required because of:
(1) Depressed spontaneous ventilation
(2) Drug-induced depression of neuromuscular function
f. Cardiovascular function may be impaired.
5. Goals and objectives of moderate sedation and analgesia
a. Maintain adequate sedation with minimal risk.
b. Relieve anxiety.
c. Produce amnesia.
d. Provide relief from pain and other noxious stimuli.
e. Overall goal: to allay patient fear and anxiety with a minimum of medication
f. Altered mood
g. Enhanced patient cooperation
h. Elevation of pain threshold
i. Stable vital signs
j. Intact protective reflexes
k. Rapid recovery
l. Unconsciousness and unresponsiveness are not goals of moderate sedation and analgesia.
6. Indications for moderate sedation and analgesia
a. Diagnostic and therapeutic procedures that require anxiolysis and/or analgesia, widely used throughout health care facilities and physician offices, including, but not limited to:
(1) Burn unit dressing changes
(2) Cardiology, heart station, cardiac catheterization and electrophysiology laboratories
(3) Cosmetic surgery
(4) Gastroenterology
(5) General surgery procedures
(6) Gynecology
(7) Ophthalmology
(8) Oral surgery
(9) Orthopedic procedures
(10) Pulmonary biopsy and bronchoscopy
(11) Radiology, interventional radiology
(12) Urology
(13) Emergency department procedures
B. Legal scope of practice issues
1. Requires:
a. An understanding of definition and levels of sedation
b. Adherence to clinical criteria outlined
2. Nurses required to comply with legal scope of practice issues in many jurisdictions
a. Legal scope of practice issues related to nursing delegated and administered through state boards of nursing
b. Nurses engaged in administration of sedation must ascertain their state board of nursing’s formal position or policy statement delineating their role and responsibility in the delivery of sedation and analgesia.
c. Most states have adopted guidelines, but some states have not taken formal action on the issue or lack statutory authority to enact such legislation.
C. The Joint Commission (TJC)
1. TJC has taken an active role in the development of policies, standards, and intents related to operative or other high-risk procedures and/or the administration of moderate or deep sedation or anesthesia.
a. The standards apply when patients receive in any setting:
(1) Moderate or deep sedation
(2) General anesthesia
(3) Spinal anesthesia
(4) Other major regional anesthesia
2. It is the obligation of each institution to develop institution-wide appropriate protocols for patients receiving sedation.
3. TJC states:
a. Moderate or deep sedation and anesthesia are provided by qualified individuals.
b. Sufficient numbers of qualified personnel are present during procedures using moderate or deep sedation and anesthesia.
c. Presedation and preanesthesia assessment is performed for each patient before beginning:
(1) Moderate or deep sedation
(2) Anesthesia induction
d. Moderate or deep sedation and anesthesia care are planned.
e. Patient’s physiological status is monitored during sedation or anesthesia administration.
f. Patient’s postprocedure status is assessed on admission to and before discharge from the postsedation or postanesthesia recovery area.
D. Professional organizations
1. In July 1991, the Nursing Organizations Liaison Forum in Washington, D.C., endorsed a position statement for the management of patients receiving intravenous sedation for short-term therapeutic, diagnostic, or surgical procedures.
a. This position statement has been adopted by many professional nursing organizations.
2. Professional organizations have developed specialty guidelines for use.
3. Participating professional organizations
a. American Society of PeriAnesthesia Nurses
b. Association of periOperative Registered Nurses
c. American Society of Anesthesiologists
d. American Association of Nurse Anesthetists
e. Society of Gastroenterology Nurses and Associates
f. American Society for Gastrointestinal Endoscopy
4. Professional organization guidelines, TJC standards, and statutory regulations require policy development that prepares the nurse participating in the delivery of sedation to demonstrate:
a. Knowledge of anatomy, physiology, cardiac dysrhythmias, and complications related to the administration of sedative agents
b. Knowledge of pharmacokinetic and pharmacodynamic principles associated with moderate sedation medications
c. Presedation assessment and monitoring of physiologic parameters including:
(1) Respiratory rate and ventilatory function
(2) Oxygen saturation
(3) Blood pressure
(4) Cardiac rate and rhythm
(5) Level of consciousness
d. Understanding of principles of oxygen delivery and the ability to use oxygen delivery devices
e. Ability to rapidly assess, diagnose, and intervene in the event of an untoward reaction associated with administration of moderate sedation
f. Proven skill in airway management
g. Accurate documentation of the procedure and medications administered
h. Competency validation for training and education conducted on a regular basis
II. PRESEDATION ASSESSMENT
A. Presedation assessment goals
1. Identify preexisting pathophysiological disease.
2. Obtain baseline patient information.
3. Take history and perform physical examination.
4. Reduce patient anxiety through education and communication.
5. Prepare a plan for the procedure.
6. Obtain informed consent.
B. Components of presedation assessment
1. General health
a. Height and weight
b. Obesity or recent weight loss
c. Current medications or herbal use
d. Baseline vital signs and temperature
e. History of tobacco or alcohol use
f. Physical handicaps and level of mobility
g. Pain assessment
2. Medical history
a. Cardiac
(1) Angina
(2) Coronary artery disease
(3) Dysrhythmias
(4) Exercise tolerance
(5) Hypertension
(6) Myocardial infarction
(7) Presence of a pacemaker or implantable cardioverter defibrillator
b. Pulmonary
(1) Asthma
(2) Bronchitis, tuberculosis, pneumonia
(3) Dyspnea
(4) Exercise tolerance
(5) Cigarette smoking
(6) Recent cold or flu
(7) Airway assessment
(a) Mallampati assessment or other assessment such as having patient open mouth, stick out tongue, and flex neck (see Figure 23-1)
(b) Craniofacial abnormalities
(8) Sleep apnea
c. Hepatic
(1) Ascites
(2) Cirrhosis
(3) Hepatitis
d. Renal
(1) Dialysis
(2) Renal failure
(3) Renal insufficiency
e. Neurological
(1) Convulsive disorders
(2) Headaches
(3) Level of consciousness
(4) Stroke
(5) Syncope
(6) Cerebrovascular insufficiency
(7) Preexisting neurological deficit
f. Endocrine
(1) Adrenal disease
(2) Diabetes
(3) Thyroid disease
(a) Hyperthyroidism
(b) Hypothyroidism
g. Gastrointestinal
(1) Hiatal hernia
(2) Predisposition to nausea and vomiting
(3) Chronic diarrhea or constipation
h. Hematology
(1) Anemia
(2) Aspirin, nonsteroidal anti-inflammatory drug use
(3) Excessive bleeding
i. Musculoskeletal
(1) Arthritis
(2) Back pain
(3) Joint pain
3. Nothing by mouth (NPO) status
a. Guidelines for Preoperative Fasting (American Society of Anesthesiologists) include:
| Ingested Materials | Minimum Fasting Period† (h) |
|---|---|
| Clear liquids‡ | 2 |
| Breast milk | 4 |
| Infant formula | 6 |
| Nonhuman milk§ | 6 |
| Light meal¶ | 6 |
| These recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in labor. Following the guidelines does not guarantee a complete gastric emptying has occurred. | |
| †The fasting periods apply to all ages. | |
| ‡Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea, and black coffee. | |
| §Since nonhuman milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period. | |
| ¶A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods must be considered when determining an appropriate fasting period. | |
b. Emergent procedures require consideration of:
(1) NPO status
(2) Risk of gastric acid aspiration
c. Histamine-blocking and gastrokinetic agents may be used to decrease gastric acidity and decrease gastric volume.
III. PROCEDURAL CARE
A. Monitoring
1. Monitoring process during the procedure includes:
a. Observation and vigilance
b. Interpretation of data
c. Initiation of corrective action when required
2. Electrocardiogram (ECG)
a. ECG monitoring during sedation procedures is required to detect:
(1) Dysrhythmias
(2) Myocardial ischemia
(3) Electrolyte disturbance
(4) Pacemaker function
b. Cardiac rhythm and dysrhythmias that may be encountered include:
(1) Sinus tachycardia
(2) Sinus bradycardia
(3) Sinus arrhythmia
(4) Premature atrial contractions
(5) Supraventricular tachycardia
(6) Atrial flutter
(7) Atrial fibrillation
(8) Junctional rhythm
(9) Premature ventricular contractions
(10) Ventricular tachycardia
(11) Ventricular fibrillation
c. See Chapter 32 for description, ECG criteria, and treatment protocol for specific dysrhythmias.
3. Noninvasive blood pressure
a. Hypotension
(1) A decrease in systolic arterial blood pressure of 20% to 30% and may be caused by a variety of factors including:
(a) Hypovolemia
(b) Myocardial ischemia
(c) Pharmacological agents
(d) Acidosis
(e) Parasympathetic stimulation (pain, vagal stimulation)
(2) Treatment
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(a) Administer oxygen.
(b) Administer a fluid challenge (300-500 mL crystalloid).
(c) Correct acidosis or hypoxemia.
(d) Relieve myocardial ischemia.
