Conscious Sedation:
It Shouldn' t Be a Bad Me,nory!
Ann Willemsen-Dun lap, C RNA, MSN
Levels of Conscious Sedation
■ Sedation Score O= Fully awake
■ Sedation Score 1 = Light sedation, largely aware
of self/surroundings. Mildly sleepy.
■ Sedation Score 2 = Moderate sedation, slightly
aware of self/surroundings; somnolent but easily
aroused with sti1nulation.
■ Sedation Score 3 = Deeply sedated; unaware of
self/surroundings.
■ Sedation Score 4 = General anesthesia; patient is
•
unconscious.
Table1.0 erational Definitjons and Characterization of Levels of Sedation-Anal esia
Sedatio Level
R ponse- R.espons Airway Ventilation,
Level of
ePatenc Oxy enation
of
Verbal
n
Consciousness
Tactile y
Sedatio
Score
n
p
p
p
p
Fully aware of self &
None
0
surround· s
p
p
p
P-L
Mostly aware of self
"Light"
l
I
I
&
surroundin but sedate
''Moderate" Slightly aware of self &
2
surroundings, usually
somnolent, arouses
easily with stimuli
Not aware of self
"Deep"
3
or
surrounding,slittle
arousal
with
stimuli
4
General Unconscious, no
Anesthes
arousal with
ia
painful stimuli
P: Present, adequate, or normal.
L: Limited, partial, mildly
L-A
P-L
P-L
§
A
L
P-L
•
*
L-A
L
L-A
L-A
(to ain)
A
A
(to pain)
Focused History and Exam
■ History should focus on factors that may
increase
• patient sensitivity to sedatives/analgesics
•
+ patie nt risk of
respiratory/cardiopulmonary
complications
♦
difficulty in managing complications
Key Points In Patient and Family
Education
■ Education, individually geared to the patient and
fa1nily, helps alleviate concerns associated with
conscious sedation.
■ Key points
• duration of sedation (children may fear never
waking up)
• interindividual variability of response to drugs
• potential for sedation failure
• alternatives to sedation
• potential for adverse events
• plan for monitoring by a nurse during the
procedure and discharge criteria.
Preprocedural Fasting Guidelines
To Minimize Aspiration Risk
Substance
Ingested
Clear Liquids
•
Breast Milk
Infant Formula
Non-human Milk
Light Meal
Minimum Fasting
Period
Pharmacology: Points To Ponder
■ Drugs administered for conscious sedation should
allow a patient to be calm, comfortable and
cooperative.
■ Clinical endpoints for conscious sedation may
include a respiratory rate of 10-12 in an adult and a
slurring of speech.
■ A drug should be allowed to exert its full effect
before ad1ninistering additional doses or another
drug.
■ When combining opioids and sedatives, administer
the opioid first to ensure the patient receives.
analgesia prior to painful stimulation.
at right
Opioids, con't
■ Opioids exert their agonist actions at opioid
receptors concentrated in the CNS.
■ Opioids are highly lipid-soluble and are therefore
rapidly and extensively distributed to tissues.
■ Opioids tend to accumulate in reservoirs of fat,
potentially producing long-lasting effects.
■ Opioids are metabolized in the liver, but so111e
active 111etabolites are excreted via the kidneys.
Opioids, con't
■ Opioids exhibit some adverse effects
including
• decreased respiratory drive/apnea
• potential increased PC0 2/ decreased P0 2
• altered hemodynamics and bradycardia
♦ GI upset & itching
■ True allergic reactions are fairly rare.
Opioids: Relative Potency
■ A standard way of evaluating opioid potency is
to compare equianalgesic doses of a drug with
morphine.
♦
Morphine is 1Ox more potent than
meperidne.
+ Morphine is 1Ox less potent than
hydromorphone.
+ Morphine is 1OOx less potent than fentanyl.
Benzodiazepines: Adverse
Effects & Special Considerations
■ BZDs may cause dose-related respiratory
depression, hypotension, and tachycardia,
particularly in the elderly.
■ Midazolam administered rapidly is particularly
likely to produce apnea.
■ BZDs are generally contraindicated in pregnancy.
■ Diazepam and lorazepa111 may cause
thrombophlebitis.
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Barbiturates, con't
■ Adverse effects
♦ Respiratory depression/apnea
• Laryngospasm, bronchospasm
♦ Tachycardia and hypotension
• CNS depression OR excitation
• Twitching & myoclonus, often mistaken
for seizures
Chloral Hydrate
■ Drug's mechanism of action is unknown.
■ Primary effects are due to the active
metabolite, trichlorethanol.
■ Metabolized by the liver
■ Degree of CNS depression is related to dose
and frequency of administration.
■ No analgesic properties.
■ Onset of action may be delayed 30-60 min.
with a duration of action of 60-90 min. May
last up to eight hours in some instances.