sedation monitoring and post sedation recovery and discharge
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Sedation monitoring and post sedation recovery and dischargeTRANSCRIPT
Sedation Monitoring and Post-sedation Recovery and Discharge
Key Principles of Procedural Sedation and Analgesia
• Determine appropriate level of sedation desired
• Have appropriate monitoring and rescue equipment
• Administer analgesic before sedative• Titrate agents to desired level of sedation• Observe and monitor until recovery to
baseline mental status
Equipment and Supplies Recommendations
• Intravenous equipment• Basic & advance airway management
equipment• Pharmacologic antagonist• Emergency medication
Procedural Sedation Monitoring
• Interactive monitoring• Mechanical monitoring
Procedural Sedation Monitoring
• Interactive monitoring:Direct observation of patient to access
- Depth of sedation- Respiratory function & Hemodynamics
Unobstructed view of the patient’s face, mouth,
chest wall
In patients undergoing procedural sedation andanalgesia in the emergency department,
what is the minimum number of personnel necessary to manage complications?
• Mostly, one clinician performs the procedure while another (usually a nurse) observe and continuously monitor the patient
Level C recommendationsClinical Policy: Procedural Sedation and Analgesia in the Emergency Department Ann Emerg Med. 2014;63:247-258.
Monitoring Depth of sedation
• Check response to verbal commands• If verbal response is not possible, “thumbs up”• Deep sedation: response to a more profound
stimulus• Response limited to reflex withdrawal from a
painful stimulus is not considered a purposeful response
Scale monitoring depth of sedation
Moderate sedation: Do not exceed level 4Deep sedation score: Level 5
Regular patient monitoring is more important than the application of scales
Bispectral Index monitoring
• uses processed electroencephalogram signals to measure the depth of sedation
• 100 = complete alertness,• 0 = no cortical activity at all• 40 - 60 is believed to be consistent with GA
Monitoring
• Interactive monitoring• Mechanical monitoring
Mechanical Monitoring
• Arterial oxygenation• Ventilation• Vital sign• ECG monitoring
Arterial oxygenation
• Pulse oxymetry is not a substitute for monitoring ventilation
• Hypoventilation or apnea develop before oxygen saturation decreases especially “Patient who receive supplemental oxygen”
Ventilation
• Capnography• ETco2 correlates with arterial Pco2• ETco2 > 50 mmHg or ↑>10 mmHg
indicates hypoventilation
In patients undergoing procedural sedation and analgesia in the emergency department, Does the routine use of capnography reduce the incidence of adverse
respiratory events?
Level B recommendation
• Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED.
• Capnography includes all forms of quantitative exhaled carbon dioxide analysis.
Vital Signs
• Before the procedure• After each dose of sedative• Regular intervals during the procedure• During initial of recovery period• Before discharge
RecommendationsLevel of Sedation
LOC Heart Rate Respiratory Rate
BP O2 Saturation
Capnography
Minimal Observe frequently
q 15 min q 15 min q 15 min and after sedative boluses
Continuously -
Moderate or Dissociative
Observe constantly
Continuously Continuous direct observation
q 5 min & after sedative boluses
Continuously Consider continuously
Deep Observe constantly
Continuously Continuous direct observation
q 5 min & after sedative boluses
Continuously Recommend continuously
If recording is performed automatically, Device alarms should be set to alert
Cardiac monitoring
Recommended for:• Preexisting cardiac disease• Dysrhythmias• During procedures in which the cardiac
rhythm is of interest
• Recovery and discharge under supervision of operating practitioner or a licensed physician.
• A nurse or other individual should monitor until appropriate discharge criteria are satisfied
• Preparation for management of complications.
Post-Sedation Recovery
Observation Duration
• In most cases, prolong observation beyond 30 min is unlikely to be necessary
• Longer duration in patients who receive reversal agents
Discharge Criteria
• Low risk procedure that additional monitoring is un necessary.
• Symptoms should be well-controlled.• Stable V/S and respiratory and cardiac function• Alert and oriented or returned to baseline• A reliable person who can provide support and
supervision at least a few hours.• Scoring systems may assist in documentation.• Patient instruction
10/12 points required before discharge
Pediatric Discharge Criteria
• Young infants or children who are handicapped should return to the level of responsiveness observed before sedation
• Because of the significant risk of apnea after sedation, term infants with postconceptual ages (PCA) ≤45 weeks and former premature infants with PCA <60 weeks should undergo prolonged observation of respiratory status prior to discharge
Minimum Duration of Observation for Infants
• All infants with PCA ≤45 weeks – 12 hours • Pre-term infants with PCA 46 to 60 weeks and
significant comorbidities – 12 hours• Healthy pre-term infants with PCA 46 to 60
weeks – 6 hours (12 hours if given opioids or other medications with significant respiratory depressant effects)
• Patients, who develop apnea during observation, warrant prolonged observation until they are free of apnea for at least 12 hours.
• In some patients with frequent apneic episodes, caffeine administration may be appropriate.
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