What drugs are best for conscious sedation? Safety of patient being priority.

AOx1 · Mar 1, 2009

The idea is NOT to be completely under for conscious sedation. Recent studies have indicated that a surprising number of patients ordered to receive conscious sedation actually receive an induction of general anesthesia.

During conscious sedation, the patient should be able to make a purposeful and appropriate response (based on their baseline data). For example, if they could squeeze your hand on command prior to sedation, they should be able to do it afterwards also. They should be able to maintain an airway and also their cardio status without requiring intervention or support.

In comparison with small amounts of sedation, where the meds are given just to relieve anxiety (ex- giving a small dose of an anxiolytic so a patient can sleep after receiving a poor prognosis), a conscious sedation patient is better able to tolerate the procedure, but still able to maintain airway and responsiveness to stimuli. If the patient only responds to painful or repeated stimuli, the sedation has moved to deep sedation, or if unarousable, to general anesthesia. One measure is vitals- you shouldn't see a huge variation in vitals for conscious sedation. Ex, if you patient originally sats 100% and now sats drop to 70% and respiratory rate is very decreased, they are too sedated.

The problem with sedation is this: every patient reacts differently to meds, so your key to safety is to have airway/oxygenation equipment including advanced airways and suction, present EVERY time you do a procedure. You should also be prepared to institute ACLS. Also key is to know what reverses what (ex- benzos are reversed by romazicon/flumazenil and opioids by narcan/naloxone.)

There are a lot of things that go into an assessment prior to conscious sedation- for example, a patient who is very obese with a short neck and lots of adipose tissue there may be more difficult to maintain an airway than an otherwise identical patient who is thin. Of course, chronic diseases (ex- kidney disease) can impact safety during conscious sedation. You need to know their baselines (mental status, vitals, labs as ordered, EKG and pulse ox). You want to know if they have had any previous reactions to meds, or familial problems with sedation, or any allergies. Also, ask how long they fasted.

Where I work, we do vitals at least every 5 minutes, more if we are working with an anesthesiologist who is providing general or deep sedation for a procedure. I make sure all my emergency equipment (including reversal agents and a TESTED laryngoscope and blades) is prepped and ready to go.

As far as meds go, we use a lot of midazolam (Versed), and sometimes fentanyl. If we are trying to help with more painful things, like a liver or kidney biopsy, we may also use some morphine, but it takes longer to have an effect and longer to clear the system. Occasionally, you see someone old school who uses phenergan or demerol (gasp!) but they aren't the best choices. Demerol sucks for most elders, you don't want to use it if they're in renal failure and it isn't even that good at relieving pain. Phenergan isn't a very good at sedating unless in combo with another drug and you can't reverse it either; plus it's irritating to the vein and lasts longer than I would like.

The thing with propofol is that in every unit I've ever worked, you can't use it as a nurse without intubation (this is an FDA statement). In the ICU, they require intubation before using this or precedex. In conscious sedation where I work, they only allow it to be given by anesthesia personnel. I won't participate in any procedure in which propofol isn't given by an anesthesiologist or nurse anesthetist unless the patient is intubated. The person managing the propofol shouldn't be the same on performing the procedure either. The problem is it can quickly lead to general anesthesia, even though this wasn't the intended effect. Whether a nurse can give it at all depends on your state's scope of practice, so check that. It's a good drug in that it acts quickly and lasts a short time, but dangerous in that it can quickly lead to arrest if the patient gets too much, and you can't reverse it. Must say I love it a lot for a patient who is on a vent and needs it when they buck/overbreathe the vent. No real hangover effect like with many meds. Does seem to thicken secretions a bit in my experience.

I think my overall advice would be to avoid any conscious sedation unless you absolutely know what you are doing and your hospital policy is clear and adheres to current guidelines; be ACLS certified and comfortable with it, and never let anyone push you to keep giving more meds too quickly. I hate to say it, but I have been pushed often to give more meds by an impatient doc who is in a hurry to go to the next procedure. Stand your ground. I often tell them "Unless you are prepared to keep me in the lifestyle to which I have become accustomed after this causes me to lose my license, I will only push the meds at a safe rate." I say it as a joke, but I'm deadly serious. Know how fast and how often you can safely push your meds, and refuse to exceed that. Also know, again, that patient response is very individualized, and really, safety of the patient is the main concern, as you mentioned. This is probably more than you wanted, but I hope it answers some of your questions. I've only been doing conscious sedation for around 7 years now, but less now that I teach full time.