Pass conscious sedation competency

applewhitern, BSN, RN · Nov 20, 2011

You will learn the levels of conscious sedation, meds used, side effects of those meds, etc. It really is quite easy; there aren't that many, so don't fret over it!

nursedanica · Nov 20, 2011

Yeah. You have to learn and pass that competency. I passed that after 20 days of hire..

Esme12, ASN, BSN, RN · Nov 20, 2011

You will have to pass a hospital beased competency so you can give the meds and monitor a patient under "conscious sedation" during procedures like a colonoscopy. Here is some information.

Procedural sedation/conscious sedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis during a potentially painful or frightening procedure.

Pharmacologic agents used in procedural sedation are of three general classes: sedatives, analgesics, and systemic agents. Using a combination of a sedative/analgesic provides a synergistic combination that generally gives consistent clinical results; using systemic agents provides very rapid sedation and relaxation with some analgesia. Patients should be NPO for at least 4-6 hours prior to procedure if at all possible.

Patients should be triaged to the appropriate Physical Status Classification before conscious sedation is performed: http://en.wikipedia.org/wiki/ASA_physical_status_classification_system

Class I: Normally healthy

Class II: Patient with mild systemic disease (e.g. hypertension)

Class III: Patient with severe systemic disease (e.g. CHF), non-decompensated

Class IV: Patient with severe systemic disease, decompensated

Class V: Moribund patient, survival unlikely

Procedural sedation is appropriate for patients in Classes I, II and III. Patients in classes IV and higher are better suited for the OR.

Procedures appropriate for procedural sedation include ANYTHING painful: debridement of wounds, placement of central lines, chest tube placement, abscess drainage, reduction of fractures and dislocations.

Contraindications

1. Recent (

2. Physical class IV or greater

3. Lack of support staff or monitoring equipment

4. Lack of experience/credentialing on part of clinician

Materials

1. Monitoring equipment: BP cuff, pulse oximeter, cardiac monitor

2. IV access

3. Oxygen delivery by nasal prongs or mask

4. Resuscitation equipment: Endotracheal tubes, Ambu bag and mask, defibrillator, emergency cardiac drugs, naloxone, flumazenil

5. Personnel trained in airway management, and recovery of sedated patients

6. Informed consent as appropriate

Medication combinations for conscious sedation:

1. Ketamine, atropine (or glycopyrrolate), and benzodiazepine

2. Benzodiazepine and analgesic

3. Systemic agents (propofol or etomidate) and analgesic

Preprocedure patient education

1. Discuss with the patient/parent(s)/guardian the need for sedation in light of the presenting clinical situation

2. Obtain informed consent

3. Explain the major steps of procedural sedation

4. Inform the patient of the possibility of transient unpleasant sensations of pain, nausea, dizziness; stress benefits of improved comfort, relaxation, and analgesia

NOTE: Procedural sedation should be appropriate to the procedure being performed. A laceration on a child may require only ketamine, whereas a hip dislocation on an obese adult probably requires a systemic agent and analgesic for proper sedation and relaxation.

Procedure

Using Ketamine, atropine and a benzodiazepine

-this is an excellent combination for children under 11 years of age. Older children and adults do not require the addition of atropine.

-emergence reactions are more common in adults, and combination treatment with a benzodiazepine may alleviate this

-ketamine is an excellent sedation agent for asthmatics, as it does not cause airway hyperreactivity

Attach monitoring equipment and obtain baseline readings

+1 minute Ketamine 1-2 mg/kg IV OR 3-5 mg IM, PLUS atropine 0.01 mg/kg IV/IM, OR gylcopyrrolate 0.005 mg/kg IM/IV

PLUS midazolam 0.05 mg/kg IV/IM

+5-10 min Begin procedure

+30-120 min Recover patient

Using Analgesic and a benzodiazepine

Attach monitoring equipment and obtain baseline readings

+1 minute fentanyl 0.001-0.002 mg/kg IV OR morphine 0.1-0.2 mg IV, PLUS midazolam OR lorazepam 0.05 mg/kg IV

+3-5 min Begin procedure

+10-120 min Recover patient

Using a systemic agent and an analgesic

Attach monitoring equipment and obtain baseline readings

+1 minute Propofol 1-2 mg/kg IV OR etomidate 0.3 mg/kg IV, PLUS morphine 0.05 mg/kg IV (NOTE THE LOWER DOSE OF ANALGESIA…this is due to the synergistic effect of the anesthetic)

+3-5 min Begin procedure

+10-120 min Recover patient

Reversal of Sedation

Rarely should reversal of agents used in procedural sedation be necessary if they are titrated appropriately.

Naloxone is a competitive antagonist of the opioid receptors; it is used for reversal of narcotic analgesics. Use 0.001 mg/kg IM/IV titrated to effect. Be aware that the duration of naloxone is less than the duration of action for most opiates. Be prepared to re-bolus the naloxone, or use a naloxone drip at .01-.05 mg/min.

Flumazenil is a pure benzodiazepine antagonist, and can be used for reversal of benzodiazepine sedation. Like naloxone, it has a shorter duration of action than the benzodiazepine agents it reverses. Prepare to re-bolus with flumazenil, or run a flumazenil drip at 0.1 mg/min. Use 0.2 mg IV every 2-5 minutes titrated to effect, or up to 2-3 mg in total if needed.

Complication, Prevention, and Management

1. Inadequate amnesia or analgesia:

a. Dosage of amnesic or analgesic agents are based upon patient weight. Make sure weights are accurate, and dosages are adequate. As a general rule, the elderly need less, muscular young men need more, and agitated children may also require slightly more medication.

b. Allow sufficient time for the agents to work. It is tempting to start the procedure(s) immediately upon drug administration, but do allow time to titrate the effect of the sedation medications.

2. Decreasing oxygen saturation: apply nasal cannula or a non-rebreather mask for increased oxygenation. Occasionally, a bag-valve-mask with positive pressure ventilation may be required transiently.

3. Prolonged recovery: prolonged offset of sedation is dependent on several factors of which the most important are drug distribution in the patient, and the patient’s own clearance of the sedation agents. Be prepared to recover the patient for a prolonged period, with adequate oxygenation and clearance of any airway secretions.

Documentation in the medical record

1. Consent (obtain if possible)

2. Indications and any contraindications for the procedure; ASA physical classification

3. Medications used, and dosages

4. Any complications of “none”

5. Who was notified of any complications (family, attending MD)

Items for evaluation of the person performing this procedure

1. Indications and contraindications for conscious sedation

2. Pharmacology of commonly used agents, and their indications in appropriate situations

3. Understanding recovery of patients

4. Understanding possible failure of the procedure and why

5. Appropriate documentation

As well as airway classification

http://en.wikipedia.org/wiki/Mallampati_score

Modified Mallampati Scoring is as follows:

Class 1: Full visibility of tonsils, uvula and soft palate

Class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula

Class 3: Soft and hard palate and base of the uvula are visible

Class 4: Only Hard Palate visible

Meds that are used.....http://www.healthsystem.virginia.edu/internet/e-learning/drugchart_sedadult.pdf

SuperStarRN · Nov 20, 2011

My employer did a pretest and then after my probation period I took the test again. It was my first nursing job and I got 100% on the pretest. It was common sense really. No need to worry just remember your nursing basics and familiarize yourself with the drugs used in your facility.

brownbook · Nov 20, 2011

Way off topic, but I thought it was politically correct, (ha ha) to call it moderate sedation, not conscious sedation? Is that not true anymore?

allnurses Guide · Nov 20, 2011

Procedural sedation and conscious sedation/moderate sedation are technically different things. Procedural sedation is used in the ER settings and follows the recommendations set forth by the ACEP and the ENA. Conscious sedation/moderate sedation usually goes by the recommendations set forth by the ASA & the AANA. The biggest differences are in the policies of how long a patient should be NPO before sedation, what medications should be administered by an RN, and what constitutes appropriate monitoring.

allnurses Guide · Nov 20, 2011

Way off topic, but I thought it was politically correct, (ha ha) to call it moderate sedation, not conscious sedation? Is that not true anymore?

Moderate sedation is used to describe sedation on a continuum. Where moderate sedation would be between light and deep sedation. Conscious sedation is kinda of misnomer, but the two terms are still used interchangeably. The term has nothing to do with political correctness...

allnurses Guide · Nov 20, 2011

Mallampati Score: (The easy version) PUSH (tonsillar Pillars, Uvula, Soft Palate, Hard Palate)

I. PUSH

2. USH

3. SH

4. H

This is easy pneumonic to help remember MP classifications.

allnurses Guide · Nov 20, 2011

esme12 i am not trying to pick on you, but i am going to comment on some of these things.

you will have to pass a hospital beased competency so you can give the meds and monitor a patient under "conscious sedation" during procedures like a colonoscopy. here is some information.
procedural sedation/conscious sedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation. the goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis during a potentially painful or frightening procedure.
pharmacologic agents used in procedural sedation are of three general classes: sedatives, analgesics, and systemic agents. using a combination of a sedative/analgesic provides a synergistic combination that generally gives consistent clinical results; using systemic agents provides very rapid sedation and relaxation with some analgesia. patients should be npo for at least 4-6 hours prior to procedure if at all possible.
patients should be triaged to the appropriate physical status classification before conscious sedation is performed: http://en.wikipedia.org/wiki/asa_physical_status_classification_system
patients are recommend to have been npo for 8hrs prior to elective sedation such as a colonoscopy. per the asa the patient should be npo for 2hrs for clears, 4hrs for breast milk, 6hrs for formula/milk/light meals, and 8hrs for normal meals http://journals.lww.com/anesthesiology/fulltext/1999/03000/practice_guidelines_for_preoperative_fasting_and.34.aspx
class i: normally healthy
class ii: patient with mild systemic disease (e.g. hypertension)
class iii: patient with severe systemic disease (e.g. chf), non-decompensated
class iv: patient with severe systemic disease, decompensated
class v: moribund patient, survival unlikely
procedural sedation is appropriate for patients in classes i, ii and iii. patients in classes iv and higher are better suited for the or.
procedures appropriate for procedural sedation include anything painful: debridement of wounds, placement of central lines, chest tube placement, abscess drainage, reduction of fractures and dislocations.
contraindications
1. recent (
2. physical class iv or greater
3. lack of support staff or monitoring equipment
4. lack of experience/credentialing on part of clinician
materials
1. monitoring equipment: bp cuff, pulse oximeter, cardiac monitor
2. iv access
3. oxygen delivery by nasal prongs or mask
4. resuscitation equipment: endotracheal tubes, ambu bag and mask, defibrillator, emergency cardiac drugs, naloxone, flumazenil
5. personnel trained in airway management, and recovery of sedated patients
6. informed consent as appropriate
medication combinations for conscious sedation:
1. ketamine, atropine (or glycopyrrolate), and benzodiazepine
2. benzodiazepine and analgesic
3. systemic agents (propofol or etomidate) and analgesic
ketamine, propofol, and etomidate are generally not approved at most facilities for rns to use. you should check with your state bon before giving any one of these medication even if your hospital has a policy approving them for use by rns. etomidate is an awful sedating agent. etomidate usually causes nausea, is short acting, and can also cause myoclonus.
preprocedure patient education
1. discuss with the patient/parent(s)/guardian the need for sedation in light of the presenting clinical situation
2. obtain informed consent
3. explain the major steps of procedural sedation
4. inform the patient of the possibility of transient unpleasant sensations of pain, nausea, dizziness; stress benefits of improved comfort, relaxation, and analgesia
note: procedural sedation should be appropriate to the procedure being performed. a laceration on a child may require only ketamine, whereas a hip dislocation on an obese adult probably requires a systemic agent and analgesic for proper sedation and relaxation.
procedure
using ketamine, atropine and a benzodiazepine
-this is an excellent combination for children under 11 years of age. older children and adults do not require the addition of atropine.
-emergence reactions are more common in adults, and combination treatment with a benzodiazepine may alleviate this
-ketamine is an excellent sedation agent for asthmatics, as it does not cause airway hyperreactivity
attach monitoring equipment and obtain baseline readings
+1 minute ketamine 1-2 mg/kg iv or 3-5 mg im, plus atropine 0.01 mg/kg iv/im, or gylcopyrrolate 0.005 mg/kg im/iv
plus midazolam 0.05 mg/kg iv/im
+5-10 min begin procedure
+30-120 min recover patient
these dosages are the induction doses for ketamine. you should be starting at half that dose for sedation. in general glycopyrrolate is preferred over atropine because it provides better antisialagogue effects and it doesn't cross the blood brain barrier.i have never dosed midazolam this way, but in general you only usually need 2mg for adult patients when using ketamine. the recommended sedating dose for midazolam is 0.02-0.04 iv and 0.07-0.08 im. when dosed right (titrated to effect) patients can be awake and ready for discharge within a just a few minutes after light moderate sedation.
using analgesic and a benzodiazepine
attach monitoring equipment and obtain baseline readings
+1 minute fentanyl 0.001-0.002 mg/kg iv or morphine 0.1-0.2 mg iv, plus midazolam or lorazepam 0.05 mg/kg iv
+3-5 min begin procedure
+10-120 min recover patient
okay, if this is 70kg patient then you are giving 70-140mcg of fentanyl or 7-14mg of morphine (that is a lot of morphine as a single dose for opioid naive patients), and then you are going to give 3.5mg of ativan or versed on top of that. those patients are going to deeply sedated, and take a long time to wake up/get back to their baseline cognitive status.
using a systemic agent and an analgesic
attach monitoring equipment and obtain baseline readings
+1 minute propofol 1-2 mg/kg iv or etomidate 0.3 mg/kg iv, plus morphine 0.05 mg/kg iv (note the lower dose of analgesia…this is due to the synergistic effect of the anesthetic)
+3-5 min begin procedure
+10-120 min recover patient
the recommended starting dose for sedating with propofol is 0.5-1mg/kg. 2mg/kg of propofol is an induction dose and most patients will be apneic within 30sec after a dose like that. etomidate 0.3mg/kg is a low dose induction dose, but again it is an awful medication to use for sedation. medications in general should be titrated to effect when giving sedation some medications are appropriate to dose on total body weight and some you should use ideal body weight to keep the patient from being over sedated.
reversal of sedation
rarely should reversal of agents used in procedural sedation be necessary if they are titrated appropriately.
naloxone is a competitive antagonist of the opioid receptors; it is used for reversal of narcotic analgesics. use 0.001 mg/kg im/iv titrated to effect. be aware that the duration of naloxone is less than the duration of action for most opiates. be prepared to re-bolus the naloxone, or use a naloxone drip at .01-.05 mg/min.
the easiest way imo to give naloxone is to take the ampule and dilute it down to 10ml. then just give one ml at a time until patient is breathing adequately. abrupt reversals of narcotics can lead to htn crisis, stroke, pulmonary edema, and mi.
flumazenil is a pure benzodiazepine antagonist, and can be used for reversal of benzodiazepine sedation. like naloxone, it has a shorter duration of action than the benzodiazepine agents it reverses. prepare to re-bolus with flumazenil, or run a flumazenil drip at 0.1 mg/min. use 0.2 mg iv every 2-5 minutes titrated to effect, or up to 2-3 mg in total if needed.
complication, prevention, and management
1. inadequate amnesia or analgesia:
a. dosage of amnesic or analgesic agents are based upon patient weight. make sure weights are accurate, and dosages are adequate. as a general rule, the elderly need less, muscular young men need more, and agitated children may also require slightly more medication.
b. allow sufficient time for the agents to work. it is tempting to start the procedure(s) immediately upon drug administration, but do allow time to titrate the effect of the sedation medications.
2. decreasing oxygen saturation: apply nasal cannula or a non-rebreather mask for increased oxygenation. occasionally, a bag-valve-mask with positive pressure ventilation may be required transiently.
3. prolonged recovery: prolonged offset of sedation is dependent on several factors of which the most important are drug distribution in the patient, and the patient’s own clearance of the sedation agents. be prepared to recover the patient for a prolonged period, with adequate oxygenation and clearance of any airway secretions.
when doing sedations the patient should already have oxygen running from either a nasal canula or face mask (with understanding that peds/some adults aren't going to always tolerate o2). the idea is to get as much o2 into the lungs/fill up the frc so the patient can tolerate apnea for longer periods.
documentation in the medical record
1. consent (obtain if possible)
2. indications and any contraindications for the procedure; asa physical classification
3. medications used, and dosages
4. any complications of “none”
5. who was notified of any complications (family, attending md)
items for evaluation of the person performing this procedure
1. indications and contraindications for conscious sedation
2. pharmacology of commonly used agents, and their indications in appropriate situations
3. understanding recovery of patients
4. understanding possible failure of the procedure and why
5. appropriate documentation
as well as airway classification
http://en.wikipedia.org/wiki/mallampati_score
modified mallampati scoring is as follows:
class 1: full visibility of tonsils, uvula and soft palate
class 2: visibility of hard and soft palate, upper portion of tonsils and uvula
class 3: soft and hard palate and base of the uvula are visible
class 4: only hard palate visible
meds that are used.....http://www.healthsystem.virginia.edu/internet/e-learning/drugchart_sedadult.pdf

carsonya · Nov 21, 2011

thank you guys so much for all of your help :))))

brownbook · Nov 21, 2011

thanks wtbcrna. I was joking about it being politically correct. I really like your response. I go through spurts of rarely doing moderate sedation, to doing it more frequently.

Thank goodness I have never had to give narcan, so therefore kind of stress over it. I don't like the idea that the first time I give a drug it would be during a, shall we say, stressful event. I would be stressing over how to draw it up, how much to give, etc.

Hopefully (in a crisis) I can remember dilute it in 10 ml and give 1 ml until patient is breathing adequately. But how long would you wait, I know I'd be so panicked I'd immediately loose track of time and probably be giving 1 ml every 2 - 3 seconds!

Since I have you on the line, ha ha, could you expand on giving romazicon. How would you draw it up, bolus it etc?

Yes I feel like a nursing student asking you to do my homework for me!!! But honestly I will take your advice to heart. Sometimes what you read in the literature doesn't carry over to how people do it in the real world!