King faisal specialist hospital




Дата канвертавання24.04.2016
Памер164.37 Kb.

KING FAISAL SPECIALIST HOSPITAL

AND RESEARCH CENTRE INTERNAL POLICIES AND/OR PROCEDURE (IPP)


TITLE/DESCRIPTION:

INDEX NUMBER:


Procedural Sedation Protocol


MCO-MC-ADM-07-003

EFFECTIVE DATE:

REPLACES NUMBER:

APPLIES TO:

APPROVED BY:

15 Rabia Al Thani 1432

(20 March 2011)



MCO-MC-ADM-08-007

(18 February 2006)



MCO-MC-ADM-07-003

02 Rabia Al Awal 1428

(10 March 2008)

Medical Staff

and

Nursing Staff



(Signature on file)

Executive Director

Medical & Clinical Affairs



PURPOSE



The purpose of this policy is to establish a safe, effective process for the administration and monitoring of patients requiring sedation for diagnostic, therapeutic and invasive procedures
DEFINITIONS


  1. Sedation is the administration of a medication (refer to Appendix 2) to an individual, in an appropriate setting, for any purpose, by any route to provide moderate or deep sedation.




  1. Levels of sedation:

Sedation occurs in a dose-related continuum, is variable, and depends on each patient’s response to various drugs. The definitions listed below progress on a continuum from a high state of consciousness to unconsciousness.
This policy addresses only practices for moderate and unintended deep sedation as administered by
non-Anesthesiologists.



    1. 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 not affected.




    1. Moderate sedation “conscious sedation”: A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response. No interventions are needed to maintain a patent airway and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.




    1. Deep sedation: A drug-induced depression of consciousness during which patients cannot be easily roused, but respond purposefully after repeated or painful stimulation. The ability to maintain a patent airway and adequate spontaneously ventilation may be impaired and require airway management and support. Cardiovascular function is usually maintained.

3. ASA Classification – Physical risk status classification of the American Society of Anesthesiologists.



POLICY/COMMENTS





  1. The Chairman of the department and/or Manager shall be responsible for ensuring that clinical practice in their department meets or exceeds the standards outlined in this general policy.

  2. The Chairman of the department and/or Manager will be responsible to ensure that their staffs are credentialed for procedural sedation and BLS certified, initially on hire and at each reappointment cycle, and for the updating and maintenance of accurate Physician credentialing records.




  1. Personnel Qualifications and Roles



    1. 3.1 Practitioner

3.1.1 Since sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should have the required knowledge and skills to successfully rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering moderate sedation should have the required knowledge and skills to successfully rescue patients who enter into a state of deep sedation, while those practitioners administering deep sedation should have the required knowledge and skills to rescue patients who enter a state of general anesthesia.


3.1.2 The administration of moderate sedation requires the supervision by a practitioner who, by virtue of training, education, certification, or applicable licensure, law or regulation, is qualified to supervise the delivery of medical care. The individual may be a physician or dentist.
3.1.3 The practitioner must apply for Procedural Sedation privileges from the Medical Staff Credentials Committee through their department chairman. To gain privileging to perform Procedural Sedation the Physician must meet the criteria set by the committee which includes evidence of a valid Basic Life Support (BLS) certification.
3.1.4 The practitioner privileged to perform procedural sedation is requested to review this policy at least annually.
3.1.4 The attending physician /designee shall obtain informed consent, assess the patient and complete the Procedural Sedation Assessment form within 24 hours prior to the procedure.
3.1.5 The practitioner performing the pre-sedation review and assessment is responsible for reviewing the patient assessment, and documenting any new information on the procedural sedation assessment form within 15 minutes prior to the procedure. The documentation on the Procedural Sedation form includes the following:

3.1.5.1 Confirmation that informed patient consent has been given and obtained

3.1.5.2 Re-evaluation of the initial ASA level

3.1.5.3 Re-evaluation of NPO status

3.1.5.4 Brief history and physical examination prior to the administration of sedation to include airway assessment.

3.1.5.5 Medication ordering and/or administration


3.1.6 The practitioner must be in the procedural area from the time sedation is administered until

the procedure has been completed.


3.1.7 The practitioner is required to remain in attendance for those patients who have progressed into

a state deep sedation and provide the appropriate management during the recovery phase.


    1. Nursing




      1. Nurses caring for patients requiring moderate sedation must have a valid Basic Life Support (BLS)

Certification, have successfully completed the Procedural Sedation self study module, post test and competency check-off.
3.2.2 The nurse is responsible for:

3.2.2.1 Ensuring emergency equipment is functional and all required medications are available

3.2.2.2 Connecting the patient to the automated vital signs monitor

3.2.2.3 Preparing the ordered medications to be administered for procedural sedation

3.2.2.4 Monitoring, recording of appropriate physiologic parameters and to assist in

supportive or resuscitation measures as required.

3.2.2.5 Administering sedation under the direction of a Practitioner who is privileged to administer procedural sedation.

3.2.2.6 Post sedation recovery and discharge/transfer of patient


3.2.3 A designated nurse is assigned to administer the medications and monitor the patient during

the procedure. This individual must not engage in any other/additional activity, which would

compromise continuous patient monitoring and/or intervention.


  1. Applicability


4.1 This policy applies to the administration and monitoring of patients receiving sedation in all hospital departments and areas except as stated below:
4.1.1 This policy does not apply to patients receiving sedation from an anesthesiologist as their practice is governed by the standards of care established by the Department of Anesthesiology.
4.1.2 Patients in the Intensive Care Units or ORLII and ORL IV Recovery Rooms.
4.1.3 Patients who receive anxiolytic or analgesic agents which are administered routinely for pre-medication prior to surgery.
4.1.4 Patients who receive anxiolytic or analgesic agents which are administered routinely to alleviate pain and agitation (e.g., sedation for treatment of insomnia, post-operative analgesia), where the medication is administered prior to a procedure without the use of adjunct medication.


    1. 4.2 In the Echocardiology Laboratory, for pediatric patients receiving 100 mg/Kg or less of Chloral hydrate

    2. and have an ASA score 1 or 2 the following modifications to the policy apply:



4.2.1 I.V access is not required

4.2.2 The practitioner performing the procedural sedation is not required to complete the “Pre-

sedation review and Assessment” section of the Procedural Sedation Assessment form, the nursing

patient assessment documented on the nursing procedural sedation flowsheet is only required.



      1. A Physician is assigned to the Echocardiology Laboratory and must attend to the patient if required within 5- 10 minutes.



5. Pre-Sedation Protocol


    1. Factors Affecting Candidacy for Sedation:

      1. For patients who have significant medical problems (e.g. severe systemic disease, morbid obesity, sleep apnea, upper or lower structural airway abnormalities) consideration shall be given for consultation with an anesthesiologist or a consultant specializing in the primary disease process affecting the patient.




      1. The following criteria are applicable based upon the initial ASA score.

  • ASA 1 – proceed as per policy

  • ASA 2 – proceed as per policy,

  • ASA 3 – consult with Department of Anesthesiology suggested

  • ASA 4– consult with Department of Anesthesiology mandatory




      1. High risk populations that may require a consult with anesthesiology to fully assess:

5.1.3.1 Infants with a history of apnea

5.1.3.2 Premature infants less that 60 weeks post-conceptual age (less than 6 months of age)

5.1.3.3 Full-term infants less than 3 months of age

5.1.3.4 Craniofacial abnormality with airway difficulty




    1. Pre-Sedation Assessment:



      1. A pre-sedation assessment is completed by the attending physician /designee within 24 hours of the procedure and documented on the Procedural Sedation Assessment Form.




      1. The patient condition must be reviewed within 15 minutes prior to the administration of sedation and analgesia by the practitioner supervising the sedation and any additional information documented on the Procedural Sedation Assessment form including the time, date and signature.




      1. Multiple Administrations of Sedation and Analgesia

In cases when a patient requires sedation multiple times per day or single/multiple times on successive days, the initial pre-sedation assessment is sufficient as long as the practitioner performing the procedure determines through subsequent evaluation of the patient that no change has occurred in patient’s clinical status that would alter the outcome of administration of sedation. A short note shall be documented in the patient’s medical record stating that an evaluation of the patient’s clinical status was performed prior to subsequent administration of sedation.


    1. Consent for Sedation

      1. The patient or the patient’s parent/legal representative must be informed of the risks and benefits and must provide their consent to the proposed sedation plan by signing the Procedural Sedation Consent Form.




      1. Documentation of Informed Patient Consent will be included in the medical record. This may be included with consent for procedure (Consent for Surgery, Special Procedure and/or Blood Products)




    1. NPO Guidelines

      1. Verification of NPO status must occur before the start of sedation.




      1. Adult: 6-8 hours solids and liquids

Pediatric: 6 hours solids and non-human milk

4 hours human milk

2 hours clear liquids (small amounts)




      1. The above NPO guidelines apply to all pediatric and adult patients, unless the risk of nutritional deprivation outweighs the benefit of NPO in the estimation of the practitioner. (Risk for aspiration is of paramount concern.)




      1. Patients at risk for regurgitation or aspiration (e.g., known gastro-esophageal reflux, extreme obesity) may benefit from pharmacologic therapy to reduce gastric volume and increase gastric pH before sedation or from a longer NPO period of time prior to the procedure. If delayed gastric emptying is present, an Anesthesiology or GI consult should be considered before sedation and analgesia.




      1. Certain radiologic procedures require the administration of oral fluids in conjunction with sedation and analgesia. Risk of aspiration during these procedures must be weighed against the benefits of sedation and analgesia.




      1. In emergenency situations when the NPO status cannot be confirmed, or the patient has not been NPO, the risks and potential complications should be considered regarding the administration of procedural sedation by a non-anesthesia practitioner.




  1. Sedation Management

Staff requirements for procedural sedation include a practitioner who has privileges to perform procedural sedation and a Staff nurse who has successfully completed the educational requirements.

The monitoring of the Patient shall start from pre-sedation until the patient has met the discharge criteria.
6.1 Monitoring and Documentation of the Procedure
6.1.1 Baseline information including vital signs, pain assessment, the patient’s general appearance, level of consciousness and response to stimuli shall be recorded on the Procedural Sedation Flowsheet before administering sedation and analgesia.
6.1.2 Prior to the procedure the practitioner shall write an order for procedural Sedation on the physician order form. Medication will be entered in ICIS as per policy
6.1.3 Just before the procedure, “time out” is performed by the procedural team and documented on the “time out” section of the Surgical/Procedural Verification Form
6.1.4 During sedation, vital signs shall be monitored and documented on the Procedural Sedation Flowsheet at 15 minute intervals for moderate sedation including:

6.1.4.1 Heart rate

6.1.4.2 Respiratory rate

6.1.4.3 Oxygen saturation (pulse oximeter)

6.1.4.4 Blood pressure
6.1.5 The patient’s general appearance, level of consciousness and responses to stimulation are

extremely important parameters and should be assessed and documented at 15-minute intervals,

utilizing the Ramsey scale with comparison to the baseline information.
6.1.6 Prevention of cold-stress in infants  1 year – the ambient room temperature may require

adjustment in the procedural area when the patient is an infant. Decrease in body temperature

resulting in cold-stress can have significant ramifications in this patient population.
6.1.7 Alternative monitors should be used and alternative vital signs measured in situations when:


        1. 6.1.7.1 The use of conventional monitors would be unsafe, as in hyperbaric atmospheres, in

        2. water, or during MRI exam.

        3. 6.1.7.2 The use of conventional monitors may negatively affect imaging procedures as they

        4. could distort the image, stimulate movement and produce artifact (e.g., blood pressure cuffs in

        5. children, verbal stimulation or responses during head CT or MRI).

        6. 6.1.7.3 Equipment specifically designed for use in these areas is utilized for monitoring.



    1. 6.2 Medications



6.2.1 Drugs which can be incrementally dosed are preferred. Special attention should be paid to

calculate dosage on a weight adjusted basis (mg/kg) instead of using fixed dosages. (See

Appendix 2 – Recommended Drugs and Dosages.)
6.2.2 Pharmacologic antagonists, including Naloxone and Flumazenil, should be immediately

available.


6.2.3 All I.V sedation and analgesia will be administered within the procedural area.
6.2.4 All drugs administered for sedation and analgesia shall be documented on the sedation flow

sheet and include the dose and time of administration


6..2.5 Intravenous Access

Patients receiving IV sedation require the insertion of an IV access. A qualified person must be readily

available to secure IV assess in adult patients and administer analgesia by other routes ( ie PO, IM, PR,

Internasal) in case of an emergency or as required.

IV access is required for all Pediatric patients regardless of the route of sedation administration with

exception of pediatric patients receiving Chloral hydrate (Refer to item 4.2 of the policy)




  1. Post-Procedure Management

7.1 Post-sedation recovery management may be conducted either in a designated recovery area or in the procedure area as long as the management criterion has been met.


7.2 Recovery time starts from the time the procedure was completed.
7.3 Equipment equivalent to that used in the sedation area shall be immediately available.
7.4 Monitoring:

7.4.1 Blood pressure, heart rate, respiratory rate, pain and level of consciousness (Ramsey scale) are assessed and documented every 15 minutes (or more often as indicated by the patient’s condition).




      1. Temperature shall be monitored and documented




      1. Oxygen saturation is monitored continuously via pulse oximetry and documented every 15 minutes.




      1. Monitoring shall continue until post-sedation discharge criteria has been met.

(See Section 5.5 – Discharge Criteria.)


      1. Additional monitoring is at the practitioner’s and/or nurse’s discretion.




    1. Transfer/Transport

Conditions for transporting patients who have undergone sedation are as follows:




      1. A patient recovering from sedation may be transferred to another unit prior to the discharge

criteria being met, only if the unit receiving the patient can provide the same level of post-

procedure care monitoring. (Recovery Room or ICU only.)




      1. Post-procedure orders shall be written by the practitioner performing the procedure, including monitoring requirements. The orders shall be reviewed and reconciled by the receiving physician after transfer.




      1. During transport of a patient under sedation , the patient shall be accompanied by a minimum of two people, one of whom must be BLS certified, has appropriate qualifications and have the appropriate equipment for continuous monitoring

7.6 Recovery Discharge Criteria (documented on the Procedural Sedation Flowsheet)


Once the following criteria has been met the post procedure monitoring has been completed, the patient can be transferred to an inpatient unit or transferred to the holding bay or any other area prior to discharge from the facility in the care of a responsible person.


      1. A baseline PARSAP score is obtained immediately post-procedure and documented in the recovery discharge criteria section (section 1) of the Procedural Sedation Flowsheet




      1. A PARSAP score of 8/10 is required before discontinuing monitoring and transferring to an inpatient unit or to a recovery area (section 1) . A nurse may determine discharge eligibility utilizing the stipulated criteria (Refer to Appendix 3.)




      1. For Patients to be discharged home their overall minimum PARSAP score must be 16 (combined section 1 and section 2) or the return to their pre-procedural assessment score.




    1. Discharge Instructions

The person responsible for the patient shall receive written instructions prior to discharge from the facility that include the following:

7.7.1 Information about expected behaviour following sedation

7.7.2 Dietary Instructions

7.7.3 Warning signs of complications

7.7.4 Special instructions in case of emergency

7.7.5 Contact telephone numbers

7.7.6 A notation shall be documented in the medical record confirming instructions were received and understood by a responsible person


8. Quality Monitoring


      1. Adverse events related to procedural sedation shall be reported in the S.R.S including but not limited to the need for reversal agents

      2. Trends will be reported by QM to the relevant individual(s), departments and committees for action and follow up

MATERIAL

Procedural Sedation Flowsheet (Form 605-16 Rev. 06-26)

Procedure Sedation Assessment Form (Form 30200-112) (04-27)

Patient Medical Record

Interdisciplinary Patient/Family Education Record (Form 623-16 06-20) IC# 172450

Physician order form (Form 750-03 Rev. 02-09) IC# 178030

Procedure/Conscious Sedation Consent Form (Form 605-17 06-20)

Surgical/ Procedural Verification Form (Form 3000-06 (08-27))



EQUIPMENT

The following equipment must be available in the room and be in good working order where moderate sedation is being administered. The equipment identified may be stocked in the room or located on the resuscitation cart, which must be available in the immediate area during the procedure. Equipment appropriate for the patient, being sedated whether it is a infant, child or adult must be available and checked to ensure that it is in good working condition prior to the sedation being given.




  1. Oxygen – functional source, adequate for the length of the procedure

  2. Oxygen – backup supply, of at least a full E cylinder, maintained in the area

  3. Oxygen delivery system and manual resuscitator with oxygen reservoir

  4. Functional suction apparatus, appropriate size Yankauer-type rigid suction device and suction catheters

  5. Oral airways, in appropriate sizes

  6. Appropriate equipment to measure vital signs, blood pressure, O2 saturation, respiration rate, and heart rate.

  7. EKG monitor (for patients who require cardiac rhythm monitoring)

  8. Reversal drugs, Naloxone and Flumazenil, readily available

  9. I.V access devices


REFERENCES





  1. MCO-MC-ADM-01-024 Interdisciplinary Assessment/Reassessment and Documentation in the Medical Record 

  2. MCO-MC-ADM-07-004 Completion of Procedural Sedation Flowsheet

  3. MCO-NA-NAA-01-015 Documentation of Nursing care

  4. Safe sedation of children undergoing diagnostic and therapeutic procedures. A National Clinical Guideline, retrieved Nov. 14, 2007 www.guideline.gov.

  5. MCO- NA_NAA-07-066 Criteria For Discharging Adult and Pediatric Patients From Phase I and Phase II Recovery Area

  6. Guidelines for Monitoring and Management of Pediatric Patients during and after sedation for diagnostic and therapeutic procedures: an update. American Academy of Pediatric Dentistry - Professional Association
    American Academy of Pediatrics - Medical Specialty Society.  1992 Jun (revised 2006 Dec).  16 pages.  NGC:005437

  7. APP 1425-06 Informed Patient Consent

  8. MCO-MC-ADM-08-003  Interdisciplinary Patient/Family Education Record 

  9. Joint Commission International Standards for Hospitals, 4th Edition 2010

  10. http://www.ncbi.nlm.nih.govl retrieved June 5th, 2007

  11. MCO-NA-NAA-06-016 Nursing Medication Administration System 

  12. MCO-MC-ADM-07-039 General & Medication Order Entry

  13. MCO-MC-ADM-07-034 Pain Assessment And Management

  14. MCO-MC-ADM-03-001 Resuscitative Techniques: Required Levels of Training 

  15. Procedural Sedation: Self-study Module for Nurses

  16. Sackland, M., Grading of patients for surgical procedures. Anesthesiology. September, 2002, vol. 66 no. 9

  17. Shababie, Afshin., Conscious sedation for interventional procedures: a practical guide, Elsevier, 2007.

  18. MCO-NA-NAA-07-035 Transport of Patients for Tests and Procedures

  19. MCO-NA-NAA-07-059 Transfer of patients within KFSH&RC and KFNCCC&R



Synopsis of change


Date

Changes

Jan 2011

Purpose revised




The roles & responsibilities of departments medical chairmen is indicated




The requirements for physicians & nurses to be privileged for procedural sedation is indicated




The time frame for valid Physician assessment prior to the actual procedure performing is indicated




Indicate the modifications to the policy for the administration of Chloral hydrate in the ECHO Lab




“Craniofacial abnormality with airway difficulty ” is added to the high risk populations require full assessment by anaesthesiologist




Clarification of nursing assessment elements is done under 6.1.1




Requirement for physician order for the procedure sedation is indicated in 6.1.2




References updated


Physical Status Classification

American Society of Anesthesiologists

Appendix 1


Status

Definition

Description and Examples


1

Normal healthy patient

No physiologic, psychologic, biochemical, or organic disturbance

2

Patient with mild systemic disease

Cardiovascular disease with minimal restrictions, asthma, chronic bronchitis, obesity, or diabetes mellitus

3

Patient with severe systemic disease that limits activity but is not incapacitating

Cardiovascular or pulmonary disease that limits activity; severe diabetes with systemic complications; history of myocardial infarction, angina pectoris, or poorly controlled hypertension

4

Patient with severe systemic disease that is a constant threat to life

Severe cardiac, pulmonary, renal, hepatic, or endocrine dysfunction

The differentiation of status 2 versus 3 patients is sometimes difficult.

Examples of a physical status 2 and 3 patient would be:
PS 2: A 2 y. o. for CT scan with history of seizures who is now stable without seizures.

The risk of seizures during the procedure is low.


PS 3: A 2 y.o. for CT scan with poorly controlled seizures.

The risk of seizures during the procedure is high.


PS 2: A 5 y.o. with pulmonary infiltrates for bronchoscopy.

The child is stable on the floor, on  50% supplemental oxygen (sat  90%).

The child ambulates and has no cardiac problems.
PS 3: The above child is bedridden, saturation  90% despite oxygen, and has a severe cough.

The child is at high risk for de-saturating during the procedure.


PS 2: A 1 y.o. for liver biopsy, status post liver transplant and presents with a fever.

HR and BP are stable, alert without labored respirations.


PS 3: The above child is unstable with HR and BP and labored respiration.
PS 2: A 3 y.o. for bone marrow biopsy.

Child has AML with platelets. BP and HR stable.

No respiratory problems.
PS 3: The above child also has pneumonia with saturation 90%, fever and tachypnea.

Recommended Drugs and Dosages

Appendix 2

Drug

Therapeutic Class

Onset

Duration

Reversal Agent

Comments


Midazolam

(Versed®)



  • Benzodiazepine

  • IV: 1-5 minutes

  • PO: 10-20 minutes

  • IV:30-120 minutes

Flumazenil

  • Rapid IV infusion may cause respiratory depression and convulsion

  • If narcotics or other CNS depressants are administered concomitantly, the midazolam dose should be reduced by 30%, if <65 years of age or by at least 50%, if >65 years of age.

Diazepam

(Valium®)



  • Benzodiazepine

  • IV: 3 -10 minutes

  • PO: 15-30 minutes




  • IV/PO: 6-8 hours




Flumazenil

  • Give slowly IV push over 3 -5 minutes

  • Rate of IV push administration: children do not exceed 1-2 mg/minute, adult 5 mg/minutes

  • Rapid IV infusion may cause apnea

  • Continuous IV infusion is not recommended

  • May displace bilirubin

  • Reduce dose by 50% in hepatic cirrhosis and avoid in severe/acute liver disease

  • Contraindicated in narrow angle glaucoma

  • PO absorption is more reliable than IM

Fentanyl

(Sublimaze®)



  • Opioid, narcotic

  • IV: 2-3 minutes

  • IM: 7-15 minutes

  • IV: 30-60 minutes

  • IM: 1-2 hours

Naloxone

Alfentanil

(Rapifen®)



  • Opioid, narcotic

  • Rapid

  • IV: 30-60 minutes (dose dependent)

Naloxone

  • Give slowly over 3-5 minutes or by IV continuous infusion

Morphine


  • Opioid, narcotic

  • IV: 5 minutes

  • IV: 2-4 hours

Naloxone


  • Rapid IV administration may cause hypotension

  • May cause histamine release

  • Avoid in hypotension and respiratory depression

  • Neonates and infants <3 months of age are more susceptible to respiratory depression

Chloral Hydrate


  • Hypnotic, Miscellaneous

  • 15-60 minutes

  • 6 hours

Supportive therapy

  • Avoid use in patients with hepatic or renal impairment.

  • Use with caution in neonates, drug may accumulate with repeated use, prolonged use in neonates associated with hyperbilirubinemia

  • Oral preparation should be diluted before administration, or to be given after feeding to reduce gastric irritation

Wh

Important Note: Parenteral meperidine is restricted as per the Pharmacy and Therapeutic Committee (July, 2007)

for the prevention and treatment of drug-induced or blood product-induced rigors, treatment of postoperative

shivering, and short term pain management in individuals with normal renal, hepatic, and CNS function,

where alternative opioids are contraindicated.

Reversal Agents

Drug

Onset

Duration

Comments

Naloxone

(Naxone®)




  • 1- 2 minutes

  • 30-60 minutes

  • Used to reverse the effects of opioids – CNS and respiratory depression

  • Note: Duration of action for opioid may be longer than that of reversal agent therefore multiple doses may be required

  • For neonate: do not use if maternal narcotic addition is suspected

Flumazenil (Anexate®)


  • 1-3 minutes

  • 1- 4 hours depend on the dose given

  • Reverse the effects of benzodiazepines

  • Does not reverse respiratory depression

  • Resedation may occur in patients who have received longer acting benzodiazepines



Indication

Procedural Needs

Suggested Strategy

CT, Echo, EEG, US, nuclear medicine studies

Motion control

  • The baby may need only simple comforting measures

  • Chloral hydrate orally

  • Midazolam IV

  • Fentanyl IV




LP, eye exam

Sedation

Motion control



  • Morphine IV

  • Fentanyl IV




Hernia reduction, cardiac cath, bone marrow aspiration


Sedation

Analgesia



Motion control

  • Morphine IV

  • Fentanyl IV

  • Midazolam and Morphine

  • Midazolam and Fentanyl




Emergency Sedation




  • Midazolam 0.1 mg/kg IV

IVF




  • Alfentanil IV


Reference:


  1. KFSHRC Formulary and Drug Therapy Guide. Accessed online through URL: http://online.lexi.com/crlonline

  2. MICROMEDEX(R) Healthcare Series. Vol.132, Exp.Mar,2008

  3. Drug Information Handbook for Preoperative Nursing, 6th ed. Lexi’ Comp; 2006

  4. Donnelly AJ, et al. Anesthesiology & Critical Care Drug Handbook, 6th ed. Lexi’ Comp; 2005

  5. Gunn VL, Nechyba C. The Harriet Lane Handbook: A Manual for Paediatric House Officers, 16th ed.

Mosby Publishing;2002

  1. Young TE, Mangum B. Neofax: A Manual of Drugs Used in Neonatal Care,17th ed.

North Carolina: Acron Publishing, USA; 2004

  1. British National Formulary. 54th ed. London: BMJ Publishing; March, 2007

Procedural Sedation Discharge Criteria



Appendix 3
The criteria identified are utilized to assess the patient’s readiness for discharge from the recovery area and reflect indications that the patient has returned to a safe physiological level. Specific criteria are utilized to assess the inpatient and the outpatient.
PARSAP Score Section 1

  • A score of 8 and above or a return to the pre-procedural assessment is required for discharge.

  • Utilized for patients who will be discharged from the sedation recovery area to an inpatient setting or outpatients for transfer to a phase II recovery/holding area.

  • Patients must remain in the sedation recovery area a minimum of 30 minutes prior to discharge to an inpatient unit. This is required to appropriately assess that the patient is stable with intact protective reflexes.

  • If a patient received reversal agents, the recovery period extends for an additional 2 hours form the time the reversal agent was administered

  • Five main criteria are assessed and scored 2, 1, or 0 based upon specific parameters.




Criteria

Parameters

Score

Activity

Able to move all extremities *

Able to move two extremities

Unable to move extremities


2

1

0



Respiration

Able to deep breathe and cough freely *

Dyspnea, splinting or tachypnea

Apneic or on mechanical ventilator


2

1

0



Circulation

BP + / - 20% pre-sedation level

BP + / - 20-49% pre-procedure level *

BP + / - 50% pre-procedure level


2

1

0



Consciousness

Awake/oriented *

Arousable/responds/protective reflexes present on calling

Not rresponsive


2

1
0


O2 Saturation

Able to maintain O2 Sat 92% on room air*

Needs O2 Sat to maintain  90%

Unable to maintain O2 Sat  90% with O2


2

1

0




PARSAP (Post Anesthesia Recovery Score for Ambulatory Patients)

  • A score of 16 and above is required for discharge home with a responsible adult (*).

  • Ten main criteria are assessed in the PARSAP scoring system. These criteria include the five from the Aldrete scoring system, with the inclusion of five additional criteria specific to patients for discharge home.



Criteria

Parameters

Score

Dressing

Dry and clean

Wet but not increasing *

Growing area of wetness


2

1

0



Pain

Pain free

Mild pain handled by oral med *

Severe Pain requiring parenteral meds


2

1

0



Ambulation

Able to stand and walk straight *

Vertigo when erect

Dizziness when supine


2

1

0



Fasting/Feeding

Able to drink fluids *

Nauseated (sip fluids, retain) *

Nauseated a and vomiting


2

1

0



Urine output

Has Voided *

Unable to void but comfortable

Unable to void and uncomfortable


2

1

0









Form 810-06 (Rev. 10-06) IC 202164 Page of


База данных защищена авторским правом ©shkola.of.by 2016
звярнуцца да адміністрацыі

    Галоўная старонка