Procedural Sedation for Clinicians

Barnes-Jewish Hospital

Initial Appointment

Developed 5/2008

Learner Outcomes:

* State the definitions of sedation according to JCAHO * Describe what patient response is expected for each degree of sedation * List appropriate pre-procedural patient assessments. * List the ongoing assessments, which should be monitored during the procedure. * List the common complications of Procedural Sedation * Discuss the management of the common complications. * Explain what is included in the post-procedural care. * Explain the evaluation for patient discharge from the interventional area/hospital. * Describe components of an airway assessment. * Identify appropriate medications for Procedural Sedation, considering patient-specific characteristics. * Outline the role for reversal agents used to reverse sedatives and describe the required monitoring parameters.

What is Procedural Sedation?

• Procedure (n) A series of steps taken to accomplish an end. Examples: EGD, bronchoscopy, fracture/dislocation reduction, cardiac catheterization

• Sedation (n) Reduction of anxiety, stress, irritability, or excitement by administration of a sedative agent or drug.

• Procedural Sedation (n) Reducing anxiety or stress with medications in order to perform a procedure. These medications may include, but are not limited to Opiates (e.g., morphine, fentanyl) and Benzodiazepines (e.g., midazolam, lorazepam).

Definitions: Four Levels of Sedation and Anesthesia (per JCAHO)

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;

Patient is fully responsive.

Description per Richmond Agitation-Sedation Scale: Briefly awakens with eye-contact to voice, >10 seconds

Moderate sedation

A drug‑induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained;

* Stable vital signs, intact airway. * Patient responds to verbal stimulation - may utilize light touch to support verbal stimulation. * Patient follows simple commands

Description per Richmond Agitation-Sedation Scale: Movement or eye-opening to voice, (but no eye contact) < 10 seconds

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 maybe impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained;

* Patient only responds to repeated or painful stimulation. * Patient does not follow commands, but may move spontaneously. * Respiratory depression is possible: may include decreased respiratory rate and/or difficulty maintaining an open airway. * BP / pulse remain stable. Description per Richmond Agitation-Sedation Scale: No response to voice, but movement or eye opening to physical stimulation

Anesthesia

Consists of general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia is adrug‑induced loss of consciousness during which patients are notarousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often requireassistance in maintaining a patent airway, and positive pressureventilation may be required because of depressed spontaneousventilation or drug‑induced depression of neuromuscular function.Cardiovascular function may be impaired.

* Depression of life sustaining functions (may include respiratory depression and/or change in BP and pulse) * No patient response to stimulation, even painful stimulation.

Description per Richmond Agitation-Sedation Scale: No response to voice or physical stimulation

Sedation Continuum Moving from one state of conscious to another is a dose-related continuum that depends on patient response NOT type, dose or route of medication, or any other external factors.. MINIMAL

SEDATION (ANXIOLYSIS)

MODERATE SEDATION

DEEP SEDATION

ANESTHESIA

Response Normal response to verbal stimulation

Purposeful response to verbal or tactile stimulation

Purposeful response following repeated or painful stimulation

Unarousable even with painful stimulus

Airway Unaffected No intervention required

Intervention may be required

Intervention often required

Spontaneous Ventilation

Unaffected Adequate May be inadequate

Frequently inadequate

Cardiovascular Function

Unaffected Usually maintained

Usually maintained

May be impaired

The person monitoring the patient and/or the person performing the procedure must be prepared and competent to

treat one level lower than the anticipated sedation level.

The most common indication patient may be beyond moderate sedation into deep sedation is respiratory depression.

If the patient develops significant respiratory depression, the clinician and assistant must be prepared to support the

paitent’s airway through oral/nasal airways and bag-mask ventilation. In addition, the clinician must be prepared for insertion of a definitive airway: for example, endotracheal

intubation or laryngeal mask airway.

Which of the following notation by the Assistant would best indicate your patient’s sedation is maintained at a moderate sedation level?

A. Opens eyes to sternal rub B. BP 128/68 C. Follows simple commands D. RR remains 14-16

Answer: C

Question 1

Within 5 minutes of the end of the procedure, your patient is snoring loudly and occasionally appears to have sleep apnea. When you vigorously shake his shoulder and call his name loudly, he arouses and takes a deep breath. This description most accurately describes which of the following?

A. Anxiolysis B. Moderate sedation C. Deep sedation D. General anesthesia

Answer: C

Question 2

You have given Ms Gray Midazolam 3 mg IVP and Morphine 2mg IVP. She remains alert but states she feels more relaxed. Select the level of sedation this patient has received.

A. No sedation B. Light sedation (Anxiolysis) C. Moderate sedation D. Deep sedation

Answer: B

Question 3

What is an indication your patient may be dropping from moderate sedation to deep sedation?

A. BP drops from 128/62 to 118/56B. SpO2 drops from 99% to 90%C. Apnea developsD. The patient squeezes your hand on command

Answer: B

Question 4

Oral Intake Guidelines• Age does not matter – what they took orally is the issue.

• Ingested Material Minimum Fasting Period

– Clear Liquids 2 hours

– Breast Milk 4 hours

– Infant Formula 6 hours

– Non-clear Liquids 6 hours

– Light Meal 6 hours

• Options for the patient not within these guidelines:

– Cancel the Procedure

• Postpone the Procedure

Emergent Procedures

• Emergent Procedures are life- or organ (i.e., CNS) saving procedures (consult anesthesiology)

• Urgent procedure are those which need to be done in 2-4 hrs – Document why it is urgent; – Assess the need for sedation and preferably

administer none; – Consider postponing, or consult anesthesiology– Monitor the patient's airway closely, and – Look for active or silent regurgitation and aspiration.

Risk Assessment

• Risk Assessment: ASA PS (physical status) classification

• ASA PS correlates with overall risk• Needs to be used as a tool along with other

factors such as type of procedure, medications, clinician comfort / skills

• “E” is added to the ASA PS number when the procedure is done on an emergency basis This indicates there is an increased risk due to the emergence of the patient’s condition, preparation or required procedure.

ASA PS (physical status) classification

Definition Details Examples

ASA PS 1

A normal healthy patient

Healthy individual with no systemic disease, undergoing elective surgery. Patient not at extremes of age. (Note: Age is often ignored as affecting operative risk; however, in practice, patients at either extreme of age are thought to represent increased risk.)

Fit patient with inguinal hernia. Fibroid uterus in an otherwise healthy woman

ASA PS 2

A patient with mild systemic disease

Individual with one system, well-controlled disease. Disease does not affect daily activities. Other anesthetic risk factors, including mild obesity, alcoholism, and smoking can be incorporated at this level.

Non-limiting or only slightly limiting organic heart disease. Mild diabetes, essential hypertension, or anemia.

ASA PS (physical status) classification continued

Definition Details Examples ASA PS 3

A patient with severe systemic disease

Individual with multiple system disease or well controlled major system disease. Disease status limits daily activity. However, there is no immediate danger of death from any individual disease.

Severely limiting organic heart disease. Severe diabetes with vascular complications. Moderate to severe degrees of pulmonary insufficiency. Angina pectoris or healed myocardial infarction.

ASA PS 4

A patient with severe systemic disease that is a constant threat to life

Individual with severe, incapacitating disease. Normally, disease state is poorly controlled or end-stage. Danger of death due to organ failure is always present

Organic heart disease showing marked signs of cardiac insufficiency, Persistent anginal syndrome, or active myocarditis. Advanced degrees of pulmonary, hepatic, renal, or endocrine insufficiency.

ASA PS (physical status) classification continued

Definition Details Examples

ASA PS 5 A moribund patient not expected to survive (24 hrs)

Patient who is in imminent danger of death. Operation deemed to be a last resort attempt at preserving life. Patient not expected to live through the next 24 hours. In some cases, the patient may be relatively healthy prior to catastrophic event, which led to the current medical condition.

Burst abdominal aneurysm with profound shock. Major cerebral trauma with rapidly increasing intracranial pressure. Massive pulmonary embolus.

ASA PS 6 A declared brain-dead patient / organ donor

Informed Consent

* The person performing the procedure (clinician) is to review objectives, risks, benefits and alternatives of Procedural Sedation (informed consent)

* This can be done at the same time as the procedure is explained

* Informed consent for the sedation does not require a patient signature. Rather there is a check box on the Pre-Procedure/Pre-Sedation Assessment

form. If paper forms are not available, it is the responsibility of the clinician to document this in the pre- procedure note.

* If the person who will monitor the patient (assistant) finds that the patient has

additional questions, the person performing the procedure (clinician) will be contacted to answer these questions before sedation is given.

Responsible Individual for discharge planning

• The person who will provide the patient’s ride home and be available to the patient after the procedure will be identified before the procedure begins.

• This person may be an adult, or someone in their late teens that the patient feels comfortable with.

• If the patient is an outpatient, this person frequently accompanies the patient to the hospital

• If the responsible individual is not present, hospital staff need to verify the individual by telephone.

• If the patient is an inpatient, it may not be necessary to identify this individual pre-procedure.

• If the inpatient is discharged within 24 hours of the procedure, the patient must be discharged to a responsible individual.

Responsible individual?

• For outpatients: If either the clinician (person performing the procedure) or the assistant (person monitoring the patient) feels the individual present would not be appropriate in this role, or the patient has no one identified, the clinician needs to determine:

– Can the procedure be cancelled (or postponed) until a responsible individual is available?

– Should the procedure be completed and the patient kept an additional 4 hours after discharge criteria are reached, then released with appropriate transportation?

Discharge to Responsible Person

Guidelines:

Best Practice: Patient accompanied by Responsible Adult

If no responsible adult present at patient admission, staff should

-Verify via phone the responsible adult who will be present at discharge

-Or

-Identify a responsible individual to whom the patient can be reasonably transported after the procedure

-Or

-Cancel the Procedure!

How do I know the person is responsible?

Use your professional judgment.

If no responsible adult present after the procedure is completed, observe the patient for 4 hours after completion of the recovery period,

then discharge (patient must not drive for 24 hours after sedation).

Pre-Procedure/Pre-Sedation Assessment form (required for all procedural sedation) includes documentation of the following:

Review of Systems: * Can be completed by nursing or medical staff. If completed by nursing, must

be reviewed by the clinician completing the pre-procedure assessment.Focused Assessment: * Must be completed by a licensed independent practitioner according to

Medical Staff Bylaws. It includes procedure-specific parameters, and addresses any new or pertinent data seen on the Review of Systems.

Airway Assessment: * Aim is to plan for airway management if that would be necessary. * Assessment parameters may include

* Assessing dentures, loose teeth, partials, etc.* When the patient opens his/her mouth, how easily can the cords and

pharynx be visualized should intubation be necessary.* Are there physical limitations, which would impede proper positioning

should intubation be necessary, such as kyphosis, short neck, etc.

•Pre-Procedure/Pre-Sedation Assessment form (required for all procedural sedation) includes documentation of the following:

Risk Assessment (ASA PS Score) * To be completed by clinician, even if you’re not Anesthesia personnel Risks/Benefits/Alternatives for Sedation * Required discussion with patient should be documented either on outpatient

forms, or in procedure noteRisks/Benefits/Alternatives for Procedure * As above, with the addition of signature on procedural consent Sedation Plan: * The level of sedation that was presented to, and accepted by the patient. This

must be documented before initiation of the procedure.

Prevent wrong site / wrong patient / wrong limb / wrong equipment

• Site Verification / Marking “YES” on the procedure site– Must be completed before the procedure starts– Is the responsibility of the person performing the procedure (clinician)– Should be a process which includes patient input / verification /

understanding

• TIME OUT!– To be completed immediately before the first dose of sedation / start

of the procedure.– Is the responsibility of the clinician, although may be documented by

the assistant– Should be a group interaction (clinician, assistant, others present in the

room)– Includes four questions:

1. Is this the Correct Patient?2. Is this the Correct Procedure?3. Is this the Correct Site?

4. Is this the Correct Equipment?

Intra-procedure Monitoring requirements

* BP, Pulse, Respiratory Rate, SpO2 required immediately before the procedure / first dose of sedation, monitored frequently and documented

every 10 minutes throughout the procedure and recovery period.

* Mechanical noninvasive blood pressure is preferred, however may use manual (cuff) method.

* Continuous Pulse Oximetry

* Sedation* Assessed and documented with vital signs* RASS Sedation Scale

Richmond Agitation Sedation Scale (RASS)

Score Term (not included on documentation forms)

Description

+4 Combative Overtly combative, violent, immediate danger to staff

+3 Very agitated Pulls or removes tube(s) or catheter(s), aggressive

+2 Agitated Frequent, non-purposeful movement. Fights ventilator

+1 Restless Anxious, but movements not aggressive, vigorous

0 Alert and Calm

-1 Drowsy Not fully alert, but has sustained awakening

(Eye-opening/eye-contact) to voice, ≥ 10 seconds

-2 Light sedation Briefly awakens with eye-contact to voice, <10 seconds

-3 Moderate sedation Movement or eye-opening to voice, (but no eye contact)

-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation

-5 Unarousable No response to voice or physical stimulation

Intra-procedure Monitoring requirements

• EKG monitor is applied* Assistants may not be able to perform rhythm interpretation* Is used by the assistant as a tool to identify when more in depth

patient assessment is required1). For example: heart rate drops, assistant may stimulate patient, check BP, or other 2). Another example: heart rate accelerates, assistant may ask patient about comfort level.

* Assistants should notify the clinician for any noticeable changes in rhythm, rate, or other concerns noted on monitor for further medical

direction.

* Capnography? * Although not essential this indicates if patient is ventilating

adequately. * This will indicate hypoventilation before pulse oximetry. * Currently available to intubated patients only

A 55-year-old woman has a history of adult onset diabetes mellitus. She also has a history of hypertension. Both diseases are controlled by diet alone. This patient is an ASA PS classification of:

A. ASA IB. ASA IIC. ASA IIID. ASA IVE. ASA V

Answer: B

Question 5

A 71-year-old woman has a history of diabetes and CHF. She is on multiple medications from her physician including nitropaste, atenolol, lasix, and micronase. She lives a very sedentary life. She presents for an EGD for a work-up of her “guiaiac positive stools. On physical exam you hear rales ¼ of the way up on both lung fields. This patient is an ASA PS classification of:

A. ASA IB. ASA IIC. ASA IIID. ASA IVE. ASA V Answer: D

Question 6

A 55-year-old man is to have a closed reduction of a fractured wrist. He has a history of ASCVD and had a MI a few years ago. He underwent a carotid endarterectomy last year. He reports that he does get a little tired after walking one block and has to rest after 1 flight of stairs. This patient is an ASA PS classification of:

A. ASA I EB. ASA IIC. ASA III ED. ASA IVE. ASA V E

Answer: C

Question 7

Required monitoring parameters during the procedure include: A. Heart rate, blood pressure, and oxygen saturation B. Heart rate, rhythm interpretation, blood pressure,

respirations, oxygen saturation and level of sedation. C. Heart rate, rhythm interpretation, blood pressure, oxygen

saturation, capnography and respirations D. Heart rate, blood pressure, respirations, oxygen

saturation and level of sedation

Answer: D

Question 8

Informed consent needs to be obtained before conscious sedation is administered. Which of the following need not be included in Mr. Brown’s informed consent?

A. Medications planned for Moderate SedationB. Benefits of Moderate Sedation C. Alternatives to Moderate Sedation D. Risks of Moderate Sedation

Answer: A

Question 9

The clinician is responsible for:A. Sedation planB. Initiating the “Time Out”C. Completing the history and physicalD. All of the above

Answer: D

Question 10

Which of the following is required for all outpatients prior to the procedure?

A. Consent for sedation B. Airway assessment C. Presence of responsible adultD. All of the above

Answer: D

Question 11

Emergency equipment * Oxygen with nasal cannula / mask* Ambu Bag with mask* Suction* Crash Cart* Airway box* Reversal Agents

Complications* Usually related to medications / patient response* Respiratory Depression

- Patient stimulation may be all that’s needed- Consider use of above emergency equipment

* Aspiration- Suction - May be silent. Watch skin color and SpO2

* Hemodynamic instability- Consider fluid bolus

* For any complication, consider ACLS guidelines / calling a code (2-4700)

If respiratory depression and/or hemodynamic instability occurs, consider use of reversal agents.

• Assistant Responsibilities

– Patient assessment and appropriate documentation throughout the procedure

– Reassure patient and monitor patient awareness.

– Provide comfort measures as needed

– Notify clinician of changes / concerns.

– Documentation of required parameters.

The Assistant is not to leave patient bedside for any reason during the procedure (although may assist the clinician with short, interruptible tasks) The assistant must be able to drop those tasks if the patient needs attention)

Choosing appropriate medications

Agents should be chosen based on the desired pharmacological response. Depending on the particular agent one, two or all three of these below effects can be achieved: * Anxiolysis

* Analgesia * Amnesia

Adverse effects - The potential side effects of any medication in a particular patient must by considered. Many sedative agents can produce cardiac or respiratory depression.

Pharmacokinetic Considerations

- When selecting a sedative, the following pharmacokinetic parameters should be considered to optimize response in a given situation.* Onset and Duration * Elimination Route * Accumulation * Drug interactions / potentiations* Cross-Tolerance (e.g. patients with prior opiate use may require higher doses of opiates; those with prior ethanol exposure may require larger doses or benzodiazepines, etc.)

During the procedure Mr.... Green’s vital signs should be documented at least:

A. Every 5 minutes B. Every 10 minutes C. Every 15 minutes D. Beginning and end of the procedure

Answer: B

Question 12

The assistant’s responsibilities DO NOT include:A. Documentation of vital signsB. Patient comfortC. Leaving the room to get suppliesD. Assisting with short interruptible tasks during

the procedure.

Answer: C

Question 13

Jane Smith is a 79-year-old female otherwise healthy female who is to have a closed reduction of a right colles fracture under moderate Sedation. Pre-procedure assessment includes BP 142/74, P82, R18, T37.4, Sat 96% room air. Immediately after administration of the medications, Mrs. Smith’s BP drops to 108/56 and her heart rate rises to 98. What should be the first intervention you provide?

A. Fluid Bolus B. Romazicon 0.4 mg IVP C. Page for Anesthesia D. Cancel the procedure and reevaluate Mrs. Smith

Answer: A

Question 14

You have planned moderate sedation. You anticipate the patient will achieve a RASS score of:

A. -1B. -2C. -3D. -4

Answer: C

Question 15

During a painful procedure, you order morphine 4 mg IV. Within a few minutes of the morphine administration the patient’s oxygen saturation is 92%. You should immediately:

A. Insert an oropharyngeal airway B. Stimulate the patient C. Apply non-rebreather mask at 12 L/min D. Give a fluid bolus

Answer: B

Question 16

Post-procedure Requirements

Procedural orders* Given orally throughout procedure* Written orders required* If assistant is utilizing handwritten documentation, sign, time and

date the bottom of monitoring form * If assistant is utilizing computer documentation, write orders for

medications etc. in patient chart when writing post-procedure orders and notes.

Monitoring requirements* BP / P / RR / SpO2 documented every 10 minutes* Aldrete Score completed with each vital sign documentation

ALDRETE POST PROCEDURE RECOVERY SCORE Aldrete Post Procedure Recovery Score Base

Line Post

Procedure

D/C Activity Moves 4 Extremities voluntarily or on command Moves 2 Extremities voluntarily or on command Moves 0 Extremities voluntarily or on command

2 1 0

2 1 0

2 1 0

Circulation SBP ± 20 mmHg of Preprocedure Level ± 20-50 mmHg of Preprocedure Level ± 50 mmHg of Preprocedure Level Preprocedure BP / .

2 1 0

2 1 0

2 1 0

Respirations Able to deep breath or cough freely Dyspnea, shallow, or limited breathing Apneic or Mechanical Vent

2 1 0

2 1 0

2 1 0

Consciousness Awake (oriented, answers questions approp.) Arousable on calling (responds to voice) Non-responsive

2 1 0

2 1 0

2 1 0

Color Normal Pale, dusky, mottled, jaundiced, other Cyanotic

2 1 0

2 1 0

2 1 0

Discharge score must be a minimum of pre-procedure score minus one, with stable vital signs to meet discharge criteria.

TOTAL:

Baseline must be done before sedation initiated. This is what post-procedure Aldretes are compared to.

Post Procedure is done at the end of the procedure, then every 10 minutes until patient meets recovery criteria. A minimum of 3 aldrete scores must be completed before the patient can be

identified as “recovered” When recovery criteria are met, the last (frequently the third) Aldrete can be the D/C score.

Recovery criteria

* A minimum of two consecutive Aldrete scores are baseline minus one with stable vital signs

* The patient’s room air oxygen saturation must be back to baseline

* Sufficient time (i.e., a minimum of 1 hour) should have elapsed after the last administration of reversal agents (naloxone, flumazenil) to ensure thatthe patient does not become resedated after reversal effects have abated.

* Patients who will be discharged to home and receive IV medications for relief of pain, nausea, vomiting etc. must be observed no less than two consecutive Aldrete / vital sign assessments following administration of such medication

Discharge criteria

* Vital signs stable (Vital signs include BP, HR, R,& O2 Sat. The VS are determined to be stable if they are consistent with the patient’s age and with the patient’s pre-operative VS)

* Swallow, cough present (patient demonstrates ability to swallow fluids and is able to cough

* Able to ambulate (patient demonstrates ability to ambulate at pre-procedure level)

* Nausea, vomiting, dizziness is minimal * Absence of respiratory distress (patient’s respiratory effort consistent with pre-procedure status)

* State of consciousness (patient is alert, oriented to time, place and person consistent with pre-procedure level of consciousness).

* Level of comfort (Pain controlled as per BJH pain policy)

* Post-procedure (oral and written) discharge instructions are given to the patient and/or significant other regarding the following: purpose and expected effects of sedation, patient’s care, emergency phone number,

medications, dietary or activity restrictions, and necessary precautions (e.g., no driving for 24 hours, avoid alcohol and use of power tools, etc.).

After the procedure is completed, your patient’s saturation drops , and Romazicon is given. She is able to support her own airway and her saturations return to normal. The minimal time she needs to be monitored after the romazicon is given before returning her to the nursing unit is:

A. 30 minutes B. 1 hour C. 2 hours D. No more monitoring is necessary, the

benzodiazepine is reversed.

Answer: B

Question 17

After the procedure, your patient states she’s ready to go home. Which of the following would indicate that she would need to stay a little longer?

A. Dizziness when first sitting up. B. Systolic BP 128-136 for the past hour C. Wrist pain, reported 3/10 D. Aldrete score 2 below pre-procedure score.

. Answer: D

Question 18

Mr. Brown’s mother has not arrived to driver her son home yet. What should the nurse do?

A. Send Mr. Brown home in a cab B. Wait another 30 minutes then allow Mr.

Brown to take a bus home. C. Allow Mr. Brown to drive home D. Release Mr. Brown only after a responsible

individual is present to drive

Answer: D

Question 19

Which of the following information should be included in the discharge instructions when a patient is discharged within 24 hours of receiving procedural sedation?

A. Return to your normal activitiesB. Avoid alcoholic beverages for the next 2 hoursC. Do not drive for 24 hours.D. Clear liquid diet for 24 hours.

Answer: C

Question 20

Procedural Sedation –Pharmacologic Considerations

Case #1A 76 year old male with a significant history of COPD, hypertension, diabetes mellitus type 2, chronic renal insufficiency and alcohol-induced liver failure presents for X procedure. The decision is made to sedate the patient with midazolam. An initial bolus dose of 5mg IV push is given and 10 minutes later, the patient remains at his baseline level of consciousness.

PharmacokineticsOnset time (Single bolus dose)

Drug Onset Time (minutes)

Diazepam 1-2

Midazolam 3-5

Lorazepam 10-20

Fentanyl 1-2

Meperidine 3-5

Morphine 5-10

Question 21

What is the usual Midazolam onset time and what is thetime interval that should elapse before a seconddose should be administered?

A. 30 seconds, 5 minutes

B. 1 minute, 1 minute

C. 3-5 minutes, 5 minutes

D. 10 minutes, 20 minutes

Answer: C

Case #2A 44-year-old male with a significant history of HIV, Chronic

renal insufficiency, and diabetes mellitus type 2 presents for X procedure. His current medicationRegimen that includes ritonavir, lamuvidine, zidovudine, pravastatin, and metformin. The patient is sedated with midazolam without apparent complication. A 2 mg IV bolus x 1 is given with an observed Ramsey score of 3 within 5 minutes. The level of sedation is maintained throughout the procedure that is performed without complication. 45 minutes into recovery (150 minutes from last drug dose) the patient is observed to have difficulty walking without assistance.

PharmacokineticsDuration of Effect (Single Bolus Dose)

Drug Duration (hours)

Diazepam (Valium®) 1-2

Midazolam (Versed®) 1-2

Lorazepam (Ativan®) 4-6

Fentanyl 0.5-1

Meperidine (Demerol®) 2-4

Morphine 2-4

PharmacokineticsRoute of Elimination

Hepatic Renal

Diazepam (Valium®) Diazepam metabolites

Midazolam (Versed®) Midazolam metabolites

Lorazepam (Ativan®) Morphine metabolites

Fentanyl Meperidine metabolites

Meperidine (Demerol®)

Morphine

Propofol (Diprivan®)

Drug Interactions

CYP3A4 Inhibitors azole antifungals diltiazem verapamil protease inhibitors macrolides nefazadone quinupristin-

dalfopristin

Drug affected midazolam

Question 22

What is the expected duration of effect of asingle bolus of midazolam?

A. 20 minutesB. 1 to 2 hoursC. 4 hoursD. 6 hours

Answer: B

Question 23

What is the explanation for the prolongedeffect?

A. Drug-drug interaction B. Chronic renal insufficiencyC. Too high of doseD. None of the above

Answer: A

Case #3

A 28-year-old female with a significant medical history of bilateral lung transplant secondary to cystic fibrosis presents for X procedure. The patient is ordered to receive meperidine 75mg IV x 1, and midazolam 1 mg x 1. When obtaining the pre-procedure history and physical the patient reports she is allergic to meperidine. She received this drug during a previous procedure and was observed to have visual hallucinations.

Opioid Cross-Allergenicity

Morphine-like Morphine Hydromorphone

Meperidine-like Meperidine Fentanyl

OpioidsEquipotent Doses

Drug Dose (mg)

Fentanyl 0.1

Hydromorphone (Dilaudid®) 1.5

Morphine 10

Meperidine (Demerol®) 75

Question 24

What alternative opioid agent should beconsidered for moderate sedation?

A. Fentanyl

B. Morphine

C. Hydromorphone

D. B or C

Answer: D

Case #4A 56-year-old female undergoing X procedure is complaining of pain. 25 mcg of fentanyl is given in addition to the already administered 2 mg of midazolam. 10 minutes after the dose of fentanyl the patient is still complaining of pain. Another 25 mcg of fentanyl is given, followed by another 25 mcg 5 minutes later (total dose = 75 mcg in 25 minutes). Shortly after the third dose of fentanyl, the patients breathing is observed to be extremely labored and the pulse oximeter reveals an SaO2 of 89%. The patient is placed on 4L/min O2 by nasal cannula with no improvement in SaO2. The decision is made to administer naloxone. 0.4 mg IV x 1. Within minutes the patient recovers respiratory rate and function.

Naloxone (Narcan®)

Opioid antagonist Dosing: 0.4–2 mg q 2-3 min, up to 10 mg Onset time: 1-2 min Duration of effect: 30-60 min Adverse effects: precipitate withdrawal,

pulmonary edema

Flumazenil (Romazicon®)

benzodiazepine antagonist Dosing: 0.2 mg q 1 min, up to 1 mg Onset time: 1-2 min Duration of effect: 30-90 min Adverse effects: seizures Reversing BZD-induced hypoventilation has

not been established

Question 25

What is the duration of effect of naloxoneand what is the minimum amount of timeafter the dose that the patient should bemonitored?

A. 30 min-1 hour, 30 minutesB. 30 min- 1 hour, 1 hourC. 1-2 hours, 1 hourD. 1-2 hours, 2 hours

Answer: B

Case #6

A 65 year old female presents to the emergency department with a separated shoulder after a fall in her bathroom. She rates her pain as 9/10. Meperidine 75 mg IV q 30 minutes is ordered prior to the moderate sedation procedure to correct the separation. What important history should be obtained prior to meperidine administration?

Meperidine (Demerol®)

Contraindicated in patients on MAOIs in previous 14 days Phenelzine (Nardil®) Tranylcypromine (Parnate®)

Effects of meperidine/MAOI combination Respiratory depression Hypotension Coma

Other drugs w/ MAOI properties

BJH IV Medication GuidelinesDrugs with Level 1 MD Coverage

Fentanyl

Midazolam (Versed®)

Naloxone (Narcan®)

Flumazenil (Romazicon®)

Level 1 Coverage: RN may initiate drug therapy with a physician order, provided a physician is available in person to the patient care area within 5 minutes of being contacted.

Question 26

What important history should be obtainedprior to meperidine administration?

A. Allergy history B. Seizure historyC. Medication historyD. All of the above

Answer: D

Question 27

What is the usual fentanyl onset time and what is thetime interval that should elapse before a seconddose should be administered?

A. 30 seconds, 1 minute

B. 1-2 minutes, 2 minutes

C. 8-10 minutes, 10 minutes

D. 15 minutes, 15 minutes

Answer: B

Please note:

• BJH residents must have an attending in the room to provide procedural sedation.

• If unsure of drug dosage, please look them up. • Please be familiar with the BJH IV Medication

Policy, and ask staff nurses if specific medications are allowed to be given in that area.

• Thank you.

References

• ASA (2002) Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 96:1004-17.

• Lin, DM & Wightman, MA. (2005). Sedation, Anesthesia, and the JCAHO (3 rd ed.). HCPro Inc. Marblehead, MA.

• Sedation by Non-Anesthesia Personnel for Procedures. (2007) BJH Policy/Procedure/Guideline

• Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery. (2007) BJH Policy/Procedure

• Sessler CN, Gosnell M, Grap MJ, Brophy GT, O’Neal PV, Keane KA et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med 2002; 166:1338-1344.

• Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S et al. Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA 2003; 289:2983-2991.