Dr.
Ghaleb Nasrallah
Head OR & AN Dept.
Chairman of CS &
pain manag. committee
CONSCIOUS SEDATION(CS)
Definition
sedation is a clinical technique that creates a
decreased level of awareness for a patient yet
maintains protective airway reflexes and
adequate spontaneous ventilation. The goals
of procedural sedation are to provide
analgesia, amnesia, and anxiolysis during a
potentially painful or frightening procedure
Definition cont.
For minor not painful procedures, to release anxiety
and frightening.
In mild to moderate painful procedures , analgesia
in its majority depends on LA given by the surgeon,
and minimum iv sed-analgesia
(given by qualified conscious sedation staff )
to maintain the Patient, sedated,but awake,
cooperative, breathing spontaneous,
hemodynamically stable ,respond to
verbal or tactile stimulation.
The Aim
To train a nonanesthesia staff to give safe sedation
for minor procedures , (ASA 1-2 ) patients in
specific places to outside the Operating Room .
Minimal
Sedation
(anxiolysis)
Moderate
Sedation/
Analgesia
Deep
Sedation/
Analgesia
General
Anesthesia
Responsiveness Normal
response to
speech
Purposeful
response to
speech or
touch
Purposeful
response to
repeated or
painful
stimulation
No response,
even to pain
Airway Unaffected Remains open May need
help to
maintain
airway
Often needs
help to
maintain
airway
Breathing Unaffected Adequate May not be
adequate
Often require
ventilatory
support
Heart Function Unaffected Usually
maintained
Usually
maintained
May be
impaired
Depth of Sedation
Scale Description
1 Anxious and agitated or restless, or both
2 Cooperative, oriented, and tranquil
3 Response to commands only
4 Brisk response to light glabellar tap or loud
auditory stimulus
5 Sluggish response to light glabellar tap or
loud auditory stimulus
6 No response to light glabellar tap or loud
auditory stimulus
The Ramsay Scale
Pre-Sedation Assessment
The patients ASA status should be determined.
The ASA describe five physical status classes:
ASA class I patients are healthy with no medical problems.
ASA class II patients have a mild,well-controlled disease(e.g. HTN)
ASA class III patients have multiple medical problems or a
moderately-controlled disease. (e.g. CHF compensated)
ASA class IV (decompensated)
ASA class V patients are moribund
Patients in ASA classes I and II can be given
moderate sedation.
Medical consultation is suggested for class III
patients.
Patients in ASA classes IV and V should not be
given moderate sedation by a non anesthesia
provider.
ASA classes and CS
Procedures Examples
Procedures such as all types of endoscopy, lumbar puncture,
and cardioversion
Wound care: suturing, dressing changes, incision and
drainage of abscesses, burn debridement
Minor surgical procedures: dental, podiatric, plastic,
ophthalmic; vasectomy
Placement of implanted devices, catheters, and tubes
Bone marrow aspiration
Reduction and immobilization of fractures
Removal of implanted devices and tubes
Procedures for which the patient is anxious but must remain
as motionless as possible, such as magnetic resonance
imaging and computed tomography scan (not usually
painful but may occasionally require sedation)
1. Ingestion of large food or fluid volumes
2. Physical class III - IV or greater
3. Lack of support staff, drugs, monitoring or equipment
4. Lack of experience/credentialing on part of clinician
5. Patient not ready ,no consent
Contraindication
Excluded cases
for non anesthesiologist
Children (except for pediatrician and very well trained staff )
Full stomach
Obese patients
Heavy smokers
Emergency cases
Liver or kidney disease
Respiratory compromise
Acute narrow angle glaucoma
Cardiovascular disease
Uncontrolled diabetes
Young children, infants, neonates
Frail, debilitated elderly
Possible or confirmed pregnancy, nursing mothers
Optimal conscious sedation/analgesia is
achieved when the patient
maintains consciousness
independently maintains his/her airway
retains protective reflexes (swallow and gag)
responds to physical and verbal commands
is not anxious or afraid
experiences acceptable pain relief
has minimal changes in vital signs
is cooperative during the procedure
has mild amnesia for the procedure
recovers to preprocedure status safely and promptly
ASA Revised NPO Guidelines for
Sedation
2 hours prior to
sedation: nothing by
mouth
Up to 2 hours prior to
sedation: clear liquids
Up to 4 hours prior to
sedation: infants may
have breast milk
Up to 6 hours prior to
sedation: may have
nonhuman milk and infant
formula
Up to 8 hours prior to
procedure: may have solid
food
Medications: gastric
stimulants, drugs that
block gastric acid
secretion, and antacids
may be ordered pre-
procedure in patients with
risk of aspiration.
DRUGS DOSAGES FOR CONSCIOUS SEDATION
MAY BE USED IN PAIN MANAGEMENT IN ER OR OTHER DEPARTMENTS
BY TRAINED STAFF ,EMERGENCY DRUGES &EQUIPMENT , VITAL SIGNS
MONITORING TO BE AVAILABLE AND CHECKED
drugs doses
Propofol amp 0.25-0.50 mg/kg IV
Ketamine vial 1-2 mg/kg IV ,IM
Etomidate amp 0.3-0.5mg/kg IV
Midazolam amp 0.02-0.1mg/kg IV , IM
Fentanyl amp 0.3-0.5 microgram/kg IV
Pethidine amp 0.3-0.7mg/kg IV IM
Morphine amp 0.07-0.15mg/kg IV ,IM
STANDARDS
(ST.1-ST.12)
ST.1
Conscious Sedation in the hospital has
policies and guidelines approved by the
Head of Anesthesia, the nurse manager,
and the appropriate department heads.
ST.2
Conscious sedation is performed
only in areas identified in policy and
the following equipment is available
to provide safe care:
2.1 Wall suction or suction equipment.
2.2 Oxygen.
3.3 Pulse Oximetry.
3.4 Automated blood pressure
monitor or means of taking BP
3.5 ECG Monitor
ST.2
ST.3
There is a crash cart with defibrillator,
medications, IV access, and intubation
equipment that is appropriate to the age
of the patient available where
sedation/analgesia is being performed.
ST.4
There is a list of all medications used in
conscious sedation and includes the route
administered along with dosage appropriate
to the age groups available where conscious
sedation is performed.
ST.5
Staff who participate in caring for
patients receiving conscious sedation
have the following certifications:
5.1 Physicians who perform conscious sedation are
certified as appropriate in BCLS, ACLS,PALS, NALS
and have privileges granted to perform conscious
sedation.
5.2 Nurses who assist with
sedation/analgesia are certified in
BCLS, and preferably ACLS or PALS,
according to the age of the patient.
ST.5
ST.6
Conscious sedation is only used for
patients having short diagnostic or
therapeutic procedures.
ST.7
Preparation before the conscious
sedation procedure includes the
following:
7.1
Availability of crash cart with defibrillator,
medications, IV access and intubation and other
equipment that is appropriate to the age of the
patient where sedation/analgesia is being
performed.
ST.7
7.2 Informed consent is obtained after
the physician educates the patient
regarding the risk and benefits of
the sedation/analgesia and the
consent is signed by the patient,
guardian, or next of kin if the patient
is unable to sign.
ST.7
7.3 An IV is inserted and venous access
is maintained in case of emergency.
ST.8
The physician obtains a history and
physical examination within the first
4 hours of admission and checks:
8.1 The history of medication allergy.
8.2 Any history of systemic illness or
major organ impairment that might
be risky for the patient.
ST.8
ST.9
The physician performs a physical exam
and checks:
9.1 Vital signs.
9.2 Age and weight.
9.3 ECG findings.
ST.10
During the procedure, the
following is required:
10.1 The physician performs a physical exam.
10.2 One registered nurse who is certified
with BCLS and preferably ACLS or
PALS is at the patient side constantly
and continuously monitors the patient.
ST.10
10.3 One physician is physically present
and close by the patient.
10.4 The IV is maintained and kept
patent in case of emergency.
10.5 The patient is continuously monitored for level of
consciousness, vital signs, oxygen saturation and skin
color and this is documented by the physician an
nurse.
ST.10
ST.11
After the procedure, the
following is required:
11.1 The physician documents the status
of the patient post procedure and
includes vital signs, level of
consciousness, and ECG findings.
ST.11
11.2 The nurse documents the status of
the patient post procedure and
includes vital signs, level of
consciousness, and ECG findings.
ST.11
11.3 The physician writes a discharge
order or transfers the patient back
to the unit with follow up instructions
for the nurses (vital signs, oxygen
saturation, etc.)
ST.11
ST.12
The nurse carries out the
physicians orders and
monitors the patient post
procedure:
12.1 Assessment/Re-assessment of vital
signs, Oxygen saturation, level of
consciousness, pain, tolerating
fluids, and voiding.
ST.12
12.2 The nurse provides education and
discharge instruction to the patient
and family that includes follow up
and emergency number to call, if
needed.
ST.12
Discharge criteria must be approved in
writing by the responsible physician
Patient is as alert and orient as baseline
Presence of protective reflexes (swallow and gag)
Stable V. S consistent with baseline for 30 min. after last drug dose
Spo2 on room air >95% or at baseline for 30 min. after last drug dose
Cardiac rhythm consistent with baseline
BP and heart rate within 20 points of baseline or within normal limits
No fever
Pain rating < or = to baseline
When applicable, no visible site drainage or excessive swelling
Patient is able to ambulate as well as prior to procedure
Responsible adult is present to drive patient home & remain with him
Summary
Conscious sedation is a safe practice in a setting with
1. Proper patient selection
2. Proper preoperative assessment
3. Proper preparation
4. (Familiarity with Ready& Functioning Equipment
&Medications)
5. Proper monitoring
6. Adequate IV access
7. Experienced personnel(doctor and nurse)
8. Recovery room( staff monitoring-discharge criteria)
For your attention
Questions?
