SCARED to death of conscious sedation

phiposurde · Mar 21, 2007

Here I come to save the dayyyyyyyy We do conscious sedation all the time at my hospital. We use propofol in 98% of the case. In the 6 years I've been there never had one complication, beside that the take longer to wake up. Just have to be sure they don't have any allergy to it! We use it mostly for reduction in our minor side. We use versed for our cardioversion and sometime for LP. That one is safe but I had more complication with it. Cause it is very easy to give too much. It accumulate in the patient system and you can have trouble for long time with big dose. Ketamine, I didn't really work with it but our children hospital use it as frequent as propofol, so I heard. Just have to be careful about possible "bad trip" they can have!!! Apparently when they do have those they are pretty nasty! Hope I help!

CHATSDALE · Mar 21, 2007

i don't know if this is any help but most of the things we worry about the most is things don't happen be observant pt will be fine

Trauma Columnist · Mar 22, 2007

First of all, you shouldn't be doing conscious sedation without two nurses present: one to solely monitor the patient and the other to assist with the procedure. One nurse and one doc in the ER isn't enough to adequately do conscious sedation. And then the question becomes what happens if a code comes in at the same time?

Secondly, once you get adequately staffed or can have trained assistance, doing conscious sedation frequently allows for a higher comfort level.

RunnerRN, BSN, RN · Mar 22, 2007

Conscious sedation is a great tool. We frequently use Versed and Morphine or Versed and Fentanyl. Occasionally Etomidate and Morphine or Fentanyl. We don't use Propofol (check your nurse practice act - nurses aren't allowed to push Propofol at my hospital). We typically use conscious sedation on kids (reducing fractures, CTs for young kids, etc), and healthy adults (shoulder dislocations, reducing fractures, etc). I prefer not to do conscious sedations on elderly people. As you said, too many comorbidities, and too many other problems to pop up.

Just make sure you have a crash cart, Romazicon and Narcan (to reverse benzos and narcs). Put the patient on the monitor (NiBP, EKG, SpO2), put on a couple of liters of Os per NC, have a NRB out just in case, and set your BP to cycle q 5 min. Don't be afraid to refuse to push more meds if the doses are getting up there. Watch your BP before giving Versed - you can tank someone's BP if you push too fast. Also, stay with your patient until he/she wakes up. As soon as the patient can keep his eyes open and respond without prompting, they're usually safe to walk away from. Just remember that if someone's sats start to drop, you're usually safe to start with a head tilt/chin lift first. Usually their sats are dropping because their tongue is flopping backwards.

My hospital policy says that the person pushing the meds cannot be the person performing the procedure. That isn't to say I haven't held counter traction for a shoulder relocation, but I always have my eyes on the monitor while I'm holding.

You'll do fine! Just remember that once the patient loses the ability to respond to auditory/tactile stimuli, they are no longer under conscious sedation....its pretty much anesthesia.

Next time you have an opportunity to do this, take a deep breath, make sure you have everything in place, and push your drugs!!

AliRae · Mar 22, 2007

We do conscious sedation lots in our PICU. We use propofol mostly, sometime versed. I've also done it off the unit, in MRI for example, when anesthesia wasn't available to do it. Like others have said, the only adverse event I've seen yet is kiddos taking a little while to wake up. Depending on the day and the kid, that's actually not such a bad thing sometimes!

I've also don't not-so-conscious sedation with ketamine for kids in Africa needing surgeries (mostly hernia repairs). This, I'm not a fan of. Ketamine is nasty and kids get some bad "ketamine nightmares" waking up ... they kick and scream and thrash. I had one kiddo get quite obstructed as well during the operation and had to place a nasal airway. HOWEVER ... not such a big deal over here in America, since problems are much more easily handled in a situation where things like monitoring equipment and oxygen are close at hand.

Just keep a close eye on your patient - use the monitors, but watch your patient as well. I've seen kids whose vitals weren't changing very much but who were grimacing away during procedures and needed a little something extra.

Oh, and make sure you check your hospital policies- I don't know if it's the case elsewhere, but our hospital requires the first dose of the medication to be given by a certified physician and only after that can I give subsequent doses.

bill4745, RN · Mar 22, 2007

1. There is a lot of controversy about nurses giving propofol - you should check out the regulations in your state and your hospital's policy about it. The big problem is that it can't be reversed.

2. You should not do conscious sedation without proof that you have been properly trained to do it. You must be ACLS also.

3. You should not eave the patient until 30 minutes have passed since the last med was given. If your ER only has one nurse, you should insist that another ACLS nurse be present in the ER if you are doing conscious sedation.

It sounds to me that you are in a position of great personal liability if something goes wrong.

NicoleRN07, RN · Mar 22, 2007

We do conscious sedation frequently in our ER as well. On adults, we always use Etomidate, because it has a short half life, and there is usually no recovery time. Usually, the patient is completely alert within 5-10 minutes after administration. With children, we use Ketamine. Ketamine scares me to death! Some of our docs prefer IM to IV, however, I refuse to administer Ketamine without an IV access. These kids become tachycardic, and in some instances hypertensive, and I've even had 1 or 2 drop their sats. Waking up from it is just as bad...these kids have drug induced nightmares, excessive crying, and agitation. It's not fun!!

You should not be working alone as the only nurse in the dept under no circumstances. That is setting you up for major problems. What happens when there is more than one code at a time, or more than one critical patient at a time? I don't know how many beds your ED has, but regardless, it can still be a sticky situation. Protect your license....you earned them. No one, not even the MD will stand behind you when something goes wrong and you're the only nurse in the dept.

TazziRN, RN · Mar 22, 2007

I love Versed! Short acting and it's an amnesiac. As long as you've got the pt hooked up to monitors and O2 and you are pushing the meds slowly, you should not have a problem.

That said, you should not be doing conscious sedation on your own with just the doc there. Your job is to give the meds and monitor the pt. There should be another staff member, be it RN/LVN/CNA/tech, helping the doc. Even if the procedure is something the doc can do without assistance, you need another nurse in the ER with you because you are dedicated to your now sedated pt. You canNOT leave the bedside, no matter what else comes in.

gonzo1, ASN, RN · Mar 22, 2007

We use versed a lot. I personally won't push ketamine or propoful, don't want to take a chance losing my license. It is scarey the first couple of times you do it, but your confidence will increase with experience. However, you do not sound like your ER is adequately staffed for this procedure. We have 10 or so nurses on at any time. There are many articles out there on CS and you would most likelly benefit from taking some time to read up on the subject.

cardiacRN2006, ADN, RN · Mar 22, 2007

I do conscious sedation all the time. My first time, I was scared to death! I was still on orientation, with my preceptor at my side, but she still made me do everything.

It's easy after you do a few.

We can never use propofol for conscious sedation. It must only be used on vented pts in my state (and most),

Usually it's me, the Dr and his assistant. I've done it is the OR for port-a-cath placements, CT for CT guided tests, GI and Radiology for kidney drains.

The only thing that makes it easier is doing it over and over. Usually, the procedure is so fast, that it's over before you know it.

I keep a different piece of paper on hand to write down all the VS and the meds I've given, and then transfer over to another paper after I'm done. Usually the Dr will ask what's been given so far, so I keep a running total of what I've given. So he will say, "what are we up to so far," and I can say, "100 and 2".

We use Fentanyl and Versed.

luanne123 · Mar 22, 2007

Check your hosptal policy and your state nurse practice act. We use it for Endoscopy, but there must be one RN to monitor and one RN/Tech to assist, Minimum of three in the room, and all emergency equipment must be avsilable.