moderate sedation review 2009 part 2: pharmacology
TRANSCRIPT
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Moderate Sedation Review 2009
Part 2: Pharmacology
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Pharmacology --Introduction
A variety of medications are used to induce the state of Moderate Sedation in the patient. These medications may be used alone, or in combination. It is important to remember that drugs used in combination may potentiate each other increasing the
effects of the combination to four to ten-times that of the same drugs used individually.
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Recall theGoals of Moderate
Sedation1. Maintain adequate sedation with
minimal risk to the patient2. Relieve anxiety and produce amnesia3. Provide relief from pain and other
noxious stimuli
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Characteristics of Medications Used in MS
Agents used in moderate sedation will have:Short duration of actionRapid recoveryLack of cumulative effectsFew side effects
Desirable: analgesic effects last longer than sedative effects
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IMPORTANT!!Per policy CL.46. All female patients age 9 (nine) and older must have a negative pregnancy test unless
menopausal surgically menopausal, or currently pregnant. Before proceeding with moderate sedation....Is your patient pregnant?
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IMPORTANTThe medications used to cause moderate sedation have been shown to have adverse affects on the fetus!!
All female patients 9-years-old or older, that are not menopausal, MUST HAVE HCG TESTING DONE AND NEGATIVE RESULTS RECEIVED BEFORE THE PROCEDURE IS BEFORE THE PROCEDURE IS STARTED.STARTED.
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Clinical Endpoints of Moderate Sedation
Beginnings of slurred speechDecreased anxiety
Goal of Moderate Sedation IS NOT unconsciousness or unresponsiveness!
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End result of Moderate Sedation
To produce a:Pain-free amnesic,Sedated patient whoRecovers rapidly withFew side-effects due to medication.
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IMPORTANT!!Per policy CL.46. All female patients age 9 (nine) and older must have a negative pregnancy test unless
menopausal surgically menopausal, or currently pregnant. Before proceeding with moderate sedation....Is your patient pregnant?
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Medication Administration Key Points:
Give only amount necessary to render the patient calm, cooperative, able to follow
commands Administered according to Corporate medication
policies When additional medication is ordered for sedation
after the initial dose: cumulative TOTAL dose will be communicated AUDIBLY to the practitioner (“I just gave 1-mg versed for a TOTAL dose of 2-mg given)
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IV AdministrationOnset is rapid (20-30 seconds)Titration: injection of small increments of drug until desired effects are achievedContinuously monitor patient’s response.
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RN must be knowledgeable about:
Drug names and classificationsAppropriate dosages for patient’s age and conditionIndicationsContraindicationsRecommended dilutionOnset and duration of action.
Expected actionsCompatibility with solutions, and other medicationsPossible side effects /adverse reactionsInterventions for side effectsEmergency management techniques
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Classes of AgentsSedatives
Opioids (morphine, Fentanyl®):
Benzodiazepines (Versed®, Valium®):
Reversal AgentsNarcan®
Romazicon®
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Opioids(e.g., morphine, Fentanyl)
Opioids (morphine, Fentanyl®):Alter the process of pain sensation, and emotional response to painSide effects:
CNS depressionRespiratory depressionNausea and vomitingHypotensionPruritis
Reversal Agent: Narcan®
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OpioidsDrug Dose
Range
IV Onset(minutes)
Clinical Duration(hours)
Comments
Morphine 2-3 mg 5 4
Inject slowly over 4 to 5 minutes
May be diluted with water for injectiondose by 30%if given with
another CNS depressant
Fentanyl 0.3 – 0.5mcg/kg
1-2 1
Has fewer side effectsTitrate in 25 mcg
increments every 2-3 minutes
Remifentanil
0.1-0.25 mcg/kg
1 10 minutes
Rapid induction with rapid elimination
Must be given SLOWLY (over 1 minute)
ReversalAgent Narcan®
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Benzodiazepines(e.g., Versed®, Valium®)
Depress CNS producing muscle relaxation, and anti-anxiety effects.Side effects:
Drowsiness, ataxia, confusionFatigue, headache, weaknessDizziness, vertigo, syncopeAntegrade amnesia
Reversal Agent: Romazicon®
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BenzodiazepinesDrug Dose
Range
IV Onset(minutes)
Clinical Duration(hours)
Comments
Midazolam(Versed®)
2.5 mg 1 1
Titrate SLOWLYInitial dose should not
exceed 2.5 mg administered over a min. of 2 minutes
DO NOT bolusWait 2 minutes between
doses to evaluate patient effects
Diazepam(Valium®)
1-2 mg 5 6
Titrate SLOWLY (over 1 min. for each 5 mg) until slurred speech occurs
Initial titration should not exceed 10 mg
If administered with a narcotic, dose of narcotic by 1/3 titrated slowly.
ReversalAgent
Romazicon(flumazeni
l)
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Reversal AgentsNarcan® (Naloxone)
Blocks effects of opiates
Romazicon® (Flumazenil)
Blocks effects of benzodiazepinesBoth may:
Precipitate withdrawal (seizures), cause increased sympathetic activities (tachycardia,
hypertension, arrhythmias, pulmonary edema)Allow re-sedation to occur (duration of action of
reversal agent is less than that of the sedatives they reverse)
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Reversal AgentsDrug Dose
Range
IV Onset(minutes)
Clinical Duration(hours)
Comments
Naloxone(Narcan®)
0.4 – 2 mg 2 1-4
Titrate slowly to desired effect
Dilute 1 ml ampoule (0.4mg/ml) in 10 ml normal saline
Give 1 ml (.04 mg) every 2-3 minutes until RESPIRATORY DEPRESSION is reversed
Patient must be monitored for up to 90 min. after time of administration
Flumazenil(Romazicon®
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Based on patient
response
1-2 (80% of patients
respond in 3 minutes)
45-90 minutes
Administer through LARGE vein
Give 0.2 mg increments (2 ml) over 15 seconds;
May repeat at 1 minute intervals
Total dose not to exceed 1 mg in 5 minutes
Maximum dose: 3 mg in any 1-hour period
Patient must be monitored for up to 90 min. after time of administration
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And now a word about PROPOFOL…
For years used in the ED as sedative for reducing fractures, in EP lab for procedures, etc.Used in some instances to bring about a state of Moderate SedationPlease note: THE RULES HAVE Please note: THE RULES HAVE CHANGED regarding the Nurse’s CHANGED regarding the Nurse’s role in its administrationrole in its administration
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Procedural Administration of Propofol
Urgent Nursing Practice Memo 12/7/07 issued by Nurse Executive Council, Quality and Patient
Safety states:As per As per Kaleida IV Administration Kaleida IV Administration PolicyPolicy TX.IV’s and MEDS_19, TX.IV’s and MEDS_19, Propofol may be titrated and Propofol may be titrated and administered by an RN administered by an RN only whenonly when a patient’s respiratory status is a patient’s respiratory status is supported by a mechanical supported by a mechanical ventilator.ventilator.
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What about for Moderate Sedation?
The same Nursing Practice memo states:
An RN may not participate in Moderate Sedation when propofol is utilized without active ventilator support
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What does participate mean?
The nurse MAY NOT be responsible for:Administering bolus of PropofolTitration of PropofolMaintenance of the airwayCare and monitoring of the patient
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The Nurse MAYAct as scribe, writing down information on the record formAct as “extra hands”, for example, by providing needed equipment, supplies
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What if I am asked to assist with propofol in a more
active patient monitoring role?
The short answer is to refuse.The longer answer is to discuss questions or concerns with your department manager.
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The reason to refuse….Nursing non-compliance with this New York State Department of Education and Licensure regulation is a NYS reportable event which places your license to practice nursing in jeopardy.
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If you need support for your refusal:
In a memo to the CMOs dated 12/6/07 it was stated:
An RN MAY NOT be the participant who is expected to push / titrate propofol OR assume the care / monitor the patient. It is the drug (propofol) which sets this situation apart.
In the case in ED, EP lab etc. where propofol is being used for moderate sedation:
A second provider (second ED attending, MOD) credentialed in moderate sedation will need to attend the patient, and provide monitoring, care, and documentation at the bedside.
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Remember!Moderate Sedation occurs on a
continuum:Awake Minimal Sedation
MODERATE SEDATIONMODERATE SEDATION
Deep Sedation General Anesthesia
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Remember!Patients can slip from one level to the next without warning. Practitioners must be qualified to rescue the patient from a lower state, i.e. deep sedation, and be skilled in airway management.
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Remember!Avoid standard mixes (e.g., x-mg of medication A, and x-mg of medication B)Treat the specific symptom (e.g., treat pain with more local anesthetic or narcotic)Titrate medication carefully—more medication can always be given, however it can never be retrieved.
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Remember!Use reduced dose of agents in patients who are
DebilitatedAt extremes of ageHypovolemic
Patients with COPD are more susceptible to respiratory depressant effects Avoid using “recipes”—no two patients will react the same to a given doseGive only the medication that is needed
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Final NoteRegardless of:
Type of procedureType of drugs usedType of venue