AJA Asian Journal of Anesthesiology

Advancing, Capability, Improving lives

Practice Guideline
Volume 58, Issue 2, Pages 57-60
Standing Committee for Sedation of Taiwan Society of Anesthesiologists 1
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Intravenous sedation is to reach sedative status via continuous intravenous anesthetics administration. It comprises a continuum of states ranging from minimal sedation (anxiolysis), moderate sedation (response to verbal commands or tactile stimulation), deep sedation (only response to pain) through general anesthesia.1 To maintain good quality of sedation and secure patient safety, this guidance includes patient evaluation and preparation before sedation, ventilatory monitoring and vital signs recording during sedation. The practitioners should have basic ability to perform the skill and provide post sedative recovery care.

Definition

  • Mild sedation (anxiolysis): by medication administration, to reduce anxiety but the patients still can obey verbal command, cognitive function may be affected but cardiovascular and respiratory function are unaffected.
  • Moderate sedation (conscious sedation): through medication administration, patient’s conscious level is inhibited but can obey order or response to tactile stimulation (withdrawal reflex response to pain is not purposeful response). Patients should breath spontaneously without airway assisted device to maintain airway patent. Cardiovascular function is usually maintained.
  • Deep sedation: a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.
  • General anesthesia: a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.

Medical Specification and Personnel Qualification

  • Doctors who are not anesthesiologist are only certified to perform moderate sedation after completing training program for sedation held by Taiwan Society of Anesthesiologists; moreover, Advanced Cardiac Life Support (ACLS) within validity is also required. Doctors provide sedation services should focus on patient monitoring and consistent care for sedation-analgesia, not involved in surgical procedure or examination. Deep sedation and general anesthesia should only be delivered anesthesiologists.
  • Medical providers for monitoring and care during sedation should complete training program and with valid Basic Cardiac Life Support (BCLS) license.
  • Training program for sedation-analgesia including:
  • (1) Definition of anesthesia and sedation-analgesia

    (2) Patient evaluation before procedure and preparation

    (3) Monitored parameters and equipment during sedation and recovery

    (4) Pharmacology of sedative and analgesic agents and antagonists

    (5) Diagnosis and management of sedation related complications

    (6) Post sedation-analgesia recovery

    (7) Airway risk evaluation and control

    (8) Simulation of sedation

Training program should be adjusted and modified depending on different medical specialists.

Patients Evaluation and Preparation

Patients (or their legal guardians in the case of minors or legally incompetent adults) should be informed of and agree to the administration of sedation/analgesia, including its benefits, risks, and limitations associated with this therapy, as well as possible alternatives before procedure.

Review medical chart and family history, patient counseling before sedation to make sure if there is situation as below:

  • Major organ dysfunction (such as heart, kidney, lung, neurology, obstructive sleep apnea, metabolic, endocrine disease)
  • Previous unpleasant experience or adverse event for sedation, analgesic, local anesthesia, general anesthesia
  • History of difficult intubation
  • Current medication, possible drug-drug interaction, allergic history, health supplements, herbal medication
  • History of tobacco, alcohol, or substance use or abuse
  • Repeated and frequent use of analgesic medication

Patients presenting for sedation/analgesia should undergo a focused physical examination:

  • Physical examination: include vital signs, auscultation of heart sound and breathing sound, airway evaluation or other vital organ examination and check laboratory data. According to physical examinations, clinical condition and other factors may have affect management during sedation, extra examination investigation may be required.
  • Try to complete evaluation few days before sedation as possible (except emergent condition)
  • Recheck all above finding before sedation
  • Confirm the patient’s physical status before sedation initiation

Airway Evaluation

  • Positive ventilation may be necessary due to airway compromised during sedation. In patients with airway abnormalities, spontaneous breathing may increase chance of obstruction and make positive ventilation more difficult.
  • Pre-sedation evaluation should include airway evaluation.

Pre-Procedure Evaluation and Patient Education

  • Adequate fasting time before sedation for patients receiving regular examination. Solid food (light meal) at least 6 hours for gastric empty.
  • Double check fasting time and nature of food before sedation. Current medication have no strong evidence to prevent or reduce risk of aspiration pneumonia and routine usage is not recommended. For patients with high risk of aspiration pneumonia, carefully evaluate risk of aspiration of gastric content and reconsider depth of sedation or postpone procedure if not emergent.
  • Checklist before sedation: patient’s identity, type of procedure, site of examination. Double check all staffs, equipment for proper function and relevant documentation (medical record, informed consent, laboratory data, image study and examination report).

Monitoring During Sedation

  • During sedation-analgesia, the practitioners responsible for vital signs monitoring and drug administration are not allowed to participate in any part of surgical related procedure.
  • Practitioners should be well trained and qualified with ability to recognize apnea, maintain airway, suction of secretion, bag mask ventilation and ask for help.
  • Monitoring should contain level of consciousness, ventilation and oxygenation, blood pressure and circulatory parameters. According to the type of medication, dosage, length of operation and patient’s clinical condition to decide interval of measurement. Minimal requirement for recording include pre-medication, post-medication, regular interval during operation, initial of recovery and before discharge.
  • During moderate sedation, oxygen should be regular administrated unless the patients are not suitable or forbidden by surgical procedure.
  • Except communication difficulties due to elderly dementia or possible injury related to intra-operative movement, patients should be monitored response to verbal command every five minutes during moderate sedation. When patients cannot phonation (e.g., oral or dental procedure, panendoscopy), make sure patients can thumb up or response to oral command or tactile stimulation. Patients should have ability to control breathing and deep breathing. If patients only withdraw to pain stimulation means entering general anesthesia status.
  • During moderate sedation, use continuous end tidal capnography to monitor ventilation status. If patients cannot cooperate, monitoring can be setup after sedation. Continuous pulse oximetry should be monitored and with adequate alarm setting. (Alarm silence is forbidden)
  • Except uncooperative patients, blood pressure should be measured before sedation. Once reaching moderate sedation status, blood pressure monitor for every five minute except interference caused by blood pressure cuff during MRI examination. Continuous and real-time EKG monitor is necessary in patients with cardiovascular disease or arrhythmic risk during procedure.
  • Vital signs, level of consciousness, condition of recovery, response to medication, result of sedation, patient education before discharge should be documented.
  • Timing of recording vital signs depends on types and dosage of drug, duration of examination and patient’s clinical condition but it should at least include:
  • (1) Before examination

    (2) After giving sedative drug

    (3) Depends on the patient’s condition during examination

    (4) Early recovery

    (5) Before discharge

Emergent Supporting System

  • Pharmacological antagonist for benzodiazepines and opioids should be available and make sure defibrillator function normally.
  • Equipment for suction, advanced airway device, positive ventilation and oxygen supplement should be immediately available and in good working order. Prepare different sizes of appropriate airway equipment in order to establish patent airway.
  • Practitioners should have license of ACLS to make sure ability to establish ventilation and IV access, perform efficient chest compression, use of defibrillator and give medication for resuscitation.

Sedative Drug

  • Sedatives can be divided into three categories due to different purposes: sedative oriented (benzodiazepines, nitrous oxide, chloral hydrate, antihistamine) and general anesthesia oriented (propofol, ketamine, etomidate) and analgesics (opioid, nonsteroidal antiinflammatory drugs [NSAIDs], local anesthetics).
  • Monitoring and professional staff setting should be same as general anesthesia if using general anesthetics during moderate sedation.
  • During intravenous sedation, secure IV access without occlusion throughout the procedure.
  • Consider re-establishing IV access when IV dislodged or occluded on a case-by case basis during non-intravenous and intravenous sedation.
  • Principle for IV medication: small titration or continuous infusion to effect. Medications given incrementally between doses to assess effects.
  • Regardless of route of administration (oral, rectal, IM or mucosal), next dose should wait until the peak effect of last dose.
  • Practitioners should have ability to recognize and rescue from unintended deep sedation and general anesthesia. Especially for practitioners administrating general anesthetics should be capable of emergent intubation and providing consistent care with general anesthesia.

Recovery

  • Patients received moderate or deep sedation should be monitored in the recovery area with licensed staff. Care unit should be set up with appropriate monitoring and resuscitation equipment, or have direct access to provide oxygen ventilation, suction and resuscitation. Patients should not leave recovery area until they are near their baseline level of consciousness and are no longer at increased risk for cardio-respiratory depression. Oxygenation should be continuous monitored during recovery period.
  • The facility should provide space for patients to recovery from sedative status with qualified staff and equipment.
  • Continuous oxygenation monitoring until patients are no longer at risk for hypoxemia.
  • Ventilation and circulation should be monitored every 5–15 minutes until appropriate discharge criteria are satisfied.
  • Discharge criteria from recovery unit:
  • (1) Patent airway and stable vital signs.

    (2) Patients are alert and oriented, mental status should have returned to their baseline status.

    (3) For special population with abnormal mental status initially should have returned to their baseline status, patients should be aroused easily and with intact protective reflex.

    (4) Using Aldrete Scoring System as assist in documentation of fitness for discharge.

  • Discharge criteria should be designed to minimize the risk depression of central nervous system and cardio-respiratory system. Patients should be observed and evaluated by trained personnel if meet the discharge criteria.
  • Adequate time interval to elapse after the last administration of reversal agents (naloxone, flumazenil) to ensure that patients do not become re-sedated after reversal effects have worn off (up to 2 hours is recommended).
  • Outpatients should be discharged in the presence of a responsible adult who will accompany them home and be able to report any post-procedure complications. Patients and their escorts should be provided with relevant written instructions for post sedation care.

Introduce and Establish Patient Safety Protocol

  • Establish standard operating procedure for sedative-analgesic procedure, furthermore, regular follow up for quality assurance and propose adverse event improvement plan.
  • Simulation training to reinforce patient safety (including teamwork training, simulation training, introducing check list).
  • Establish emergent rescue plan including activating emergent rescue team and calling 119 for help.

References

1
Practice guidelines for moderate procedural sedation and analgesia 2018: a report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology.
Anesthesiology. 2018;128(3):437-479.

References

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