Please share your wisdom and experience on a couple of questions

brownbook · May 30, 2011

First of all you have to do some critical thinking. Assess your patient. Do they have sleep apnea? Do they use oxygen at home? How have they responded to anesthesia or moderate sedation before. Do they take a lot of opioids at home? Are they generally healthy in no apparent distress or are they debilitated elderly in some apparent distress?

Always have narcan and romazicon by you and know how to give them.

If the vital signs change kind of suddenly don't panic. Did the pulse oximeter drop off the finger? Did one of the EKG leads fall off? Did the BP tubing get kinked or did the BP cuff slip down the arm? If the O2 sat drops, check the finger probe, turn up the oxygen, continue to monitor. Tell the patient to take a few deep breaths. That will clue the MD that you have a concern and the patient should not be so sedated that they can't respond to verbal commands!

I know the conscious sedation manual I studied had a lot of information about moderate sedation drugs. Based on the patients weight, giving drugs over (I can't remember exactly) 1 - 2 minutes, (which is a joke). The drugs are pushed, not FAST, but not slowly either, just kind of regular. You often open up the IV clamp so the IV is dripping fast, and if it is a slow, positional IV, you might even push some saline into the injection port after the drug to get it in faster.

I don't use Demerol a lot. I kind of don't like it. I know there is a concern with seizures with higher amounts of Demerol but I would guess even that has no exact number of mgs? I once had a patient have a weird ???? seizure??? (I wasn't sure what it was, it lasted about 30 seconds, heart rate and O2 sat were fine) after 25 mg of Demerol but the MD said it was nothing, the exam went on and the patient was fine.

There is no written, exact, number of mgs or mcgs you can or cannot give. Kind of sort of if you are up to 200 mcg's of fentanyl, or 10 mg of versed, or 100 mg of Demerol (and honestly those amounts would make me nervous) and the patient is still needing more, well even then???? You go by how the patient is responding, how the vital signs are. However if I had a patient getting that much sedation (and I've never had to go that high) and no response I would do some critical thinking. This patient should be sedated, why aren't they? Is the IV infiltrated? Is this patient on a lot of opioids at home and has built up a tolerance?

I've done GI nursing 10 years and have never had a problem with the MD ordering too much sedation. Very rarely they just stop the exam and tell the patient they will need to reschedule the exam to be done with an anesthesiologists.

hgorrondona · May 30, 2011

Thanks, Brownbook,

The info is very helpful. We use Demerol/versed or Fentanyl/versed combos (depending on the doctor). I don't know if everyone does conscious sedation the same or not. I'm being taught to give an initial dose of 50mg Demerol or 50mcg Fentanyl and 2mg Versed; then give another 25mg/mcg of demerol/fentanyl and 1mg versed before the procedure starts, and give more if necessary during the procedure. The problem is that the medicine takes a little while to work, and it seems the procedure is over before it takes full effect. Is this the norm? I'm afraid I'll end up giving more than I should. We usually end up with 75-100mg Demerol or 75-125mcg Fentanyl and 4-5mg of Versed. So far, there hasn't been any problems, but I don't want to cause any either.

Any thoughts on this?

brownbook · May 31, 2011

Well, "full effect" is confusing. Many patients are talking, complaining "it hurts" during the procedure then get to the recovery unit and say they didn't feel a thing, how wonderful it was (thank goodness for versed).

If by full effect you mean they are ??? unconscious ???? or not feeling a thing ??? you may, or should, seldom reach that state with moderate sedation. The MD wants them a little conscious so they can follow commands "swallow" or "turn on your back" etc. And the MD wants them a little conscious because an overly sedated patient is on a dangerous continuum towards not maintaining their own airway!!!!!

The amounts you are giving are very normal, what I usually give. Actually we have started using more anesthesiologists (MD's) and propofol replacing the moderate sedation nurse. According to some nurses that is becoming the accepted norm for GI sedation?

I'm not sure how you could end up giving more than you should. You make it sound like you alone are deciding how much to give? I have always been under the MD's orders, I only give what they verbally order during the procedure. If you are afraid the MD might order too much sedation that may be a legitimate concern and that would be what I was referring to in my first reply.

hgorrondona · May 31, 2011

Thanks again, for the info. Our doctors don't say what meds to give, or how much to give during procedures. We have a written order that says to start at 2mg Versed and 50mg Demerol (or 50mcg of Fentanyl)...and then titer to maintain conscious sedation.

The nurse decides when and how much to give. That's what I meant by worrying about giving too much. The problem I see is that the word "conscious" seems to mean different things to different people. You describe what I think of as conscious (talking, possibly complaining of pain but not in distress, moving when asked). However, the nurse I work with (I don't know what the other ones do) seems to have a different definition (and the doctors don't say anything about it). Most of the patients we have are pretty out of it during the procedures and after. Some open their eyes spontaneously, but they don't talk at all ( if they do, the nurse gives them more drugs); the others do open their eyes of you talk loud to them or tap on them, and will help a little when moving them to their backs (although I think we do most of that work with the draw sheet).

I was told that I would be giving meds tomorrow. I'm a little nervous about it. I wish our unit would go to anesthesia sedating....but then they may not need as many RNs :confused:

brownbook · May 31, 2011

Thanks, interesting thread for me. I never knew sedation nurses would have a standing protocol and use their judgement to titer to the patients sedation.

I think your ideas, worries, are a sign of good intelligent critical thinking. As you said, what is too much sedation for one nurse is okay for another nurse.

You will NEVER (but I can't promise) need to use these, but keep your romazicon and narcan handy. Watch You Tube videos or somehow practice to feel comfortable doing a little head tilt chin lift if the patient is too somnolent and just needs their airway opened and some extra oxygen (hopefully with just nasal cannula providing enough) for a few seconds.

If I started working in your clinic I would have a hard time also. I would tend to lean towards less sedation at first. Kind of go by the MD hinting, commenting, that the patient might need more?

hgorrondona · Jun 2, 2011

Your posts have made me feel more comfortable, and confident in my own judgement. I wasn't sure if I was just being a "new grad" and worrying about things that weren't really important, or not. I've been an LPN for 12years, but this is my first RN job, and my first time working with sedation. I'm used to having specific orders for everything I do. Using my own judgement for titrating sedation is very new to me.

I made it through my first day handling room on my own....well my preceptor was right there with me, but you know what I mean :) The doctor was very nice, and didn't rush me at all. I wish I could work with him all the time. I think I did all right. My patients were not overly sedated....they opened eyes readily to verbal stimulation, and even talked some. One patient complained of pain at one point (when tube went around the spenic flexure) I asked the doctor if he thought she needed more meds (I had already given 75mg Demerol and 4 Versed)....and he said no. She wasn't in a lot of pain, from what I could tell....she just said it hurt. It only lasted a minute or so, and he was past that turn, and she settled down again.

When I brought the patient to recovery, she opened her eyes right away, and asked if the doctor was ready to do the procedure yet LOL. I felt good about how I had managed her case.

We'll see what happens today; but I think I'm started to feel more at home in the unit. Thanks so much for the input.