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This chapter focuses on the pharmacology of the drugs commonly used to provide moderate and deep sedation and their available reversal agents. Intravenous sedative and analgesic drugs should be given in small, incremental doses titrated to desired end points of sedation and analgesia, with adequate time allowed between doses to achieve those effects. Preemptive analgesia is a treatment that is initiated before surgical procedure to reduce sensitization of pain pathways. Potential drug interactions require the clinician providing sedation to be cognizant of potential drug-drug effects, which can lead to morbidity and mortality. Opioids in combination with benzodiazepines provide adequate moderate and/or deep sedation and analgesia for many potentially painful procedures. Other drugs used for deep sedation include propofol, ketamine, dexmedetomidine, and etomidate. Local anesthetics (LA) have the potential to produce deleterious side effects. The choice of a local anesthetic and care in its use are the primary determinants of toxicity.
The number of minimally invasive procedures and diagnostic imaging examinations requiring moderate sedation has increased greatly in the radiology department. Many procedures in radiology are performed with the use of iodinated contrast media, and safe use of contrast media is important to everyday radiology practice. Providing moderate sedation in the magnetic resonance imaging (MRI) suite presents both patient and environmental challenges. The most common need for moderate sedation in MRI arises from severe anxiety from claustrophobia while in the scanner. It is important to limit patient movement to acquire clear diagnostic images, and in some instances patients require deep sedation or general anesthesia administered by an anesthesiologist. The American College of Radiology and the Joint Commission have published safety guidelines and alerts, and all personnel working in the MRI environment must review these guidelines and receive facility-specific safety training and screening prior to caring for patients in the environment.
This chapter covers pre-screening, history and physical for evaluation of patients who are potential candidates for procedures under sedation, as well as instructions for patients. Patients for elective procedures may be referred by their primary care physician or may be self-referred. Screening, evaluation, and instruction of patients requires clinical experience, and clerical staff members should not be performing any more than simple initial screening or instructing patients as to time, location, and routine standard instructions. The scope of practice of the surgeon/practitioner/physician(s) involved and the individual facility determine the range of procedures possible. The setting may be quite flexible and general (an operating room) or very specifically designed and equipped. Procedures should be scheduled in locations equipped both for the procedure and for sedation and any contingencies that can be routinely expected as a result of either the procedure or the patient.
Nurse practitioners (NPs) and physician assistants (PAs) are healthcare professionals committed to delivering high-quality health care, and they strive to meet the needs of their patients in an effective, caring, and efficient manner. There are several entities that govern how NPs and PAs can practice. These include but are not limited to the Centers for Medicare Systems (CMS), Medicare Conditions of Participation (CoP), the Joint Commission (TJC), state law, private payer policies, established institutional polices and medical staff bylaws and the defined scopes of practice of the NP or PA. This chapter provides clarification on each of the entities' policies regarding NPs and PAs providing moderate sedation and highlights the nuances of such language. All practitioners should have the ability to manage complications during moderate sedation and have the ability to activate the appropriate emergency response team for that practice area.
The modern practice of sedation is the end result of a process of evolution in alteration of consciousness, likely starting with the discovery of the analgesic properties of ether. Recent technological advances have drastically changed the practice of sedation. One of the most significant was certainly the development of pulse oximetry during World War II by Glen Millikan. In 2002, the American Society of Anesthesiologists (ASA) appointed a task force to update practice guidelines for non-anesthesiologists administering sedation and analgesia. The Association of periOperative Registered Nurses (AORN) has produced guidelines for what every registered nurse should know about "conscious sedation". According to the AORN, moderate sedation/analgesia is produced by the administration of amnesic, analgesic, and sedative pharmacologic agents. With continued attention to a high standard of safety, many different professionals are able to provide sedation services to those patients who need them.
The nurse plays a very important role in administering procedural sedation and monitoring the patient receiving it. Receiving specialized training and adhering to strict institutional standards helps to keep patients safe. The nurse's primary responsibility during procedural sedation is exclusively to that patient. The American Association of Nurse Anesthetists (AANA) suggests that the registered nurse managing and monitoring the patient receiving sedation and analgesia should have no other responsibilities during the procedure. One of the most important things the nurse can do to prevent complications is to avoid overmedication. Intravenous sedative and analgesic drugs should be given in small, incremental doses that are titrated to the desired end point of sedation and analgesia. The American Society of Anesthesiologists (ASA) agrees that continued observation, monitoring, and predetermined discharge criteria decrease the likelihood of adverse outcomes for both moderate and deep sedation.
The demands made on a modern emergency department (ED) are such that having an internal capacity to provide a range of procedural sedation is essential to its functioning. Emergency physicians (EPs) have advanced airway management and resuscitation training to manage complications arising from sedation. A good working relationship between the department of anesthesia and the ED is thus of great importance in creating and maintaining a procedural sedation program. Both moderate and deep sedation have been shown to be safe tools in the hands of EP. Striking a balance between safety and prompt treatment is a prime consideration for the EP. The drug and dose should be primarily chosen as a function of the sedation assessment. For many ED sedations, propofol is chosen for its effects and short duration of action. The chapter also presents a few representative cases describing procedural sedation management of patients in the ED setting.
Sedation is described as a continuum, and it is often categorized according to the patient's level of consciousness as minimal, moderate, and deep sedation. Intravenous sedation can potentially cause numerous complications. The clinicians should therefore have a thorough knowledge of these possible complications and understand their management strategies. There are several scoring systems used to document the patient's mental status and depth of sedation, such as the Richmond Agitation-Sedation Scale (RASS) and the Inova Health System Sedation Scale (ISS). Prevention of complications starts with a thorough pre-procedural patient assessment. This chapter discusses, among other things, some of the patient-related risk factors and procedure-related risk factors. Among all the complications induced by intravenous sedation, respiratory complications are the most common. Moderate and deep sedation may have varying degrees of depressive effects on cardiovascular function, depending on the patient's physiological status and the dosage of sedatives administered.
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