Curious about sedation

[AnewerRN]

I work on a busy tele unit and often recieve patients back from procedure (cath, pacer placement, egd/colo, etc.) who have recieved some amount of conscious sedation. My question is what is the usual dosage for these medications (i.e. fentynl, versed). I know this varies with patient weight/tolerance. I am just curious as to what doses you find yourself administering and over what period of time (if IVP is it back to back)? Thanks in advance!

[GHGoonette, BSN, RN]

There is nothing on the Aldrete score that directly relates to reversal of neurmuscular blockers. Movement is scored, but a deeply anesthetized/sedated patient doesn't move either. There is nothing in the alderete score that would help you directly determine reversal of neuromuscular blockers.

Yes, that's logical... Actually, we don't use Aldrete or a scoring system as such, (most people here haven't heard of it!) but we work according to the basic principles relating to consciousness, muscle control, haemodynamic stability etc.

A couple of questions I'd like to ask relating to best practice as regards CS; 1-Is a qualified anaesthesia provider always present? 2-Are all monitors routinely attached during the procedure, ie ecg, bp & oximetry? 3-Do you have any laws or regulations regarding the practising of CS in doctors' or dentists' private rooms?

An interesting comment I heard the other day was "These guys think there's nothing to sedating a patient in their rooms. They go in with this cowboy attitude, and think an oximeter is sufficient equipment." It's very scary, and I have heard of a few shocking tragedies occurring in out-of-hospital settings.

[CCL RN, RN]

Scary to think of what happens of outside of hospitals...

In our hospital, CS has to be done in the ICU, ED or other specialty area such as cath lab/pacu. We have to pass competencies, have them monitored, pulse ox and ekg, iv bag hanging, and for us in the lab, we also place them on defib pads.

What they do in dentist offices is something I don't know if I want to know....

[wtbcrna, MSN, DNP, CRNA]

Yes, that's logical... Actually, we don't use Aldrete or a scoring system as such, (most people here haven't heard of it!) but we work according to the basic principles relating to consciousness, muscle control, haemodynamic stability etc.

A couple of questions I'd like to ask relating to best practice as regards CS; 1-Is a qualified anaesthesia provider always present? 2-Are all monitors routinely attached during the procedure, ie ecg, bp & oximetry? 3-Do you have any laws or regulations regarding the practising of CS in doctors' or dentists' private rooms?

An interesting comment I heard the other day was "These guys think there's nothing to sedating a patient in their rooms. They go in with this cowboy attitude, and think an oximeter is sufficient equipment." It's very scary, and I have heard of a few shocking tragedies occurring in out-of-hospital settings.

1. Moderate Sedation (Conscious Sedation) is supposed to be done by an RN that his/her only responsibility is to monitor the patient during the procedure/administer drugs. The RN should be competent/trained in providing sedation, but no there is usually not anesthesia provider immediately available.

2. When providing Moderate Sedation the minimum monitors should be on the patient: EKG, pulse ox, IV, and automatic BP cuff cycling at least every 5 min. There also needs to be suction, O2, ambu bag (appropriate size for that patient) in the room within easy reach of the patient. A crash cart should be easily accessible to the room where you are doing sedation also ie. you should be able to have the defibrillator pads/paddles on the patient and be able to deliver the 1st shock if necessary within 3min of change in rhythm.

3. It doesn't matter what the setting is these are the bare recommendations. There is some exceptions to who can administer the drugs in the Dental office, but they still need to be trained to provide moderate sedation and their only responsibility should be to providing sedation/monitoring the patient not passing instruments assisting the dentist etc.

Moderate Sedation Medication and Patient Monitoring | Joint Commission

Practice Guidelines for Sedation and Analgesia by Non Anesthesiologists

AANA - Position Statements, Advisory Opinions, and Considerations

See: Registered Nurses Engaged in the Administration of Sedation and Analgesia

4. Using only pulse ox during moderate sedation can lead to all sorts of trouble. One of the biggest problems is that patients undergoing moderate sedation are often dehydrated/NPO and as soon as you start giving sedation their BP will drop because you have lost part of the sympathetic tone/response. You are also likely to miss changes in the EKG such as flipped T waves, ST elevation/depression, and other subtle changes that could signal early ischemia or MI.

[oncall24/7]

totally correct about reversal of these agents. Personally I believe that patients are much better off having an anesthesia provider administer their sedation (especially for endo); better drugs and no artificial limits on doseage......i just finished a protracted conversation with a patient who had an absolutely awful CS experience with her colonoscopy and she was quite reluctant to undergo another.. the nurses in the GI lab had used midazolam/fentanyl appropriately and she still had lots of pain and an incomplete exam. trying to reassure her that I could do better with propofol pretty much fell on deaf ears, once a patient has a bad sedation experience, it's hard to "reverse" that. it's impossible to predict how much (mg) of a sedation drug that an individual patient will require..this patient was a healthy 50 year-old with essentially no medical issues undergoing repeat screening colonoscopy. still she required 190mg of propfol and lots of reassurance; but she ended up having a totally comfortable experience with no complications. I have often wondered: for endo procedures (especially colonoscopy), would it be advantageous to have anesthesia do ALL of these cases rather than the GI nurses administering midazolam/fentanyl? With anesthesia administered propofol, the patientwould be almost assured of a totally comfortable procedure, emerge clear-headed and be safely discharged quickly. With difficult to sedate patients, midazolam/fentanyl can resuly in an oversedated patient rquiring 1:! nursing care in recovery, which must slow things down considerably. I'm not an expert on this, but I just had a colonoscopy and watched a fair number of patients go thru this process and it looked inefficient; the GI nurses have more important things to do than administer CS with yesterday's drugs. For my own exam, I chose no sedation and the GI nurse talked me thru the procedure and it was a breeze; she was a gem. I must admit that an unsedated colonoscopy is not for everyone.

[CCL RN, RN]

. I have often wondered: for endo procedures (especially colonoscopy), would it be advantageous to have anesthesia do ALL of these cases rather than the GI nurses administering midazolam/fentanyl? .

No, it would not be advantageous, mostly because CRNAs/MDs cost too much.

I work in CCL, and we sedate just fine, with fentanyl and versed. We live next door to a GI lab, and I hear those patients moaning and crying all the time.

They don't need propofol, or a CRNA, or MD, they just need more sedation!! In my experiences, both in CCL and in the ICU, physicians do not like to medicate! I remember doing many GI procedures on my ICU pts and they would give 1/25 or MAYBE 2/50.

And rarely do we see or hear of over sedating. My pts are awake with plenty of time. We have to recover them anyway, even if they were unsedated. For pts going home after a cath, we have to monitor them for 4 hours.

Sure, if the CRNA/MD is there, then they can sedate the way they want, but that's a high price to pay (literally, not figuratively).

GI docs just need to be educated better on proper sedation, that's all...

[OCNRN63, RN]

totally correct about reversal of these agents. Personally I believe that patients are much better off having an anesthesia provider administer their sedation (especially for endo); better drugs and no artificial limits on doseage......i just finished a protracted conversation with a patient who had an absolutely awful CS experience with her colonoscopy and she was quite reluctant to undergo another.. the nurses in the GI lab had used midazolam/fentanyl appropriately and she still had lots of pain and an incomplete exam. trying to reassure her that I could do better with propofol pretty much fell on deaf ears, once a patient has a bad sedation experience, it's hard to "reverse" that. it's impossible to predict how much (mg) of a sedation drug that an individual patient will require..this patient was a healthy 50 year-old with essentially no medical issues undergoing repeat screening colonoscopy. still she required 190mg of propfol and lots of reassurance; but she ended up having a totally comfortable experience with no complications. I have often wondered: for endo procedures (especially colonoscopy), would it be advantageous to have anesthesia do ALL of these cases rather than the GI nurses administering midazolam/fentanyl? With anesthesia administered propofol, the patientwould be almost assured of a totally comfortable procedure, emerge clear-headed and be safely discharged quickly. With difficult to sedate patients, midazolam/fentanyl can resuly in an oversedated patient rquiring 1:! nursing care in recovery, which must slow things down considerably. I'm not an expert on this, but I just had a colonoscopy and watched a fair number of patients go thru this process and it looked inefficient; the GI nurses have more important things to do than administer CS with yesterday's drugs. For my own exam, I chose no sedation and the GI nurse talked me thru the procedure and it was a breeze; she was a gem. I must admit that an unsedated colonoscopy is not for everyone.

I will never allow an RN to administer "anesthesia" for me if I need another gi procedure.

I had to have an endoscopy, and nurses did the conscious sedation. It was a nightmare. I was wide awake, gagging and tearing throughout the procedure. The GI doc was yelling at me to stop gagging (as if you can control an involuntary reflex) or he would stop the procedure. I remember the drugs they used were demerol and valium. I felt like I was being tortured.

If I ever have to go through that again, I am going to demand MAC, or I am not having the procedure. (I'll also get a different doc.) Some procedures require the expertise of more than an RN.

[canesdukegirl, BSN, RN]

I will never allow an RN to administer "anesthesia" for me if I need another gi procedure.

I had to have an endoscopy, and nurses did the conscious sedation. It was a nightmare. I was wide awake, gagging and tearing throughout the procedure. The GI doc was yelling at me to stop gagging (as if you can control an involuntary reflex) or he would stop the procedure. I remember the drugs they used were demerol and valium. I felt like I was being tortured.

If I ever have to go through that again, I am going to demand MAC, or I am not having the procedure. (I'll also get a different doc.) Some procedures require the expertise of more than an RN.

I had this same experience many years ago. I had a lower GI and was awake for much of it. The nurse was administering CS and I told him that I would likely require a lot of sedation since I had been in the hospital at that point for 2 weeks, had q12h Phenergan and q4h MS04. He waved me off and said, "Yeah, I'll take care of you." He did not. They had to abort the procedure because the dumb*** GI doc was trying to get around a particularly painful bend that turned out to be a stricture. He was yelling at me too..."be still! I can't help you if you don't help me!" It was awful.

At our facility, our CRNAs deliver CS. They usually start with 1-2 mg of Versed and 50 mcg of Fentanyl. If the pt has a hx of ETOH abuse or drug abuse, they will add some Propofol. Some of our CRNAs like Ketamine for kids.

[oncall24/7]

What an absolutely awful experience. Patients deserve an anesthesia provider and proper drugs (ie: propofol) for these procedures. I have many years of experience doing endo sedation and have NEVER had a patient "moaning or struggling" durinf an endoscopic procedure. Never. Propofol as a single agent given by an anesthediologist; maybe with some fentanyl, never with amnestics like midazolam unless the patient wants amnesia and a hangover. We use anesthesiologists for every case and NEVER have problems. Some nurses (including crna) can and do give CS, but the results often are poor. I want a patient to be willing to return for future procedures....my 2 cents worth