Moderate Sedation and GI

  1. Hi...Today was my 2nd day at new job in GI. It was my 1st day in procedure, with a nurse and observing and assisting with the cases..mainly learning how they do things, and the paperwork aspect of it.

    I have lots of concerns.

    The patient acts like they are asleep.. They seem more like deep sedation than moderate sedation, is this normal....they once in a while wince if they get more awake. And then they are given more Fentanyl and Versed. Like I said, I am not familiar with doing these types of cases for moderate sedation. When we did moderate sedation at the hospital, the pt was much more alert and responsive. I have never done moderate sedation for upper/lower GI cases, so I am not sure if this is typical.

    Also I was told the pt can't leave the procedure room if they aren't an aldrete of 9 or above. The nurse said they had to have 3 vitals of the pt on RA (done every 3 min) before the pt can be brought out..so she stops (they all probably do) stop the O2 at the beginning of the procedure for Egd . (so the pt can be brought out almost immediately to the recovery area.

    The dr writes an order for the mod. sedation at the beginning of the case that says what to give, then he steps out of the room until the pt is asleep and the tech is sent to get him/her. Once it has been 3 minutes, whether the dr is in the room or not, they are pushing 25 Fentanyl with 1 Versed every 3 minutes until the pt is "asleep". They maintain this until the dr reaches the cecum. They like to stop then, so that the pt will be awake and able to roll out of the procedure room once the procedure is over...and that way they will usually have been on RA x 3 sets of vitals as well, once the procedure is over.

    The doctor then signs the order on the sheet where the nurse writes down what was given...and we are told to circle the "verbal order" part written under each section where we write what was given, when.

    I voiced my concerns about not having actual orders and was told it is their policy.

    Is this all reasonable? I would like to see the actual policy but I have yet to see ONE.

    Disturbingly, the GI doc said they do ASA 3, ASA 4 all the time with RN moderate sedation. Where I used to work, that was a big no-no.

    For the record, my new position is at a military outpatient GI clinic; my last job was at a small community hospital in the PACU and Pre-op area. We did moderate sedation on pain patients and bronchoscopes and some AV grafts or pacemaker implant. The patient obviously had local with some of these procedures, and they were far more awake.
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  2. 12 Comments

  3. by   angeloublue22
    I can't speak to all of it but I understand your apprehension at the order situation. Many places have protocol orders that can be given without the provider explicitly ordering them because the protocols have been agreed upon and written as standing orders for certain situations. For instance, in the facility I work at the provider doesn't see our clients until the next day after admit but we follow our standing orders to medicate clients as these orders are standard for each client. The provider then signs them the next day. You may want to ask for their written protocols so you are clear on exactly what is allowed.
  4. by   Marshall1
    I currently work a GI Endo job. Fent and Versed are used though occasional Demerol will be and depending on the case sometimes Phenergan is added. ASA 3 and 4 are not done in the clinic I work in. We document using EMR so there is no written order other than the one in the computer - meaning no paper is used. Patients sometimes sleep, sometimes are semi- awake, sometimes awake and watch on the monitors the procedure..the goal is to keep the patient comfortable..this is "conscious sedation" NOT general. Patients are given enough medication to keep their vitals stable, airway patent and as comfortable as possible w/o tipping that scale. A standard dose is not applied because everyone will react differently so medication is titrated for the individual patient.
    As far as "Also I was told the pt can't leave the procedure room if they aren't an aldrete of 9 or above. The nurse said they had to have 3 vitals of the pt on RA (done every 3 min) before the pt can be brought out..so she stops (they all probably do) stop the O2 at the beginning of the procedure for Egd . (so the pt can be brought out almost immediately to the recovery area." I don't know what this means so I can't comment on it. But O2 is not used on all the patients we get - only those whose history dictates it for some reason or if their Sats keep dropping or won't stay 90 or above. Heart monitor is only used for patients over 65 or those w/a history were this may be needed. For EGD's in addition to the Fent/Versed, Hurricane spray for the throat is used as well.
    The facility you are at should have policies - I would think in order to operate they would whether military or not..I'd ask and if there aren't policies/procedures in place I don't think I would remain there. As far as orders being verbal, I really don't see any issue with that if documented/signed off properly.
  5. by   sameasalways
    Thanks it's helpful to see what others are doing. The dr writes a 1st time order such as 75 of Fentanyl and 3 of Versed. Then we give the dose and he is not present. He comes back when the pt is "asleep". (Nurse rubs her finger across forehead and pt doesn't react).

    After that, it's 25 of Fentanyl and 1 of versed as needed every 3 minutes.

    Do your patients have to have an aldrete before they leave? Our general anesthesia patients could be an 8 to be discharged from the hospital I worked at before. Here, they say the pt must be a 10 for discharge. I have not been in the recovery area yet working. Friday was my 1st day in procedures.

    One other thing...they make the sedating RN document all the biopsies and findings as the dr calls them out. Is that typical? I don't want to be a whiner but everything I have read about moderate sedation states the sedating RN can not have other responsibilities.
  6. by   Nurse_cox
    in my experience, "other responsibilities" referred to other patients. I have worked areas where the nurse put in orders for specimens/biopsies, etc without any issues. Of course, the specimen would be carried to pathology/lab by someone else or after I was done recovering the patient.
  7. by   Marshall1
    My the GI doc I work with takies biopsies oe polyps he will tell me where he is taking them from..i.e. rectum, ascending colon..I document this in the EMR, the tech who is working w/him places them in specimens jars marked "A" "B" etc. Once the procedure is done I am able to print labels for the jars that have the patients info, the doctors info and where the specimen is from...I double check this info then attached the labels to the jars that correspond to them.
    Sedation is given to the point the patient is comfortable..this does not mean they are asleep necessarily. Some are awake & watch put are comfortable, some are semi-conscious, some sleep. We sedate to this point as it's safer for the patient in not being overly medicated.
    As far as "aldrete" - I have no idea what that is. The patients are discharged when stable and/or after a certain amount of time depending on procedure and a few other markers - it is not based on just whether they are awake or not, it's based on vitals, gag reflex returning (if EGD), etc.
  8. by   Double-Helix
    Quote from sameasalways
    One other thing...they make the sedating RN document all the biopsies and findings as the dr calls them out. Is that typical? I don't want to be a whiner but everything I have read about moderate sedation states the sedating RN can not have other responsibilities.
    According to moderate sedation regulations, the person responsible for monitoring the patient may be involved in “short, interruptible tasks.” Labeling specimens and documenting would fall in that category.
  9. by   LollygaggerRN
    At my facility we do both RN propofol sedation and fent/versed sedation. The RN procedures are different for each type of medication, but you seem to do only fent/versed so I will speak only to that. I work at an outpt facility.

    Our docs typically come in to the procedure room, do the time out and make a medication order. A typical order would be "2mg Versed, 50mcgs fentanyl". Some docs will ask us to repeat the initial dose at 2 minutes, some will not. After the initial order is given the doc leaves the room to document or speak to a patient and returns in just a few minutes. Some docs we do have to "chase down", but they are really only a few feet away at a computer station.

    After the patient is asleep/comfortable/calm- whatever the case may be we typically stop giving meds unless they express that they are in pain. We rarely end up giving more than 6/150 although I have given 10/200.

    The sedation RN is the only staff in the room with the doc for colonoscopies. The RN sedates and monitors the pt, documents, and collects and labels specimens. If there are many specimens or a pt requires intense intervention a tech or additional RN is just the push of a call button away. There are two staff in the room for uppers.

    The pt is wheeled out of the procedure room after the procedure as long as they are stable. We do an aldrete and it would be unusual for a conscious sedation pt to have an aldrete of less than 7 or 8.

    When the doc signs the electronic chart at the end of the procedure he is signing his verbal orders.

    I don't see anything too odd about your facility's practices. The ASA 4 is concerning, but I have sedated plenty of ASA 3s in a hospital GI setting- not at my current facility. Also, the three sets of vitals at the end before coming out of the proc room is strange. I can't see any value in the pt hanging out in the room for an additional 6 minutes or more when they could be moved to recovery and monitored by an RN in that setting. If the pt isn't stable that is one thing, but in my 4 years of GI experience it is very rare that a pt is not stable after a procedure. Six minutes is a long time when the room could be cleaned and turned over in about half that time.
  10. by   brownbook
    Our gastroenterologist almost always gave patients ASA's of 2 - 3. I know it's way above my pay grade but these patients seemed pretty stable/healthy in my humble opinion.

    I finally realized he was basing it on their GI issues. I am pretty sure GI issues are not that major of a concern in ASA classifications. I wondered if it had something to do with coding or insurance reimbursement?
  11. by   KSGMaine
    I am new to GI nursing and working in an Endoscopy unit and have been trained on the job for moderate sedation. I have used the SGNA site and did the sedation overview, but am curious how others have been trained. I know some organizations have their employees do this American Association of Moderate Sedation Nurses course, and am interested in doing this but my organization wants to know how this compares to the SGNA module. Any thoughts? (FYI - I am a fairly new nurse as well - 5 years in May!)
  12. by   BklynHeightsRN
    Quote from LollygaggerRN
    At my facility we do both RN propofol sedation and fent/versed sedation.
    I'm curious who accredits your facility? AAAASF prohibits RNs (except CRNAs of course) from administering propofol. It is used in the ICU for intubated patients, but for outpatient procedural settings, I didn't think it was allowed so I'm just curious.
  13. by   BklynHeightsRN
    Quote from sameasalways
    The patient acts like they are asleep.. They seem more like deep sedation than moderate sedation, is this normal....they once in a while wince if they get more awake. And then they are given more Fentanyl and Versed. Like I said, I am not familiar with doing these types of cases for moderate sedation. When we did moderate sedation at the hospital, the pt was much more alert and responsive. I have never done moderate sedation for upper/lower GI cases, so I am not sure if this is typical.
    Closed eyes doesn't mean unconscious necessarily. I get what you're saying though because when I worked in the ED consciously sedated patients were still in pain and much more responsive. I would just remember that these patients aren't in pain beforehand, and not even during insertion necessarily. Many people do it without sedation at all, and it has been described as an uncomfortable high pressure feeling. The sedation is just to keep them comfortable, and it is to allow for a better exam with a colon that isn't spasmotic.

    As long as the patient can make purposeful movement from verbal (or a combination of verbal and tactile) stimuli it's considered moderate sedation. Deep sedation is being able to do stuff we do under propofol, like move a patient in awkward positions sometimes to facilitate the passage of the scope, and lift their head up to tape their eye, etc. Basically, deep sedation is dead weight. Personally, given the amount of Versed/Fentanyl it sounds like the patients are getting, I'd be very surprised if they could not open their eyes if you loudly told them to and tapped them on the shoulder. When I have sedated patients for GI procedures, I usually tell them to try to close their eyes and relax and focus on the breathing as I'm pushing the medication.

    Quote from sameasalways
    Also I was told the pt can't leave the procedure room if they aren't an aldrete of 9 or above. The nurse said they had to have 3 vitals of the pt on RA (done every 3 min) before the pt can be brought out..so she stops (they all probably do) stop the O2 at the beginning of the procedure for Egd . (so the pt can be brought out almost immediately to the recovery area.
    I'm not sure what to make of this (stop the O2?), but what I'm guessing is that you are uncomfortable with how quick the patient is being brought out? I think this largely depends on the setting because I've worked in one where the anesthesiologists bring them out to recovery as soon as the procedure is over, and I've worked a couple of places were the anesthesiologist prefers that they are somewhat alert before pushing them out of the room. All of these areas, however, were with propofol. With just fersed/fentanyl, I would be comfortable with getting the patient out as soon as the procedure is done, but that of course depends on the patient and what the policy is. It is very common to do a procedure and then try to flip the room quickly to prepare for the next. It is all about maintaining the "flow" because a difficult colon is just around the corner that can thrown everyone off.

    Quote from sameasalways
    The dr writes an order for the mod. sedation at the beginning of the case that says what to give, then he steps out of the room until the pt is asleep and the tech is sent to get him/her. Once it has been 3 minutes, whether the dr is in the room or not, they are pushing 25 Fentanyl with 1 Versed every 3 minutes until the pt is "asleep". They maintain this until the dr reaches the cecum. They like to stop then, so that the pt will be awake and able to roll out of the procedure room once the procedure is over...and that way they will usually have been on RA x 3 sets of vitals as well, once the procedure is over.
    Okay, if the doctor wants to give an order and walk away while it's being carried out, that's up to him. I have no problem with that. However, I do not agree that the nurse should keep giving 25mcg/1mg every 3 minutes until the doctor waltzes back in to start the procedure. As the nurse I would not be okay with that, as it means more medication than is necessary going into the patient. So personally, if I had a doctor do this habitually, I would be forced to speak up.

    In terms of stopping the medication once withdrawal begins, that is very appropriate. Often, an anesthesiologist will do the exact same thing, unless the GI is going to take 30 biopsies on the way out or something. The discomfort is more during insertion, and withdrawal time usually takes less time (depending on the patient). Either way, you do not want to sedate the patient more as the procedure is finishing up.

    Quote from sameasalways
    The doctor then signs the order on the sheet where the nurse writes down what was given...and we are told to circle the "verbal order" part written under each section where we write what was given,
    I voiced my concerns about not having actual orders and was told it is their policy. Is this all reasonable? I would like to see the actual policy but I have yet to see ONE.
    Giving and following verbal orders is fine in this case since it's dependent on real-time patient response. The doctor signing afterward is all you need. The important thing to look at is whether you're bothered by this common practice because it's not what you are used to, or is it because it actually poses the patient harm? If you are the nurse giving sedation, and you are not comfortable with the every 3 minute ongoing rule of thumb, then let the physician know when 3 minutes has passed and ask him to tell you each time. I would be shocked if any doctor turned his nose up to that.

    Did they not at least show you where the facility's policies and procedures can be found? You shouldn't have to go digging... you should know where to access it whenever you want.

    Quote from sameasalways
    Disturbingly, the GI doc said they do ASA 3, ASA 4 all the time with RN moderate sedation. Where I used to work, that was a big no-no.
    If your facility is performing endoscopy on ASA 4 patients, run for the hills. Have you personally seen an ASA 3 or 4? Methinks that GI doc has no idea what "ASA" is.
  14. by   sameasalways
    Somehow I don't THINK I read everyone's posts/replies and just now saw them. It is obvious to me I was not clear about a few things.

    The pt did not have "order", verbal or written, to give the meds every 3 minutes and titration to effect.

    After everyone acting like I had 3 heads at that GI clinic, they finally posted a written order. I was happy with that.

    The AK board of nursing requires the physician ordering the mod sedation to be present at bedside..the docs on base do not do that. I wrote the BON specifically about it and they stated that the doc can not leave the room.

    In terms of the O2, the policy is to get 3 room air vital signs, taken 3 min apart, with an Aldrete of 9 prior to bringing pt to recovery. I understand this is to make sure the pt is safe in recovery since there might only be 1 RN there with multiple pts recovering.

    The pts .. some of them are an ASA 3 and 4. Why? Because the doc doesn't care. He specifically told me that the CRNA s at the facility he doesn't trust and that propofol itself is dangerous. he said he doesn't like to get anesthesia from the hospital involved because of those 2 reasons. It breaks their own facility policy but he is a Lt Col, and what he says goes. Asa 3 and 4 are not all the time obviously but they happen there. They do not have xmas trees hooked up in recovery. a they had a broken ambubag bag mask for who knows how long there.

    Essentially I quit working there due to safety concerns over my license as moderate sedation is a high risk procedure for nurses and the person in charge could care less about my nursing license. Also, the facility will not support or back an RN there who is hired as a contractor. I was educated on this at a very large legal briefing I went to there.

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