moderate sedation in the ER?

Trauma Columnist · Mar 30, 2006

I work in a large level one. We generally use versed, fentanyl, propofol. We to have competencies for these medications. I have pushed propofol - however, there is some controversy about it, we are re-vamping our policy and will see where that leads.

RunnerRN, BSN, RN · Mar 31, 2006

At our hospital (~40 bed Level I) RNs cannot push Propofol - it is something that an MD must push if he wants it. For moderate sedation, we generally use versed (midazolam) and morphine. Occasionally etomidate by itself or fentanyl with the versed. We have a few GI docs who like to use versed and demerol, but not many.

What kind of info are you looking for?

mmcdon78 · Apr 1, 2006

I too work in large level one trauma and burn center. Our sedation policies are written by the Head of Anesthesiology. Any time an opiod and sedative are given together it is considered procedural sedation and a special packet of paperwork must be initiated. This packet includes initial airway assessment, consent forms, and seperate sheets to document pre, intra, and post procedural vitals and effect of meds.

We most commonly use Fentanyl and Versed, but have used Morphine, Demerol, or Ativan as well, all of which can be pushed by RN's. Be aware that it usually takes 2 minutes or so after administration to reach full effect. Some residents are not aware of this, and order another dose pushed 30 seconds later when the initial dose hasn't taken effect yet. This will lead to deep sedation and/or respiratory arrest. Always make sure you have working suction and an Ambu at the bedside.

Etomidate is not approved for sedation in my ED, and can only be used for RSI

Propofol is only allowed to be administered to mechanically ventilated patients in our ED, however RICU can supercede this policy if they order it (such as if they are STAT paged to the ED for a difficult airway or failed intubation; doesn't happen often, have only seen it twice in my 6 years at my current facility.) Also, propofol will be given in the ED by cardiac anesthesia for TTE or cardioversion in an otherwise stable patient.

Ketamine is used primarily for pedi sedation. IM is given by the RN, IV is administered by MD, usually preceeded by anticholinergic dose of Atropine.

- One last note- --- Always make sure your med orders are written and signed prior to med administration if possible. You don't want someone to give verbal orders, have the patient be overmedicated and a bad outcome, and then have the ordering MD deny ordering such doses.

suzanne4, RN · Apr 1, 2006

I agree with the poster above, MMCDON78. What he is talking about is the "Conscious Sedation" policy that most facilities have in place now, or are in the process of doing so.

Make sure that what ever drugs that your physician orders can actually be given by an RN in your state, as well.

Etomidate should only be used for RSI, not for Conscious Sedation procedures unless you have anesthesia there. Masking the patient for the procedure is not considered Moderate Anesthesia. I push it only when we are intubating.

Propofol needs an extremely controlled situation, not good for conscious sedation protocols in most facilities. It is much better with smaller bolus, then titration, and unless you actually work with it frequently, you can get into trouble quickly. It is wonderful sedation for a patient that is already on a ventilator. It is used quite a bit by anesthesia in the OR for putting a patient under a quick sleep while a block is being done, such as for podiatry surgery, etc. It lasts only a few minutes, but the patient may require bagging. And it is done by anesthesia strictly there.

Remember that most physcians that are writing conscious sedation oders, usually do not have the anesthesia skills behind them.

Just be very, very careful.

Trauma Columnist · Apr 1, 2006

I should have added that in our ER, we too have stringent competencies that our RN's must do including annual testing. We obtain consents, do Aldrete scoring, ASA scoring and document, document, document. Plus, we always, always, always have the crash cart at the door with suction at the bedside and ready to go.