Procedural Sedation by
Non-Anesthesia
Providers
Learner Outcomes:
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Identify sedation levels according to the Joint Commission’s definitions
Describe anticipated patient responses for each level of sedation
List the required pre-procedural patient assessments
Describe the components of an airway assessment
Indentify the required assessments and monitoring parameters during
procedural sedation
Identify appropriate medications for procedural sedation
Identify the role for reversal agents and describe monitoring parameters
List the common complications associated with procedural sedation
Discuss the management of the common complications
Recognize the components of post-procedural assessment and care
Identify the required criteria for patient discharge after receiving
procedural sedation
What is Procedural Sedation?
 Procedure: A series of steps taken to accomplish an end.
Examples: EGD, bronchoscopy, fracture/dislocation
reduction, cardiac catheterization
 Sedation: Reduction of anxiety, stress, irritability, or
excitement through the administration of a sedative agent
or drug
 Procedural Sedation: Reducing anxiety or stress with
medications in order to perform a procedure. These
medications may include, but are not limited to Opiates
(e.g., morphine, fentanyl) and Benzodiazepines (e.g.,
midazolam, lorazepam)
Objectives of Procedural Sedation
 Maintain adequate sedation with minimal risk
 Provide relief from pain and other noxious stimuli
 Relieve anxiety and produce at least partial amnesia
 Preserve modesty
 Prompt and safe return to activities of daily living
For many procedures, procedural sedation has replaced the use of
general anesthesia because it :
 Is easier on the patient
 Reduces potential complications
Definitions: Four Levels of Sedation and
Anesthesia (per TJC)
Minimal sedation (anxiolysis)
A drug-induced state during which patients respond normally
to verbal commands. Although cognitive function and
coordination may be impaired, ventilatory and cardiovascular
functions are unaffected.
 Patient is fully responsive
Definitions: Four Levels of Sedation and
Anesthesia (per TJC)
Moderate sedation
A drug-induced depression of consciousness during which patients
respond purposefully to verbal commands, either alone or
accompanied by light tactile stimulation. No interventions are
required to maintain a patent airway, and spontaneous ventilation is
adequate. Cardiovascular function is usually maintained.
 Stable vital signs, intact airway
 Responds to verbal stimulation – may utilize light
touch to support verbal stimulation
 Follows simple commands
Definitions: Four Levels of Sedation and
Anesthesia (per TJC)
Deep sedation
A drug-induced depression of consciousness during which patients cannot
be easily aroused but respond purposefully following repeated or painful
stimulation. The ability to independently maintain ventilatory function may be
impaired. Patients may require assistance in maintaining a patent airway and
spontaneous ventilation may be inadequate. Cardiovascular function is usually
maintained.
 Responds to repeated or painful stimulation
 Does not follow commands but may can move spontaneously
Respiratory depression is possible: may include decreased
respiratory rate and/or difficulty maintaining an open airway
 BP and pulse remain stable
Definitions: Four Levels of Sedation and
Anesthesia (per TJC)
Anesthesia
Consists of general anesthesia and spinal or major regional anesthesia. It
does not include local anesthesia. General anesthesia is a drug-induced
loss of consciousness during which patients are not arousable, even by
painful stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance in maintaining a
patent airway, and positive pressure ventilation may be required because of
depressed spontaneous ventilation or drug-induced depression of
neuromuscular function. Cardiovascular function might be impaired.
 Depression of life sustaining functions (may include respiratory
depression and/or change in BP and pulse)
 No response to stimulation, even painful stimulation
Sedation Continuum – Movement from one level of sedation to another is
a dose-related continuum that depends on patient response
MODERATE
SEDATION
DEEP
SEDATION
Responsiveness
MINIMAL
SEDATION
(ANXIOLY SIS)
Normal
response to
verbal
stimulation
Airway
Unaffected
Spontaneous
Ventilation
Unaffected
Adequate
May be
inadequate
Cardiovascular
Function
Unaffected
Usually
maintained
Usually
maintained
Purposeful
response to
verbal or tactile
stimulation
Purposeful
response
following
repeated or
painful
stimulation
No intervention Intervention
required
may be required
ANESTHESIA
Unarousable
even with painful
stimulus
Intervention
often required
Frequently
inadequate
May be
impaired
Sedation level is dependent on patient response NOT external factors
or type, dose, route of medication.
Procedural Sedation is NOT:
Chemical Restraint: Medication given for
behavioral management or to restrict the patient's
freedom of movement and is not a standard treatment
for the patient's medical or psychiatric condition
Pain Control: Although some of the same
medications are given for pain control, the intent of the
intervention is different
Anxiolysis: A medication given to relax the patient
Additional information: Side rails are NOT
restraints when used as safety precautions during
procedural sedation as long as the DOCUMENTATION
is there! Can be up on carts for procedure and recovery
period, then removed!
Procedural Sedation by Non-Anesthesia Providers
 Moderate Sedation = Procedural Sedation
 Policy is applicable throughout the institution (See BJWCH policy)
 Applicable to all health care providers when anesthesia personnel
not present.
Proceduralist
 Physician, Dentist, or Podiatrist
 Person performing the procedure
 Hospital Privileges must include Procedural Sedation
Assistant
 A credentialed Registered Nurse
 The person who monitors the patient during the procedure
 Some situations require more than one assistant—e.g. one
person to assist the Proceduralist and one to solely monitor the
patient
The person monitoring the patient and/or the person performing the
procedure (Proceduralist) must be prepared and competent to treat one
level lower than the anticipated sedation level.
The most common indication the patient may be beyond moderate sedation
into deep sedation is respiratory depression, frequently identified through
a drop in pulse oximetry (Sp02 ).
If the patient develops significant respiratory depression, the Proceduralist
and Assistant must be prepared to support the patient's airway through the
use of oral/nasal airways and bag-mask ventilation. In addition, the
Proceduralist must be prepared to insert a definitive airway [i.e.,
endotracheal intubation or laryngeal mask airway (LMA)].
Properly inserted LMA
Assistant Responsibilities
 Patient assessment and interventions
 Appropriate documentation throughout the
procedure
 Reassure patient and monitor patient
awareness and responses.
 Provide comfort measures as needed
 Notify Proceduralist of changes/concerns
 Documentation of required parameters
The Assistant is not to leave patient bedside for any reason during
the procedure (although may assist the Proceduralist with short
interruptible tasks). The assistant must be able to drop those tasks
if the patient needs attention)
Pre-Procedural Assessment Steps Include:
1. Informed Consent (risk, benefits, alternatives for both procedure & sedation)
2. Physical Assessment:
• Based on Health History and Review of Systems
• “Focused Assessment” includes basics
• Heart & Lung
• Whatever else is appropriate
3. Airway Assessment:
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4.
5.
6.
7.
Dentures, loose teeth
Inability to open mouth
Cervical arthritis/kyphosis
Other Structural issues
Prepare for the possibility of airway
management issues
Home/Present Medications
Planned Level of Sedation
Identified Risk Level (ASA PS Score)
Site Marking
Mallampati
Scoring
Responsible Individual for Discharge
Patient is accompanied by a responsible adult at discharge
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The person who will provide the patient’s ride home and be available to
the patient after the procedure must be identified before the procedure begins
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For outpatients, this person frequently accompanies the patient to the hospital
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If the responsible individual is not present, hospital staff need to verify
the individual by telephone
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If the patient is an inpatient, it might not be necessary to identify this
individual pre-procedure. If the inpatient is discharged within 24 hours
of the procedure, the patient must be discharged to a responsible individual
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For outpatients: If either the Proceduralist (person performing the procedure)
or the Assistant (person monitoring the patient) believes the individual would
not be appropriate for this role or the patient has no one identified, the
Proceduralist will determine:
;1r
 Can the procedure be cancelled/postponed until a responsible individual is available?
 Should the procedure be completed and the patient kept an additional 4 hours after
discharge?
Informed Consent
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The person performing the procedure (Proceduralist) is to review
the objectives, risks, benefits of both the procedure and the
plan for sedation
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May be completed at the same time the procedure consent is
obtained
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Informed consent for the sedation does not require a patient
signature, but is completed by checking the box on the PreProcedure/Pre-Sedation Assessment Form. If paper forms are
not available, it is the responsibility of the Proceduralist to
document the patient’s consent for sedation in the pre-procedure note
•
If the patient has questions, the Proceduralist will be contacted
to answer patient questions before consent is signed (witnessed)
Assess NPO Status
Adult patients undergoing sedation for elective
procedures may not eat solid foods or drink nonclear fluids for six hours before administration of
sedation. Patients may have clear liquids up to two
hours before the procedure
Options for the patient not within these guidelines:
Cancel or postpone the procedure
In urgent, emergent, or other situations when gastric
emptying is impaired, the clinician may proceed with
the procedure after considering the potential for
pulmonary aspiration of gastric contents, the nature
of the intervention, and the degree of sedation
Risk Assessment:
American Society of Anesthesiologist (ASA)
PS (Physical Status) Classification
 ASA PS correlates with overall risk
 Needs to be used as a tool along with other factors such as type of procedure, medications, and
clinician comfort
Definition
ASA PS 1
ASA PS 2
A normal healthy
patient
Details
Examples
Healthy individual with no systemic
disease and undergoing elective
surgery. Patient not at extremes of A fit patient with inguinal hernia.
age. (Note: Age is often ignored as
affecting operative risk; however, Fibroid uterus in an otherwise
in practice, patients at either
healthy woman.
extreme of age are thought to
represent increased risk).
Individual with one system and
well-controlled disease. Disease
does not affect daily activities.
Other anesthetic risk factors,
A patient with mild including mild obesity, alcoholism,
systemic disease
and smoking can be incorporated at
this level.
Non-limiting or only slightly
limiting organic heart disease.
Mild diabetes
Essential hypertension
Anemia
Risk Assessment: ASA PS (Physical Status)
Classification (continued)
Definition
Details
Examples
Severely limiting organic heart
disease.
ASA PS 3
A patient with
severe systemic
disease
ASA PS 4
A patient with
severe systemic
disease that
is a constant threat
to life
Severe diabetes with vascular
Individual with multiple system
complications.
disease or well controlled major
system disease. Disease status
Moderate to severe degrees of
limits daily activity. However,
pulmonary insufficiency.
there is no immediate danger of
death from any individual disease.
Angina pectoris or healed
myocardial infarction.
Organic heart disease showing
Individual with severe,
marked signs of cardiac
incapacitating disease. Normally, insufficiency.
disease state is poorly controlled
or end-stage. Danger of death
Persistent anginal syndrome or
due to organ failure is always
active myocarditis.
present.
Advanced degrees of pulmonary,
hepatic, renal, or endocrine
insufficiency.
Risk Assessment: ASA PS (Physical
Status) Classification (continued)
Definition
ASA PS 5
ASA PS 6
Details
Patient who is in imminent danger
of death. Operation deemed to be a
last resort attempt at preserving
A moribund patient life. Patient not expected to live
not expected to
through the next 24 hours. In some
survive (24 hours) cases, the patient may be relatively
healthy prior to catastrophic event,
which led to the current medical
condition.
Examples
Burst abdominal aneurysm with
profound shock
Major cerebral trauma with rapidly
increasing intracranial pressure
Massive pulmonary embolus
A declared braindead patient/organ
donor
"E" is added to the ASA PS number when the procedure is done on an
emergency basis. This indicates that there is an increased risk due to the
emergence of the patient's condition, preparation, or required procedure.
Prevent: Wrong Site / Wrong Patient/
Wrong Limb / Wrong Equipment
Site Verification: Marking is done by
marking "YES“ on the procedure site
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Responsibility of the Proceduralist
Site marking is required for cases
involving right/left distinction, surfaces
(flexor/extensor); multiple structures (such
as fingers, toes) or multiple lesions,
wounds, or levels (such as the spine)
Completed before the procedure begins
Marking should include the patient’s input,
verification, and understanding
For more information, see
the BJWCH policy:
Universal Protocol for
Preventing Wrong Site,
Wrong Procedure, and
Wrong Person Surgery
Preparation for the Procedure
• Obtain IV access
• Have emergency/resuscitative equipment immediately available:
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Method of Positive Pressure Ventilation--Ambu Bag
Laryngoscope/ET Tubes
Emergency Drugs (especially reversal agents)
Oxygen delivery devices & Functioning Suction
Crash Cart / Respiratory Box
• Patient Monitors:
• Noninvasive blood pressure machine
• Cardiac Monitor
• Pulse Oximetry / Capnography (optional)
• Perform the Time Out
Prevent Wrong Site / Wrong Patient
Wrong Limb / Wrong Equipment
COMPLETE THE “TIME OUT”!
The “Time Out” is completed immediately before the first dose of
sedation/start of the procedure
All members of the procedural team will verbally acknowledge their
agreement to the following elements as applicable to the procedure:
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Patient identity
Procedure to be done
Confirmation that correct site/side is marked and visible
Correct patient position
Consent form accurately and correctly completed
Relevant image/test results correctly labeled and displayed
The need to administer antibiotics or fluids for irrigation purposes
Any safety precautions based on patient history or medication use
Intra-Procedural Monitoring Requirements
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REQUIRED - documentation at least every 10 minutes, or more
frequently if indicated:
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BP
Pulse
Respiratory Rate
SpO2 (Continuous Pulse Oximetry)
Sedation Level (RASS)
End Tidal CO2 Capnography (optional)
 REQUIRED—Cardiac Monitoring
Assistants (Procedural Sedation Credentialed RNs) will be able to utilize
rhythm interpretation as a tool to identify when more in-depth patient
assessment is required:
 Example #1: Heart rate drops – assistant may stimulate patient, check BP, etc.
 Example #2: Heart rate accelerates – assistant may ask patient about comfort level
Assistants should notify the clinician for any noticeable changes in rhythm,
rate, or other concerns noted on monitor for further medical direction.
Intra-Procedure Monitoring Requirements
Level of Sedation:
 Assessed with vital signs and documented
 Richmond Agitation Sedation Scale (RASS) used for sedation assessment
Richmond Agitation Sedation Scale (RASS)
Score
Term (this column is not
included on forms)
Description
+4
Combative
Overtly combative, violent, immediate danger to staff
+3
Very agitated
Pulls or removes tubes(s) or catheter(s), aggressive
+2
Agitated
Frequent, non-purposeful movement. Fights ventilator
+1
Restless
Anxious but movements not aggressive, vigorous
O
Alert and Calm
Alert and Calm
-1
Drowsy
Not fully alert but has sustained awakening
(eye opening/eye contact to voice, > 10 seconds)
-2
Light sedation
Briefly awakens with eye contact to voice, <10 seconds
-3
Moderate sedation
Movement or eye opening to voice (but no eye contact)
-4
Deep sedation
No response to voice but movement or eye opening to
physical stimulation
-5
Unarousable
No response to voice or physical stimulation
Types of Complications:
Complication Causes: Generally due to over dosage of sedative and
analgesic drugs. May also may be due to drug-drug interaction. Consider
patient age, medical history and size
Types of Complications:
Respiratory depression: resulting in hypoxemia and /or hypercarbia
• May show as a drop in O2 Saturation or Respiratory Rate
• May be related to a changing level of sedation, i.e. going from Moderate Sedation
to Deep Sedation
Cardiovascular depression: Hyper- or hypotension, brady- or tachycardia
• Observe trends in blood pressure and pulse
• Proceduralist is to be notified if cardiac rhythm changes
Aspiration:
• Silent regurgitation is more likely to happen when the patient is over sedated
• Only evidence may be changes in oxygen saturation, changes in breath
sounds, or skin color
Treatment for Potential Complications
 Respiratory depression
• Stimulate the patient (may be all that’s needed)
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Chin Lift
Oral/Nasal Airway
Oxygen-increase flow if already on O2
Positive Pressure Ventilation (bag-valve mask)
Consider use of emergency equipment (LMA, ET tube)
Consider use of reversal agent
Call Anesthesia
 Aspiration
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Suction
Consider intubation
Chest X-ray
Bronchoscopy if particulate matter
For any complication, consider ACLS Guidelines
or calling a RRT/Code (x8444)
Treatment for Potential Complications
Hemodynamic instability
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Consider fluid bolus/increase IV fluids
If patient is bradycardic, consider giving Atropine (0.5mg IV Push)
Vasopressors (e.g. dopamine)
Antihypertensives (e.g. nitroprusside)
Monitor respiratory status and oxygenation
Consider use of reversal agent
ACLS Protocols
For any complication, consider ACLS Guidelines
or calling a RRT/Code (x8444)
Procedural Sedation
Pharmacologic Considerations
3f)
Medication Classes Used for Sedation
 Opiates:
 Pain control
 Give medications only allowed by the IV Medication Administration Policy
 Benzodiazepines :
 Sedation
 Watch times of onset. Midazolam IV Push has onset of 3-5 minutes.
Lorazepam IV Push takes 10-20 minutes
 Both opiates and benzodiazepines are frequently administer together
 Synergist action on the level of consciousness and respiratory depression
 If the patient is in pain, it is helpful to give analgesics first. As the pain decreases,
the patient may more easily respond to sedatives
 Pain may not be present before the procedure but most procedures are
uncomfortable
 Have reversal agents readily available:
 Remember, reversing benzodiazipines does not necessarily reverse respiratory
depression
 When reversal agents are given, the patient must be monitored a minimum of 1 hour
after the reversal due to possibility of re-sedation
Choosing Appropriate Medications
Agents should be chosen based on the desired pharmacological response.
Depending on the particular agent, one, two, or all three of the effects below can be
achieved:
 Anxiolysis
 Analgesia
 Amnesia
Adverse effects - The potential side effects of any medication in a particular patient
must be considered. Many sedative agents can produce cardiac or respiratory
depression
Pharmacokinetic Considerations - When selecting a sedative, the following
Pharmacokinetic parameters should be considered to optimize response in a given
situation
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Onset and Duration
Elimination Route
Accumulation
Drug Interactions/Potentiations
Cross-Tolerance (e,g. patients with prior opiate use may require higher
doses of opiates. Those with prior ethanol exposure may require larger doses
of benzodiazepines, etc)
Pharmacokinetics-Route of Elimination
Hepatic
Diazepam
Midazolam
Lorazepam
Fentanyl
Meperidine
Morphine
Propofol
Renal
Diazepam metabolites
Midazolam metabolites
Morphine metabolites
Meperidine metabolites
Critical thinking question: How would dosages change if the
patient has liver or kidney insufficiency?
Drug Interactions
CYP3A4 Inhibitors
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Azole antifungals
Diltiazem
Verapamil
Protease inhibitors
Macrolides
Nefazodone
Quinupristin-dalfopristin
Drug Affected
 Midazolam
Opioid Cross-Allergenicity
Morphine-like
Meperidine-like
Morphine
Meperidine
Hydromorphone
Fentanyl
Opioids – Equipotent Doses
Drug
Dose (mg)
Fentanyl
0.1
Hydromorphone (Dilaudid®)
1.5
Morphine
10
Meperidine (Demerol®)
75
Benzodiazepines:
Cautions:
Consider Dose Adjustments:
 Lower doses require in elderly, debilitated or chronically ill
patients
 Patient who receive concomitant opiates should have the
dose reduced by 30-50%
 Benzodiazepines are cross-tolerant with alcohol, higher
doses may be required to achieve sedation in current heavy
drinkers.
Examples of Benzodiazepine Medications:
 Midazolam (Versed®)
 Valium (Valium®)
Midazolam (Versed®)
Onset: 1-5 minutes
Usual Duration: 30-120 minutes (dose-dependent)
Elimination Route: Hepatic
Dose: <60 years: 1-2 mg slow IV push. May repeat q2 min
prn; max 0.1 mg/kg (10 mg)/hour
>60 years or debilitated: 0.5 mg slow IV push. May repeat q3 min
prn; max 0.05 mg/kg (5 mg)/h
Dose Adjustment: Lower doses by 30-50% in elderly, debilitated,
severe hepatic impairment, chronically ill, or patients receiving
concomitant opiates.
Potential Adverse Effects: Respiratory depression, apnea,
respiratory arrest, hypotension, tachycardia, inability to maintain
airway
Diazepam (Valium®)
Onset: 3-10 minutes
Usual Duration: 6-8 hours
Elimination Route: Hepatic
Dose: 2-5 mg slow IV push. May repeat dosage q10
min prn; max 0.1-0.2 mg/kg (10mg)
Concerns: Irritating to veins, Significant accumulation
can occur, hypotension and bradycardia may occur
with rapid injection
Potential Adverse Effects: Respiratory depression,
apnea, respiratory arrest, hypotension, tachycardia,
inability to maintain airway
Opiate Analgesics
Examples of Opiate Analgesics Include:
 Fentanyl (Sublimaze®)
 Morphine
Fentanyl (Sublimaze®)
Onset: 1-2 minutes
Usual Duration: 30–60 minutes
Elimination Route: Hepatic (inactive metabolites)
Dose: 25-50 mcg/dose slow IV push. May repeat q3-5 min prn; max
500 mcg/4 hours. Rapid I.V. infusion may result in skeletal muscle and
chest wall rigidity, impaired ventilation, or respiratory distress/arrest;
nondepolarizing skeletal muscle relaxant may be required.
Half Life: 2-4 hours
Notes: Rapid onset sedative and analgesic effect, synergy with
benzodiazepines, minimal histamine release (less hypotension than
morphine)
Concerns: Tolerance develops, Accumulates over time
Potential Adverse Effects: Respiratory depression, apnea, respiratory
arrest, hypotension, tachycardia, inability to maintain airway, bradycardia.
Morphine
Onset: 5-10 minutes with a peak at 20 minutes
Usual Duration: 2-4 hours (prolonged in elderly with
hepatic dysfunction)
Elimination Route: Hepatic
Dose: 1-2 mg slow IV push. May repeat dosage q3-5 min prn;
max 20 mg
Concerns: Hypotension due to histamine release, may
accumulate, tolerance develops, decreases GI motility
Potential Adverse Effects: Respiratory depression, apnea,
respiratory arrest, hypotension, tachycardia, nausea/vomiting,
inability to maintain airway
Other Agents:
Examples of Other Agents Use for Sedation Include:
• Ketamine (Ketalar®)
• Propofol (Diprivan®)
Ketamine (Ketalar®):
Onset: within 1 minute
Duration: 10-15 minutes
Dosage: 0.2-0.75 mg/kg slow IV push over 1-2 minutes
Half Life: 45 minutes
Elimination: Hepatic and excreted in the urine and feces
Notes: Should be administered with a benzodiazepine to
decrease emergence reactions including vivid dreams,
hallucinations, and/or delirium. Assistant should have no other
duties—only monitoring the patient. Patients should be monitored
a minimum of one hour after completion of the procedure
Potential Adverse Effects: Tachycardia, systemic and
pulmonary hypertension, hallucinations, vivid dreams, delirium
Propofol (Diprivan®)
Onset: less than 1 minute
Duration: 3-10 minutes
Dosage: 1 mg/kg slow IV push. May repeat with 0.5 mg/kg q3-5 minutes prn
Half Life: 40 minutes
Elimination: Hepatic
Notes: Rapid onset sedative with NO analgesic effect. Tolerance develops,
urine turns green
Potential Adverse Effects: Respiratory depression, apnea, respiratory arrest,
hypotension, inability to maintain airway
BJWCH RN’s may not administer an IV bolus
of Propofol for Procedural Sedation. If this
agent is used, the Proceduralist must
administer the bolus.
Etomidate (Amidate®)
Onset: less than 1 minute
Duration: 3-5 minutes
Dosage: 0.1-0.2 mg/kg slow IV push over 30-60 sec. May repeat with
0.05 mg/kg q3-5 minutes prn
Elimination: Hepatic
Potential Adverse Effects: Commonly causes myoclonus, pain upon
injection, adrenal suppression (typically no clinical significance unless
repeated doses are used within a limited time span); may cause nausea,
vomiting, and lower seizure threshold; does not alter hemodynamics;
causes a slight to moderate decrease in intracranial pressure that only
lasts for several minutes; does not cause histamine release; useful for
patients with trauma and hypotension
Reversal Agents
Naloxone (Narcan®)
Flumazenil (Romazicon®)
Reverses
Opiates
Benzodiazepine
Dosing
0.4-2 mg q 2-3 min, up to 10 mg
0.2 mg q 1 min, up to 1 mg
Onset
1-2 min
1-2 min
Duration
30-60 min
30-90 min
Adverse
Effects
Can precipitate withdrawal,
pulmonary edema
Seizures
Reversing BZD-induced
hypoventilation has not been
established
Post-Procedural Requirements
Procedural Orders:
• Orders given orally throughout the procedure must be
written in the patient medical record or entered via
computerize provider order entry (CPOE)
• If the assistant is utilizing handwritten documentation
forms, the Proceduralist’s signature, date, and time must be
included on the bottom of the monitoring form.
• A post-procedural note must be documented in the patients
medical record
Monitoring Requirements:
• Blood Pressure, Pulse, Respiratory Rate, and SpO2 are to be
documented every 10 minutes (more frequently, if indicated)
• An Aldrete Score must be completed upon completion of the
procedural and with each vital sign documentation during the
recovery period
ALDRETE POST PROCEDURE RECOVERY SCORE
A Baseline Pre-Procedural
Aldrete Score must be
obtained before sedation is
initiated, because the PostProcedural Aldrete Scores are
compared to the baseline
score
A Post- Procedural Aldrete
Score is obtained at the end of
the procedure and then
repeated every 10 minutes
until the patient meets
discharge criteria.
To meet discharge criteria, a
minimum of two (2)
consecutive Aldrete Scores
AFTER the end of the
procedure must be at the
baseline score or the baseline
score minus one with stable
vital signs
Discharge Criteria
Discharge Criteria (cont.)
• In the event that reversal agents (naloxone, flumazenil)
were used, allow a minimum timeframe of 1 hour after the
last dose to ensure that the patient does not become resedated after reversal effects have abated
• Patients who will be discharged to home and received IV
medications for relief of pain, nausea, and/or vomiting, etc.
must be observed for no less than two (2) Aldrete/vital sign
assessments following the administration of such medication
• Critical thinking: If the patient has liver/kidney
insufficiency, metabolism and/or excretion of the drugs
might be impaired. This might prolong the effect of the
drug(s) resulting in a need for longer recovery-area time
Discharge Instructions
Discharge Instructions Need to Include:
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Purpose and expected effects of sedation
Patient's post-discharge care
Emergency phone number
Post-discharge Medications
Dietary/activity restrictions
No driving for 24 hours
Avoid alcohol for 24 hours
Other instructions appropriate for the procedure
References
• Anesthesiology & Critical Care Drug Handbook. (2011). (10th Ed.).
Hudson, OH: Lexi-Comp, Inc.
• ASA (2002). Practice Guidelines for Sedation and Analgesia by
Non-Anesthesiologists. Anesthesiology 2002; 96:1004-1017.
• Department of Health and Senior Services (DHSS) Centers for
Medicare and Medicaid Services (CMS) Conditions of
Participation: Anesthesia Services.
• The American College of Emergency Physicians (ACEP) (Nov 8,
2011) Medscape Reference:
http://emedicine.medscape.com/article/109695-overview.
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• The Joint Commission (2011) Comprehensive Accreditation
Manual for Hospitals.