Conscious Sedation

  1. I work in a surgery dept. with an endoscopy lab, and we give alot of sedative medications during endoscopic procedures.We usually use Versed in combination with either fentanyl or demerol.We have one Physician in particular that wants us to give as much as 14mg of versed and 100mcg of fentanyl during an EGD for instance.My question is-Does anybody else do conscious sedation for endoscopic procedures at their facility that can enlighten me on how much medication they typically give during these procedures???I am just wondering 1) How much is too much for an RN to administer and monitor without an anesthetist and 2) Is there a point when we should say something to the doc like "You are aware the patient has already had XXX.... amounts of these drugs" in order to CYA should; God forbid, respiratory arrest or some other unfortunate incident occur.
    Also, if you do endoscopic procedures do you have 2 nurses or more present for the procedure and if there is 2, which one does the biopsies(ie:get the forceps, pass them , open/close them and handle/mark specimin).We had been in the practice of the nurse assisting with holding the scope continue to hold the scope in place while the dr. manipulates the forceps thru the biopsy channell, and the RN administering conscious sedation was doing the biopsies & handling the specimins.We have recently had some controversy in our dept.regarding the possible lack of close monitoring during conscious sedation while handling the biopsies.All input appreciated!Thanks!

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  2. 10 Comments

  3. by   StudentSarah
    Today, as part of my practicum, I got to shadow the nurses in Endo. There are 2 nurses in the room here, and I was wondering to myself the very same thing ~ legalities with RN's sedating patients? The doctor was not even present when the nurses started sedating the pt.
    I too am interested in everyone's responses!
  4. by   Q.
    We have used conscious sedation a few times in obstetrics - and our policy is very strict in that as an RN you can administer Versed, but never fentanyl. The Versed is to be administered with a physician present (a resident will do)

    Typically, when asked to do this, we shy away from it and most physicians will simply administer it themselves. The few times we have given Versed, the attending is usually present anyway as our residents NEVER order that.

    The same sort of concept holds true for our epidural infusions. We use a combo usually of fentanyl and marcaine, or sometimes just fentanyl. As a RN we are trained to titrate the drip, and even pull the epidural catheter out, however if in need of a bolus, only the anesthesiologist can do this. It all depends on your facility, I think. However I would personally NEVER give a bolus of anything through an epidural, no matter what was commonplace in my facility.
  5. by   ornurse2001
    Originally posted by Susy K:
    We have used conscious sedation a few times in obstetrics - and our policy is very strict in that as an RN you can administer Versed, but never fentanyl. The Versed is to be administered with a physician present (a resident will do)

    Typically, when asked to do this, we shy away from it and most physicians will simply administer it themselves. The few times we have given Versed, the attending is usually present anyway as our residents NEVER order that.

    The same sort of concept holds true for our epidural infusions. We use a combo usually of fentanyl and marcaine, or sometimes just fentanyl. As a RN we are trained to titrate the drip, and even pull the epidural catheter out, however if in need of a bolus, only the anesthesiologist can do this. It all depends on your facility, I think. However I would personally NEVER give a bolus of anything through an epidural, no matter what was commonplace in my facility.
    Thanks for responding-In our facility we have CRNA's that do all the epidural boluses in OB-I think our OB nurses monitor the infusion, and a few select nurses that feel compfortable remove them.(Just tid bits-I think its interesting to learn how other places do things in comparison to what becomes commonplace for us in our current jobs)
    Thanks again !
  6. by   ornurse2001
    Originally posted by StudentSarah:
    Today, as part of my practicum, I got to shadow the nurses in Endo. There are 2 nurses in the room here, and I was wondering to myself the very same thing ~ legalities with RN's sedating patients? The doctor was not even present when the nurses started sedating the pt.
    I too am interested in everyone's responses!
    Hi-Thanks for responding-thought i should clarify that we never administer these meds in these doses without a physician present, in fact, they usually give the first dose.
  7. by   Stargazer
    I have given large doses of Versed and fentanyl in conscious sedation procedures and basically feel comfortable doing so as long as:

    1. I am monitoring the pt's SaO2
    2. I have O2, airways and an ambu bag handy, and
    3. I have sufficient reversal agents ready (Romazicon, Narcan)
  8. by   ornurse2001
    Originally posted by Stargazer:
    I have given large doses of Versed and fentanyl in conscious sedation procedures and basically feel comfortable doing so as long as:

    1. I am monitoring the pt's SaO2
    2. I have O2, airways and an ambu bag handy, and
    3. I have sufficient reversal agents ready (Romazicon, Narcan)
    Thanks for responding.We do have those things available-maybe I just need to chill a little.
  9. by   buck227
    I have administered alot of concious sedation in the ER and in the ICU. The key to know where the line is as far as what is anesthesia's responsibility and where your privaleges stop is in your hospitals policy. It is very important your are familiar with this prior to giving any sedation. There are fine lines. I have seen policies against fentanyl and I have seen them also omitted. If you go outside your hospitals policy, then you are on your own. You can be subject to charges such as practicing medicine without a license and nursing malpractice or negligence. I have seen physicians push nurses to do things out of their relm just for their own convenience. Be very careful!

    Now, If you are giving concious sedation, you should have no other duties other than patient monitoring. You need to have the appropriate antidotes and be familiar with them. Although it is not required in many places (it should be) you should also have recieved training in ACLS. A crash cart must be close by with appropriate airway management equiptment. The patient must be hooked to a monitor and pulse oximetry.

    I have seen 2mg versed be too much for a 200LB young male and I have seen 65 yo ladies take 15-20mg and remain awake. Versed is a very individual-dose type of drug. It is also very effective.

    I hopes this helps. Let me know if I can be of any further assistance.

    buck
  10. by   RedZeppelinRN
    Quote from buck227
    I have administered alot of concious sedation in the ER and in the ICU. The key to know where the line is as far as what is anesthesia's responsibility and where your privaleges stop is in your hospitals policy. It is very important your are familiar with this prior to giving any sedation. There are fine lines. I have seen policies against fentanyl and I have seen them also omitted. If you go outside your hospitals policy, then you are on your own. You can be subject to charges such as practicing medicine without a license and nursing malpractice or negligence. I have seen physicians push nurses to do things out of their relm just for their own convenience. Be very careful!

    Now, If you are giving concious sedation, you should have no other duties other than patient monitoring. You need to have the appropriate antidotes and be familiar with them. Although it is not required in many places (it should be) you should also have recieved training in ACLS. A crash cart must be close by with appropriate airway management equiptment. The patient must be hooked to a monitor and pulse oximetry.

    I have seen 2mg versed be too much for a 200LB young male and I have seen 65 yo ladies take 15-20mg and remain awake. Versed is a very individual-dose type of drug. It is also very effective.




    I hopes this helps. Let me know if I can be of any further assistance.

    buck
    Hi Buck: I am an RN. I have go for cautery endoscopy every six months for a rare disorder, AVM of the stomach or "watermelon stomach." I started out with this about 2-3 years ago when it developed and had severe anemia. The condition has been well controlled but is something I have to have for life. My concern now, does a doctor have to be present when conscious sedation is given? My concern arose when one of my last endoscopies, 2 nurses, I assume gave me my sedation medication and I started having s.o.b. Although they claimed my sats were 100 % and just pushed the rest of the medication. They apparently did not tell the doctor, and I forgot to tell him under the influence of the sedation. I did, the next day, report this incident to his nurse. Assuming any doctor wanted to be told of any problem, he became angry and defensive. Apparently he ordered an extra dose of 50 mg IV Benydrel that had caused my reaction. His nurse referred me to the manager of the endoscopy center. We talked and ended it by asking that the doctor to be in the room when medication was given. He was very sullen and there was no discussion with him the next endoscopy. Only a nurse stating "you won't be given any more IV Benadryl." Today, I was left in a very cold holding area for 1 hour and 45 minutes before they even took me in for my procedure. I was so cold I started to cry and called for a nurse. I could not find my call bell. When I was finally taken in for the procedure, I was told by 2 staff members, that they were "techs." 2 staff members who did not identify themselves showed me syringes of medication. I never saw the doctor any place, but of course he could have been standing behind me, so I could not really prove he was not in the room.

    I am thinking that I would try to get another doctor to perform my endoscopy cauteries. But I started thinking how difficult this would be with the years this doctor had been treating me. Even with another "corporate" hospital, they would have to have my history as documented for treatments.

    Would it be a good idea to get a copy of my medical records and read their documentation before I looked for a new doctor so I would know what I would be up against. Even though I would try for another hospital corporation doctor, I am sure they would want to know why I wanted to try and change doctors. As is well known, doctors all protect their own.

    I don't want to get into any legal entanglements. I would only want to drop this corporation and go to another.

    Any information you can throw my way, I would truly appreciate.

    Regards
  11. by   NRSKarenRN
    red zepplin,

    per our terms of service we can not provide you with individual personal advice.

    since you have concerns re cold room, staff presence in room, i would contact the short procedure or endoscopy unit nursing manager to best address your concerns. you may also insist on a crna to administer meds during procedures too. please discuss your other concerns with gi doctor.
  12. by   RedZeppelinRN
    Quote from nrskarenrn
    red zepplin,

    per our terms of service we can not provide you with individual personal advice.

    since you have concerns re cold room, staff presence in room, i would contact the short procedure or endoscopy unit nursing manager to best address your concerns. you may also insist on a crna to administer meds during procedures too. please discuss your other concerns with gi doctor.
    sorry to bother you.

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