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Trina VanGuilder, RN, BSN, CGRN
Franklin, Tennessee
October 16 th , 2010
4/12/2020

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 Why we administer sedation agents for
Endoscopic procedures?
 How do we know we are administering
Sedation properly?
 How do we prevent poor outcomes?
 How should we respond when sedation does not go as planned?
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 www.sedationfacts.org
 Comprehensive resource for evidenced based information
 Joint efforts by SGNA,ASGE,AGA, ACG
 Funded by a grant from Ethicon Endo-Surgery, Inc
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What does SedationFacts have to offer you?
 24/7 Fingertip access FREE to…
 Emerging Agents and Technologies
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Upcoming conferences and Training
Reference websites and articles
Ask a question to the experts
State by state BON Position statement
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Newsletter and Sedation updates
Airway management
SGNA Position statements related to Sedation
(staffing guidelines, pt classification, etc.)
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WHY?
Reduce patient anxiety
• Brings them in
• Fear of pain
• Patient satisfaction
Ability to perform procedure successfully
• Enhanced outcome
• Reduces potential injury to patient
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Why Not…those who prefer no sedation
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Fear, curiosity, convenience
Loss of control
Effects of drugs (short and long term)
 What may go on in the room
 Desire to watch the procedure
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Cost
Drive/return to work
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If you are following National standards
And
You have guidelines to meet these standards
And
You have current policies in place and follow them
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CONGRATULATIONS!!!!!
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Liability and Standards
Liability
Guidelines
Standards

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Example: Colon Cancer Screening
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Standard
 Screening Colonoscopy (National Gold Standard)
Guideline
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50 years old (family history, symptoms, high risk
Other: time in/out, to cecum, polyp removal, etc.
Policy
 Facility policy (policy on screening, preps, sedation)
Liability
 If policy, guideline , standard is not followed and bad outcome occurs
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Sedation
 Standard (Examples)
 BOD Position Statement
 Regulatory process (JC, AAAHC, State, FDA)
 Administered by properly trained personnel
 Nationally recognized practices (SGNA, ASGE, etc)
 Dept training and competency policy
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 Guidelines (Examples)
 Documented training/competency
 Quality Monitoring of each sedation case
 Assessment process
 Drug dosage
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Continued
 Policy (Examples)
 Number of staff in each procedure room
 How often VS are taken
 Discharge instructions
 Liability
(when the unexpected happens)
 Did you perform your trained r esponsibilites in a customary way that others in your same role would perform under the same or similar circumstances?
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Why Do We Need Policies and
Competency?
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 To care for our patients safely and effectively.
To prevent disaster
To protect us legally
To build confidence
To standardize practices
To validate that staff are properly trained
 To care for our patients safely and effectively.
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 “An ability to do something, especially measured against a standard.”
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SEDATION COMPETENCY
Knowing and following national standards (based on EBP)
Knowing and following the drug label
Knowing how to intervene effectively if a crisis arises
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Competency is not…
 Taking a class
 Passing a test (written or clinical)
 Getting CE’s
 Doing something the way you have always done it (unless it is the standard of care)
 Doing it because this is the way you were shown to do it
(unless it is the standard of care)
 Administering sedation without an event
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Always remember this question
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Physician
Dentist
Registered nurse
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 Radiology technologist ( in the presence of the direct supervision of an individual permitted to perform procedures under sedation
)
CRNA
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 Staff must possess skills in airway management.
 A secure IV access ,emergency equipment and reversal agents must be available.
 Know and respond to warning signs (restlessness and agitation must ALWAYS first be evaluated as potential hypoxia.)
 O
2 saturation does not equate to ventilation.
 Room environment
 Know patient previous response to sedation
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 Staff must possess skills in airway management.
 A secure IV access ,emergency equipment and reversal agents must be available.
 Know and respond to warning signs (restlessness and agitation must ALWAYS first be evaluated as potential hypoxia.)
 O
2 saturation does not equate to ventilation.
 Room environment
 Know patient previous response to sedation
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Tips for Successful Sedation of the
Difficult to sedate patient?
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Know your patient BEFORE you schedule the exam.
Know to what degree your patient may be affected by AOD.
Review the case with your physician
Schedule patient with anesthesia when necessary or possible
Use Droperidol using proper criteria
Use Phenergan prior to the procedure
Be prepared for administration of larger doses of routine sedation agents.
Be prepared to treat the patient who may become deeply sedated
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Regulatory Standards (JC, AAAHC, CMS)
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Sufficient number of qualified staff are present
Individual administering moderate or deep sedation much be qualified to do so
RN must at least supervise nursing care provided to patient
Appropriate equipment must be immediately available
Resuscitation equipment must be available with a person trained in proper use of the equipment
Patient must be assessed ( H&P)
Patient must be assessed immediately before sedation
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Regulatory standards Continued
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Time out must be performed
Education must be provided to the patient before and after the procedure
Monitoring must occur throughout the procedure
Sedation medication must be monitored and documented
Patient assessment must be performed upon arrival to RR
DC must occur through DC criteria or by a qualified practionier
Verbal/Written DC instructions must be given/signed
Med Reconciliation must be completed and given to pt
PI monitoring of sedation cases must take place
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ASA Revised NPO Guidelines for
Sedation
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2 hours prior to sedation: nothing by mouth
Up to 2 hours prior to
sedation: clear liquids
Up to 4 hours prior to
sedation: infants may have breast milk
Up to 6 hours prior to
sedation: may have nonhuman milk and infant formula
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Up to 8 hours prior to
procedure: may have solid food
Medications: gastric stimulants, drugs that block gastric acid secretion, and antacids may be ordered preprocedure in patients with risk of aspiration.
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Airway Assessment
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Airway assessment
Why do we EVALUATE?
 1 in 10,000 patients will have airway problems
 1% have a failed airway (pt. cannot be intubated after 3 tries)
 Be prepared for emergent intubation
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Assessment
How do we assess airway?
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History of airway compromise
Physical assessment
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Morbidly obese
Facial Hair
Narrow Face
Overbite
Trauma
Obstructions
Neck Mobility
IT IS TOO LATE TO ACCESS AN AIRWAY
WHEN YOUR IN A CRISIS
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Mallampati Grades
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Class I
Soft palate, fauces,
Uvula, tonsular pillars
Class II Class III
Soft palate, fauces,
Uvula

Difficulty 
Soft palate, base of uvula
Class IV
Hard palate only

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Mallampati Score
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Patient sitting up with neck extended
Open mouth wide
Protrude tongue
No phonation
View posterior pharynx
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Assessment / Documentation
 Pre-procedure is done before giving sedation. The assessment and documentation should include:
 Intra-procedure begins when patient enters procedure room before sedation is administered
 Post-procedure begins when sedation administration and procedure has ended
 Assignment of ASA (American Society for Anesthesiologist) classification per the physician.
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ASA Revised NPO Guidelines for
Sedation
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2 hours prior to sedation: nothing by mouth
Up to 2 hours prior to
sedation: clear liquids
Up to 4 hours prior to
sedation: infants may have breast milk
Up to 6 hours prior to
sedation: may have nonhuman milk and infant formula
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Up to 8 hours prior to
procedure: may have solid food
Medications: gastric stimulants, drugs that block gastric acid secretion, and antacids may be ordered preprocedure in patients with risk of aspiration.
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Tips for Successful and Safe
Sedation Administration
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Staff must have knowledge of:
Dosage limits
Onset
Duration
Interaction
Precautions
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Tips for Successful Sedation of the
Difficult to sedate patient?
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Know your patient BEFORE you schedule the exam.
Know to what degree your patient may be affected by AOD.
Review the case with your physician
Schedule patient with anesthesia when necessary or possible
Use Droperidol using proper criteria
Use Phenergan prior to the procedure
Be prepared for administration of larger doses of routine sedation agents.
Be prepared to treat the patient who may become deeply sedated
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Tips for Successful and Safe
Sedation Administration
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START LOW AND ADMINISTER SLOW
Initiate sedation at the lowest dosage
Titrate slow
CAUTION when administering 2 drugs.
THE NURSE IS THE MOST
IMPORTANT MONITORING TOOL.
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Cardiac monitor
Pulse oximeter
Oxygen and administration equipment
Bag valve mask device
Oral and nasal airways
Intubation tray
LMA
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Intravenous supplies
Emergency cart/AED
Defibrillation equipment
Reversal agents
Suction equipment
Blood pressure monitor
Thermometer
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Pediatric/Geriatric Reminders
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Geriatrics
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Altered metabolism/excretion
 Liver or kidney or heart disease effects
Weakened muscles
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Respiratory muscles
Cough reflux
Gastric sphincter
Heart contractions
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May require lower dose
May require same doses at less frequent intervals
Watch for increase fall risk
Post procedure care after leaving facility
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Pediatrics
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Airway
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Small airway
Larger tongue
Less pulmonary reserve
Easier to become hypoxic, harder to restore ventilation
Dosing
 Dose by weight not by age
 When unsure have another HCP double check doses
Rescue intervention
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Have appropriate size rescue equipment in room BEFORE starting procedure
REVERSE WITH CAUTION
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D R U G
ONSET PEAK
NAME CLASS
R E V E R SA L
A G E N T
DURATION ELIMINATION
Dose : IV: 0.25-2mg Q2-5 minutes
MIDAZOLAM Onset: 30-60 secs.
Versed 10-15 mins. secs. May repeat over 60
Class: Benzodiazepine Duration: 1-2 hrs
Elim ination: Excreted in the
ROMAZICON 0.2 mg over 15 seconds f or total dose of 1 mg urine half lif e1.2-12.3 hrs
A D V E R SE
E F F E C T S
Pain at injection site, H/A,
Respiratory depression, Euphoria, agitation, insomnia,N/V
Dose: IV 1.0mcg/kg, q 5-
10mins.
FENTANYL 1-3 mins
NARCAN 0.1 mg - 0.2 mg Q 2-3
Sublimaze : 5-15min s. minutes
Class: Opioid Duration: 30-60 mins
Seizures, Respiratory depression
Euphoria, laryngospasms, skeletal muscle rigidity, bradycardia
Elim ination: Metabolized in the liver Excreted by kidneys
C O N T R A IN D IC A T IO N
P R E C A U T IO N S
Patients w ho receive narcotics may need smaller doses.
Know n hypersensitivity to Fentanyl. Use w ith caution in patients w ho have asthma, COPD, seizures, head injury
MEPERIDINE
Class: Opioid
Dose : IV:12.5 - 25mg Q2-15 minutes
Onset:
Demerol
1-5 mins.
10-20 mins.
Duration: 1-2 hrs
Elim ination: Metabolized in the liver Excreted by kidneys
Respiratory depression,
NARCAN 0.1 mg - 0.2 mg Q 2-3 drow siness, dizziness, conf usion,
H/A, convulsions at high dosed, minutes
Tachycardia or bradycardia, asystole, f lussiong, tinnitus
Know n hypersensitivity to Demerol Use w ith caution in patients w ho have asthma, COPD, seizures, head injury, supraventricular arrhythmias Use cauti on i n the el derl y. M ay cause hypertensi on, anxi ety, tachycardi a.
Dose : IV: 1-4mg Q 2-15 mins.
MORPHINE Onset: 1-3 mins.
Duramorph: MS Contin,
Roxanol
Class:Opioid
Peak: 10-20 mins.
Duration: 1-2 hrs
Elim ination: Excreted in the
NARCAN 0.1 mg - 0.2 mg Q 2-3
Sedation, dizziness, delirium, seizure, nausea, hypominutes hypertension, f lushing, rash urine and bile
Dose : IV: 0.1- 0.2mg Q 2-3 mins.
NALOXONE
Onset: 1-2 mins.
Narcan
Peak: 5-15 mins.
Class: Narcotic
Antagonist
Duration: 45 mins.
Elim ination: Excreted in the urine
Excessive amount may cause excitation reaction and cardiac arrest.
Know n hypersensitivity to Morphine, codeine, hydrocodone, oxycodone. Use w ith caution to patients w ith supraventricular arrhythmias, head injury, increased intracranial pressure, asthma, COPD seizure disorder.
Contraindication in patients w ith know n hypersensitivity to naloxone. If administered to opioid dependent patient severe w ithdraw al symptoms may result. Administer w ith caution to patients w ith supraventricular arrythmias, head injuries or convulsive diso
Dose : IV: 0.2mg over 15 secs.may repeat at 60 second
Romazicon Onset:
Class: Narcotic 30-60 seconds
Peak: 6-10 mins.
Duration: Inf luenced by the dose administered and the dose
Agitation, dizziness, N/V f atigue, blurred vision.
Contraindication in patients w ith know n hypersensitivity to f lumazenil or benzodiazepines f or anti-seizure treatment,cyclic antidepressant overdose,

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INDICATORS OF HYPOXEMIA /
INADEQUATE VENTILATION
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MILD
 Slight pallor
 Increase heart rate
 Slight decrease in respiratory rate
 Slight decrease in baseline oxygen saturation
MODERATE / SEVERE
 Pallor
 Increase in heart rate
 Shallow respirations
 Decrease in respiratory rate
 Decrease in oxygen saturation
 Delayed capillary refill ( in
Pediatric Patient )
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AIRWAY MANAGEMENT
 Attempt to awaken patient first
 Reposition head- sniffing position
 Insert airway: nasal or oral
 Mask ventilation
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TIPS
Best way to deal with trouble is to avoid trouble, learn the signs of bad airway.
Most patients who have respiratory compromise can be managed with simple maneuvers
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What is a rescue intervention?
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Chin lift > than 30 seconds
Oxygen delivery necessary to increase O 2
Airway (oral or nasal)
Ambu
Reversals
Intubation
Code
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Sedation Bloopers
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Stepping on O2 tubing
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Syringes
Unlabeled syringes
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Wrong size airway
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Wrong size ambu bag
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Unattended narcotics
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Others Bloopers…
Pulling out the ambu bag and losing the mask on the floor
Improper intubations
Oblivious to staff narcotic misuse
Malfunctioning Intubation blade
Drug administration to please physician
Drug administration to please patient
Using O2 NC > 6 liters
Inability to perform (quickly) in crisis due to anxiety or lack of training
Treating patient without confirming monitoring issues
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Difficult to Sedate?? Now What?
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The Difficult to
Sedate Patient
Indicators
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Chronic narcotic usage
Use of street drugs
Alcohol usage (31%)
Anxiety
Difficult or prolonged procedures
Past experiences with sedation and procedures
IBS/IBD
Antidepressants
History of substance abuse
Assessment of lifestyle habits
Old records
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How can you determine if a patient may be difficult to sedate?
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Assessment of lifestyle habits
Lab work
Patient history
Patient behavior/appearance
4/12/2020

Tips for sedation of the difficult to sedate patient?
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Know your patient BEFORE you schedule the exam.
Know to what degree your patient may be affected by AOD.
Review the case with your physician
Schedule patient with anesthesia when necessary or possible
Use Droperidol using proper criteria
Use Phenergan prior to the procedure
Be prepared for administration of larger doses of routine sedation agents.
Be prepared to treat the patient who may become deeply sedated
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EtCO2 monitoring
SCHEDULE AHEAD FOR DEEP SEDATION WHEN NECESSARY
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Drug requirements for difficult to sedate patients
 Patients with alcohol and drug dependencies (AOD) often require 2.5 times more sedation agents than patients without AOD
 When Propofol is used for sedation the patient does not routinely require additions amounts to achieve the same level of sedation
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Adjunct Drugs to administer to promote a positive outcome in the difficult to sedate patient.
• Phenergan- 25 mg IV 15 to 30 minutes prior to procedure
• Benadryl- 25 to 50 mg IV
• Droperidol- ONLY if patient not high risk for QT problems and if cannot use propofol
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• Propofol
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Hot topics and updates in Sedation
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Airway
CMS requirements
Staffing
Time out
Medical Reconciliation
New and upcoming technologies/drugs
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Summary of 2009 CMS Guidelines
“Because we cannot always predict individual pt response to drugs, procedures must be in place to ensure pt rescue from a deeper level of sedation than intended.”
“Health Care Facilities must have policies and procedures consistent with the State scope of practice law that assure all anesthesia services are provided in a safe, well organized manner by qualified personnel.
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