RE.1 Conscious Sedation

Purpose
To outline the clinical management of adult patients receiving conscious sedation for procedures.  To ensure that the clinical person responsible for the treatment of the patient and/or the administration of drugs for sedation is competent to use the techniques required to provide the level of monitoring/assessment described in these guidelines to maximize the safe delivery of patient care.
 
Definition
Conscious sedation is a condition produced by the administration of pharmacological agents.  The patient who has received conscious sedation will exhibit moderately depressed levels of consciousness but should retain the ability to independently maintain protective reflexes.  Use of narcotics/analgesics for pain control in the absence of a procedure being performed does not fall under this protocol.
 
Goals:
1.  To maximize the patient's safety and welfare.
2.  To minimize physical discomfort or pain.
3.  To minimize negative psychological responses to treatment by providing analgesia while maximizing the potential                for amnesia.
4.  To control behavior that would impede performance of the procedure.
5.  To return the patient to a state in which safe discharge, as determined by recognized criteria, is possible.
 
Indications for Use of Conscious Sedation
Conscious sedation may be utilized for therapeutic/diagnostic procedures such as surgery, endoscopy and management of 
patients undergoing painful procedures.


Adults
1.  Painful or uncomfortable diagnostic or surgical procedures.
2.  Limited duration painful or uncomfortable therapeutic or elective procedures.
3. Prolonged painful procedures that must be performed repeatedly
 
Infants and Children 
1.Painful or uncomfortable diagnostic or surgical procedures.
2. Diagnostic procedures requiring maintenance of a position without moving.
3. Limited duration painful or uncomfortable therapeutic procedures.
4. Prolonged painful procedures that must be performed repeatedly.
 
Patient Selection Guidelines
1. ASA classifications in the outpatient facility usually are limited to classes I, II or--under special circumstances approved        by the Medical Director--III
2. NPO for solids or liquids x 6 hours for planned deep IV sedation; may take AM medications with limited water).
3. IV access/saline lock started and maintained for all patients receiving IV conscious sedation and, if ordered, for                     patients receiving conscious sedation by other routes.
4. Current history and physical available.
 
Relative Contraindications to Conscious Sedation
1. Patient has received sedation medication (within previous 12 hours)
2. Underlying health conditions not previously known to the physician which could be masked or exacerbated by sedation       (e.g., neurological impairment, concurrent stroke or MI, adrenal insufficiency or long-term steroid use, severe COPD,         obvious anatomic airway abnormalities).
3. Patient has received a MAO inhibitor within the last 14 days.
4. Patient not NPO.
5. Patient is pregnant.
6. Recent previous MI (within 6 months)
 
Absolute Contraindications to Conscious Sedation
1. Allergy to drug class ordered.
 
Patient Preparation
1. Signed consent prior to receipt of any medication.
2. Good faith pre-op assessment by anesthesia provider.

3. Pre-op assessment by medical provider performing the procedure immediately prior to administration of sedation,               including review of;
     A) Findings of Patient history and physical exam
     B) Current medications and allergies
     C) Previous adverse reactions to anesthetic by patient and/or family members
     D) Any cardiac, liver, renal, endocrine, or sickle cell disease, or seizure disorder
     E) Respiratory status (including recent infections/smoking habits)
     F) Prior surgical/diagnostic procedures
     G) Use of MAO inhibitors
     H) Significant medical history to include possibility of pregnancy
     I)  Diagnostic studies, if ordered
     J)  Indications for procedure

     K) NPO status
     L) History of neck pain
4. Physical and Psychological Assessment will include:
    A.  Upper airway (presence of dentures/dental appliances)
    B.  Vital signs (heart rate and rhythm, respiratory rate, blood pressure and baseline oxygen saturation)
    C.  Concurrent pain
    D.  Mental status
    E.  Emotional state, appropriateness for procedure
    F.  Expectations regarding procedure and sedation
    G.  Breath sounds
    H.  Height and weight
5. Patient to understand post-op care requirements and to have been advised of self-care follow-up instructions
    (instructions also to have been reviewed with responsible person who will accompany patient home).
 
Assessment during Procedure
Patient will be assessed by an appropriately-trained clinical person during procedure
1. If appropriate and ordered by physician, will be placed on monitoring equipment with patient specific                                 alarm mechanisms activated.
2. Continuously monitored EKG status and oxygen saturation.
3. Blood pressure cuff readings (NIBP or manual) at 5-15 minute intervals.
4. Responsiveness to verbal and physical stimuli 10 minutes after administration of any agent and at 10-15 minute intervals         thereafter
5. Pain Level assessment at 10-15 minute intervals.
 
Documentation during Procedure
 Oxygen saturation, BP, pulse, respirations, response to verbal/physical stimuli will be documented every 5-15 minutes.  All  changes in cardiac rate/rhythm to be documented. 
 
Post Procedure Assesment
1. Continuous monitoring of level of consciousness, BP, heart rate and rhythm, respiratory rate and depth, and      oxygen saturation.
2. Documentation of monitoring levels to be recorded at 15 minute intervals until discharged.
3. Pain level assessment at 5-15 minute intervals.

4. Any significant change in patient's status is to be immediately reported to the staff provider performing the 
    procedure.

Discharge Criteria
1. Patient alert and oriented to time and place 
2. Patient able to ambulate without dizziness
3. Stable vital signs (return to baseline)
4. Ability to take oral fluids with minimal nausea
5. Verbally appropriate
6. Free from unusual pain, nausea or bleeding
7. Aware of post-operative restrictions:

   A. No driving for 24 hours
   B. Potential for drowsiness, dizziness, and nausea
   C. No alcohol for 24 hours; use only prescribed medications

   D. Notify MD of any sudden changes in mental or physical  status

   E.  Follow-up with physician as requested

  

Approved By Governing Board
RE.1
Control #41.2
Gupta Gastro