Conscious sedation in the ER

[merilynRN]

I recently transferred from floor nursing to ED at my hospital. I am looking for a good concise nursing resource for conscious sedation in the ED with information on the various medications used, how to safely administer them, what to specifically watch out for with each one for example. Generally, what one really needs to know for the utmost safety of the patient, adult and pediatric.

Also, which ones can RN's give, which ones should only MD's / providers give. (A little confused because some push meds that only providers can but say it's okay because the provider is present).

Education in this level 3 is basically O-T-J. I am finding I need to do a lot of informal research on my own to get to more of what I need to know beyond the basics. I do know the set-up (suction, BVM, cardiac monitor, continuous pulse ox, code cart nearby).

[dsherman]

propofol must be pushed by provider in most facilities due to serious side effects. same with ketamine

I'm sure a Google search would turn up some decent info but here's some information from my personal experience:

Set-up

• Oxygen by NR at 10-15L so that pt is pre-oxygenated in the event that they need to be intubated.
  

• Monitoring: Cardiac, continuous oximetry, capnography, BP q5 minutes
  

• Available Equipment: Suction (connected and on, Yankauer at patient's head), airway supplies for rapid intubation if needed (including OPA and NPA), BVM
  
  • Crash cart isn't necessary at bedside unless that's the only place where reside the airway supplies
    

• Functional venous access with NS running... typically wide-open unless contraindicated
  

• Drugs:
  
  • Fentanyl, Versed, and diphenhydramine are common... typically pushed by RN...
    
    • Fentanyl usually 50 mcg per dose, q1-2 min PRN
      
    • Versed, usually start with 2-4 mg, additional 1 mg q2-5 min PRN
      
    • Benedryl, 25 mg 1x
      

    [*]Naloxone and flumazenil at bedside for reversal

    [*]Ketamine (typically 0.5 mg/kg loading then 0.5mg q2-5 min PRN), propofol (typically 20-40 mg every 1-2 min PRN) , and Brevital (1-3 mg q2-3 min) typically given by MD

[mish_RN]

Don't forget your CO2 monitor. Find out which meds your docs like to use and look them up, familiarize yourself so you know what to be on the look for. We used to have RT at bedside prior to procedure too, but I don't know your policy. Speaking of, understand your protocol too so you can CYA.

[chare]

As information presented here is specific to the individual poster's state, you really should consult your state's Board of Nursing if you have not done so.

For example, in my state (NC), propofol is considered an anesthetic and must be administered by the physician. However, if the physician is physically present at the bedside, the RN is allowed to administer it on her or his order, as doing so is considered an "extension" of the physician.

UVA HS Adult and Geriatric Sedation/Analgesia

Procedural Sedation (Medscape, requires free registration)

[Sassy5d]

Every doc I work with does things differently. I would just look up typical meds. Ask some questions to other nurses for general idea, never depend on them for 100% as they might give you wrong info.

1 doc uses etomidate, another versed and morphine.

Know how quickly you make em drowsy, how quickly they will wake up.

My worst case senario was an elderly lady with broken ankle that was dilaudid up for hours. Copd. Tolerated everything except couldn't bring up her spo2 post procedure. I personally don't like dilaudid and Ativan on my older folks but some docs do.

[1fastRN]

Most of our docs use etomidate or versed. The MD is supposed to give the first dose even though we use these drugs in other situations freely with an order.

Propofol can only be pushed by anesthesia in my facility.

So in general it's: draw up the meds, have O2 set up, have fluids set up if needed, and monitor. This is a 1:1 task at my facility though, so generally we pull another nurse to monitor the conscious sedation.

[Altra, BSN, RN]

Some good suggestions here, but one thing I see is often missing is to talk with your docs about what meds they like to use for what situations and why. You need good communication and rapport - especially when jointly doing patient interventions that are not without risk.

And know your organization's policies. I guarantee there is a lengthy policy describing conscious/moderate sedation. Follow it absolutely, as otherwise you will be left twisting in the wind when something unexpected happens.

[zmansc, ASN, RN]

Some good suggestions here, but one thing I see is often missing is to talk with your docs about what meds they like to use for what situations and why. You need good communication and rapport - especially when jointly doing patient interventions that are not without risk.

And know your organization's policies. I guarantee there is a lengthy policy describing conscious/moderate sedation. Follow it absolutely, as otherwise you will be left twisting in the wind when something unexpected happens.

^^^^^ Exactly!

When I get a CS pt, I usually ask the provider what they are going to want, and start to prep accordingly. Gather the proper meds, if narcs are being used I always pull narcan as well, etc. Make sure you have all the supplies you will need, nothing like running out of flushes or alcohol preps in the middle of putting someone under! lol

Fortunately, my facility has a good set of forms that make it really easy to follow, and if you do, then you won't miss anything. I think the only thing that's not on there that I always check is that suction is ready and on and working. Haven't needed it yet, and respiratory almost always checks it when they get there, but I would never want to forget to have it and need it.

[1fastRN]

Yup definitely ask the doc, draw up the meds, and double check your math. I do the same prior to intubation. You begin to learn what docs prefer what drugs.

And having narcan handy is def a smart idea! As well as a fluid bolus.

Oh and make sure you have a GOOD functioning line!

[Esme12, ASN, BSN, RN]

Does your facility not have a conscious sedation policy and competency? Check your state nurse practice acts to see what med are allowed.

[Cardiac-RN]

I agree with previous posters that drug selection is a combination of facility policy, provider preference, & (somewhat) nursing comfort/ input. I have recently seen providers use etomidate, ketamine, propofol, versed, morphine, etc. Some of it depends on age of the patient- ketamine is preferred for the pediatric patient by some because of its ability to provide sedation, analgesia, and amnesia. Half-life is taken into account, as well as considerations for the geriatric population. Typically, if conscious sedation is done in our ER, respiratory therapy is present in addition to the provider/ nurse/ support staff. Patient is hooked up to continuous monitoring and ambu/ suction is set-up and ready in case of emergency. The crash cart is present outside/ inside of the room. There is a patent IV line running NS. Provider generally pushes the drug.

Cardiac-RN