Procedural Sedation
Changes
Go live: APRIL 24th
Why These Changes?
 Per the Cal Dept of Public Health (ie, the “state”) and
CMS (federal) nurses cannot push an anesthetic drug
for procedural sedation. This includes propofol,
ketamine, barbituates and etomidate.
 On April 24th we will change our process to meet this
regulation.
What can RNs do?
 Moderate sedation- ONLY
 Those performing moderate sedation must have
attended SMCS sedation class AND have current ACLS
or PALS
 Regardless of intent of sedation, some drugs are
defined as agents of deep sedation and can NOT be
administered by an RN for procedural sedation
 Ketamine, Propofol, Barbituates and Etomidate
BRN Position Statement for RN
 RN only task.
 Can not be delegated to non licensed personnel
 Recognize emergency situations and institute
emergency procedures
 Assess if sedation by RN is in pt’s best interest
 Airway management skills and training
 1:1 care
RN is patient’s advocate.
Sedation Privileging- MD
 Up to date list of privileges located on SHIPER
 RN to check privileges before starting procedure
 MD are privileged by the Department of Anesthesia
 Exception: ED MDs maintain privileges per their
department
What will MDs do?
 The physicians must push the drug or push the button
on a pre-programmed IV pump for these drugs, or give
an IM shot of ketamine.
 For longer orthopedic procedures, the doctor may ask
you to program an on-going infusion, then they will
start the drug after they see the confirmation screen on
the IV pump.
Does this effect RSI and infusion of
vented patients?
 You will still be allowed to push propofol and/or
etomidate for a rapid sequence intubation (RSI)
because the doctor is there to intubate the patient.
 This does NOTeffect infusions of propofol in the
vented ICU patient. This regulation applies to
procedural sedation.
 New order set developed
 Must be used on Med-sug/ tele units
 Verify patent IV
 Hang NS 1000 ml
 May administer 250 ml bolus for hypotension
 Reversal agents prechecked on sheet
Why? Pulse Oximetry and ETCO2
 American Society of Anesthesiologists requires use of
ETCO2 on all case of MODERATE and DEEP sedation.
 Funding for more ETCO2 monitors has been approved.
Respiration and Ventilation
 Respiration
 Exchange of 02 and CO2
dependant on Ventilation
 Ventilation
 Movement of air in and out
of thoracic cavity
Ventilation!
Ventilation!
Ventilation!
 Control of ventilation
 Brainstem
 Phrenic nerve
 Diaphragm, intercostals,
accessory muscles
Pulse Oximetry
 Arterial oxygen saturation
 Measures respiration, NOT ventilation
 Decreased O2 Saturation is a very late sign of
hypoventilation
ETCO2
 ETCO2 is required for ALL sedation cases- moderate
and deep!
 Place on pt prior to sedation
 Establish their baseline
 Normal 35- 45
ETCO2
 Measures Ventilation
 Normal CO2 is 35-45
 CO2 will rise 6 – 8 mm Hg during
the first minute of apnea
 CO2 - early indicator
 Pulse oximetry - late indicator
TCM Monitoring - Pediatrics
 Transcutaneous monitoring
 non-invasive technique
 Probe heats site to 41-45 degrees C to ↑ diffusion

Takes a few minutes to equillibrate
 continuous monitoring of the partial pressure of
arterialized capillary blood.
 Typically this will be the PCO2 level.
TCM Monitoring
 May keep on site for 8 h
 Have available when deep sedation is planned.
 patients 5 years and under
 Small body mass more accurate
Rising ETCO2
 Pt may become agitated and start pulling off ETCO2 ,
IVs ect.
 Critical Thinking Needed: is this under medication or
is this increasing ETCO2.
 Increasing ETCO2 = Treatment is Ventilation!!
 Under medication= administer more meds.
Programming a pump for MD
administration
Medication administration by MD
 For short procedures: Draw up and label syringe for
Physician administration
 For longer procedures: MD may want to have a bolus
administered via infusion pump followed by a
continuous infusion during the procedure
 With all new procedures there is a learning curve…. Be
prepared with NS one liter hanging for hypotension
induced by too rapid administration of the drug!!
Propofol – Recommendations for
longer procedures
 Initiate moderate sedation with Fentanyl and Versed.
 Follow with continuous infusion of Propofol during
the procedure.
 Recommended dosage is 25 – 75 mcg/kg/min for
adults.
 MONITOR airway and ventilation!!
 Stop infusion at the end of the procedure.
Anesthesia Recommendations
 Short procedures: single dose of Propofol 0.5 mg/kg IV
over 1-2 minutes using a syringe. An additional 20-40
mg IV may be needed for some patients.
 Longer procedures (adult patient):
 Have the RN administer Versed 1 mg IV and Fentanyl 50 mcg IV to provide
baseline moderate sedation while preparing for the procedure.
 Have the RN set up a Propofol drip on an infusion pump and connect to the
patient’s IV.
 Determine the dosing of Propofol you wish to administer for your
procedure. Anesthesia recommends a continuous dose of Propofol 25 to
75µg/kg/min, with a dose of 50µg/kg/min working well for most patients.
Stop the Propofol at the end of the procedure.
Programming a bolus
dose: Confirm with
the MD that you are
giving a BOLUS and
the amount they
wish to give.
They must hit the
YES button
This would be the
confirmation screen
the doctor will see
when you want to
run an infusion.
The doctor must
push YES
Documentation
 Document all medications administered on the
appropriate procedural sedation flowsheet or
departmental documentation tool.
 For medications administered by physicians, please
document the name, dose, route, and name of
administering physician.
 Ask the physician to sign the order set and/or the
flowsheet in the appropriate location.
Anesthetic Review
•Etomidate
•Ketamine
•Propofol
•Pentobarbitol
Adult medication review
Etomidate
 IV anesthetic
 Commonly used for rapid sequence intubation
 NO analgesic effect; produces hypnotic state in about 1
minute
 Minimal hemodynamic effects
 May have myoclonic contraction
 Benzodiazapines may ↓
Etomidate
 Adult Dose:
 300 mcg/kg
 Elderly or Hepatic 150- 200 mcg/kg
 Children May require 30% MORE than adult dose
 May be used IV only as bolus or slow push 10mg/ min
 Onset:
< 1 minute
 Duration:6- 10 minutes
Propofol (Diprivan)
 Sedative hypnotic for anesthesia
 Little to no analgesic effect
 No anti- anxiety effet
 Has negative inotropic effect – can lead to hypotension
 Can progress easily and rapidly to general anesthesia
 May be given as S L O W IV push or for non intubated patients
(infuse over at least 3-5 min)
Don’t give to patients who are
allergic to eggs or soybeans.
Propofol
 Adult Dose:
 0.5 mg/ kg IV over 3- 5 min for bolus dosing
 Incremental boluses 10- 20 mg
 Continuous infusion for procedural sedation:
25 – 75 mcg/kg/min
 Onset:
< 30 seconds
 Duration: 3 -10 minutes
 ½ life:
5 - 10 minutes
May cause allergic reaction in those with allergy to
eggs or soybean
Ketamine (Ketalar)
 An anesthetic agent with a
short half-life
 Disassociative anesthesia,
 Trance like state, Pts eyes may be open
 Amnesia
 Provides analgesia
 ↑ muscle tone
 Stimulates the CV system so may increase
BP and pulse
Emergence
reactions can occur
and are more
common in
adolescents, with
large doses of drug,
and following rapid
IV administration of
drug.
Ketamine
 May increase oral secretions - Watch airway
 Give atropine or glycopyrrolate to help decrease
oral secretions.
Ketamine
 Hallucinations with awakening or emergence
(5- 30%)
 May give benzodiazepine to prevent emergence
hallucinations in older children.
 Limit verbal, tactile, & visual stimulation
 Peds may not recognize caregivers during the post
procedure duration
Ketamine
 Abuse– 1979; sexual assaults
 Special K, Horse tranquilizer, animal tranq, elephant
tranq, green, honey oil, jet fuel, Kay Jay, Ket, Keta, Kit
Kat, Lady K, Purple, special la coke, super acid, Super C,
Vitamin K, Super K
 Hallucinogenic effects, disassociative, out of body
experiences
Ketamine





Pediatric Dose - IV: 0.25 – 0.5 mg/kg (give over 1 minute)
Titrate with 0.25 – 0.5 mg/kg every 5 – 10 minutes
Onset:
1 - 2 minutes
Peak:
2 - 5 minutes
Duration:
15 - 45 minutes
IM: 2 – 4 mg/kg
 Onset:
2 - 5 minutes
 Peak:
5 -10 minutes
 Duration:
15 - 45 minutes
This can be given IM or IV with IM doses providing sedation for
approximately 15 - 45 minutes and IV doses 15-45 minutes
Ketamine (Ketalar)
 Contraindicated in patients with increased
intracranial, systemic or intraocular hypertension.
Pentobarbital ( Nembutal)
 Infants > 6 months and children:
 IV- 0.5-3mg/kg titrate slowly over 5 minutes to max dose of 6 mg/kg or
100mg whichever is less.
 PO Administer 15- 30 min prior to procedure
 2-6 mg/kg max 100 mg/dose
 IV Onset:
1 – 15 min
 IV Duration: 15 – 30 min
 PO onset
15 - 60 minutes
 PO duration 1 – 4 hour
 May be preferred for pts. with increased ICP
 Limited information is available for use in infants < 6 months
Propofol (Diprivan)
 Sedative hypnotic for anesthesia
 Little to no analgesic, no anti-anxiety effect
 Can progress easily and rapidly to general anesthesia.
 May be given as S L O W IV push or short continuous drip for
non intubated patients (infuse over at least 3-5 mins)
 May cause allergic reaction in those with allergy to eggs or
soybean
Propofol
 Pediatric Dose
 0.5 mg/ kg, IV over 3- 5 min
 Titrate to effect
 Onset:
< 30 seconds
 Peak:
1 min
 Duration: 3-10 min
 ½ life:
5- 10 min