CONSCIOUS SEDATION

PROCEDURAL SEDATIONFOR ADULTS

Dr. CATHERINE GALLANT

Department of Anesthesiology

University of Ottawa

General Campus

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OUTLINE

Definition

Indications for use

Contraindications

Pharmacology

Complications

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DEFINITION

A technique to provide an altered state of consciousness by administration of medications that permits a patient to undergo painful procedures but still respond to verbal commands while maintaining an unassisted airway

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INDICATIONS

Used to facilitate many diagnostic and therapeutic procedures

May be used intra-operatively

May be performed in a location remote from the operating room

Ever increasing demand fuelled by patients

Limited capacity for anesthesiologists to provide these services

Used to facilitatein a wide variety of settings such as hospitals. free standing clinics, physician, dental and other offices.

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APPLICATIONS

Primarily day surgeries

Lack of dependence on hospital beds

More flexibility in scheduling

Shorter waiting lists

Improved efficiencies

Low morbidity and mortality

Low rates of complications

Lower costs

Less special investigations required

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APPLICATIONS

Dental

Dermatology

Gynecology

General surgery

Ophthalmology

Orthopedics

Pain Clinic

Plastic surgery

Urology

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DEFINITIONS

Analgesia - Relief of pain without intentionally producing a sedated state. Altered mental status may occur as a secondary effect of medications administered for analgesia.

Sedation is a continuum

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DEFINITIONS

Minimal sedation drug induced state where the patient responds normally to verbal commands. Cognitive function and coordination may be impaired but ventilatory and cardiovascular function are unaffected.

Anxiolysis alternate term

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DEFINITIONS

Moderate sedation and analgesia a drug induced depression of consciousness where the patient responds purposefully to verbal commands alone or when accompanied by light touch. Protective airway reflexes and adequate ventilation are maintained without intervention. Cardiovascular function remains stable.

Conscious sedation

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DEFINITIONS

Deep sedation and analgesia - A drug induced depression of consciousness where the patient cannot be easily aroused but responds purposefully to noxious stimulation. Assistance may be needed to ensure the airway is protected and adequate ventilation maintained. Cardiovascular function is usually stable.

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DEFINITIONS

General anesthesia a drug induced loss of consciousness, during which the patient cannot be aroused, even with painful stimuli, and often requires assistance to protect the airway and maintain ventilation. Cardiovascular function may be impaired.

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EUROPEAN UNION OF MEDICAL SPECIALISTS

Level 1

Fully awake

Level 2

Drowsy

Level 3

Rousable by normal speech

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OBJECTIVES

To achieve sedation level 2 and 3 (minimal to moderate sedation) which allows patients to undergo and tolerate unpleasant procedures

To avoid deeper levels of sedation and the related complications

This cannot be completely avoided!

Continuum which is difficult to divide into discrete stages

Always maintain verbal contact

Because sedation is a continuum, it is not always possible to predict how an individual patient will respond.

Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation/analgesia should be able to rescue patients who become deep

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BENEFITS

Appropriate sedation/analgesia will allow the patient to tolerate unpleasant procedures by relieving anxiety, discomfort or pain

In the uncooperative patient, sedation/analgesia may facilitate those procedures which are not uncomfortable but which require that the patient not move

At times, these sedation procedures may result in cardiac and respiratory depression, which must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest or death.

Conversely, inadequate sedation may result in undue patient discomfort or patient injury because of lack of cooperation or adverse response to stress

MUST HAVE QUALIFIED PERSONELL TO ADMINISTER THIS

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QUALIFIED INDIVIDUALS

Competency based education, training and experience in:

Patient evaluation

Performance of sedation

Knowledge of pharmacology of drugs used

Rescuing the patient from complications of deeper levels of sedation

Airway compromise

Inadequate ventilation

Cardiovascular instability

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PATIENT EVALUATION

Screening for medical risk factors

How will these alter response to sedation?

Abnormalities of major organ systems?

Previous adverse reactions with sedation/analgesia as well as regional and general anesthesia?

Allergies to drugs?

Medications drug interactions?

History of drug and alcohol abuse?

NPO status

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PATIENT EVALUATION

Abnormalities of major organ systems

Cardiac

Respiratory

Renal

Hepatic

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PATIENT EVALUATION

Previous adverse reactions with sedation/analgesia as well as regional and general anesthesia

Details

Where it happened

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PATIENT EVALUATION

Allergies to drugs?

What is the reaction?

When did it occur?

Family history?

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PATIENT EVALUATION

History of drug and alcohol abuse?

May indicate tolerance

Cross tolerance between classes of drugs

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PATIENT EVALUATION

Review medications possible drug interactions?

MAOIs such as phenelzine (Nardil) , tranylcypromine (Nardil), moclobemide

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PATIENT SELECTION

Focused physical exam

Evaluation of airway

Auscultation of heart and lungs

Assessment vital signs

Review labs

Consider consult prn

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PATIENT SELECTION

Airway issues that may present concerns

History

Previous problems with anesthesia or sedation

Snoring, stridor or sleep apnea

Advanced rheumatoid arthritis

Chromosomal abnormalities e.g. trisomy 21

Physical examination

Obesity especially involving neck and facial structures

PPV +/- ETT may be needed if respiratory compromise develops during sedation-analgesia. This may be more difficult in patients with abnormal airway anatomy. Some airway abnormalities may increase the likelihood of airway obstruction during spontaneous ventilation.

Sine factors that may be associated with difficulty in airway management are:

History

PE

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PATIENT SELECTION

Airway issues that may present concerns

Physical examination

Short neck, limited neck extension, decreased TMD of < 3 cm in adult, neck mass, c-spine disease or trauma, tracheal deviation, dysmorphic features

Small mouth opening (< 3 cm in adult), protruding incisors, loose or capped teeth, dental appliances, high arched palate, macroglossia, tonsillar hypertrophy

Micrognathia, retrognathia, trismus, significant malocclusion

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DIFFICULT AIRWAY

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PATIENT SELECTION

Who is a candidate for sedation?

ASA 1 and ASA 2

ASA 3 in stable condition

Must be compatible with the procedure

Must be capable of giving informed consent

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PATIENT SELECTION

Who is at increased risk of complications?

Extremes of age

Multiple co-morbidities

Severe systemic disease

Drug and/or alcohol abuse

Uncooperative patient

Morbidly obese patient

Potential difficult airway

Obstructive sleep apnea

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ADVANCED AGE

Higher risk of adverse events

Increased sensitivity to sedative drugs

Medication interactions

Higher peak serum levels of medications

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MULTIPLE CO-MORBITIES

ing ASA status correlates with ing risk of adverse events (ASA III or >)

Any co-morbidity that increases risk of cardio-respiratory depression with sedatives is significant

CHF, neuromuscular disease

COPD, dehydration

Anemia

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PATIENT SELECTION

Who is not a candidate?

Language barrier

History of problems with previous anesthesia

Known or suspected difficult ventilation or difficult intubation

No person to accompany them home

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PREPARATION

Do you have informed consent?

Is patient aware of risks and the limitations? Have they been given alternative choices to procedure? Have questions been answered?

What is the NPO status?

Risks versus benefits

Machine and drug check?

Drugs and antagonists

Emergency equipment available and checked?

Defibrillator and skills of use

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ASPIRATION RISK

Fasting pre-procedure decreases risks during moderate sedation and strongly decreases risks during deep sedation

ASA guidelines