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Transesophageal Echocardiography (TEE) Procedural Sedation

Purpose To provide guidelines that promotes safety and best practice for patients receiving conscious sedation for a Transesophageal Echocardiography Procedure.

Description:

Conscious Sedation: Increasingly patients are receiving short-term conscious sedation and analgesia for invasive diagnostic procedures. Advantages of conscious sedation and analgesia include a short rapid recovery, early ambulation, and the preference for patients to experience light sleep while maintaining adequate cardio-respiratory function and the ability to respond to verbal or tactile commands. It is impossible to predict individual responses to sedation, therefore specific post procedural monitoring of each patient is required.

Sedation Levels (ASA – American Society of Anesthesiologists)

ASA Levels of Minimal Moderate Deep General Sedation (anxiolysis) (conscious Anesthesia sedation) Responsiveness Normal response Purposeful Purposeful Unarousable even to verbal stimuli response to verbal response after with painful or tactile repeated or painful stimulation stimulation stimulation Airway Unaffected No intervention Intervention may Intervention often required be required required Spontaneous Unaffected Adequate May be inadequate Frequently ventilation inadequate Cardiovascular Unaffected Usually Usually May be impaired function maintained maintained Most common level for the performance of a TEE

Policy

Staff Responsibilities:  Must be able to differentiate the different levels of sedation  Full explanation must be provided to patient with time to answer questions  Must acquire written consent to proceed with test  Patient safety and comfort a priority  Emergency equipment (crash cart) in direct proximity of the room

1 of 2  Must know how to activate a code blue  Appropriate staff present during the procedural sedation  Vital signs are monitored and documented by a dedicated and qualified staff member  Must document all medications given (name, dose, time and effect)  Must be aware of and able to identify adverse reactions  Must be able to assess for airway patency and able to identify life-threatening arrhythmias  CPR certification maintained (BCLS)  The regulated health care professional (RN, Anesthetist Assistant) responsible for monitoring of the patient during and after the procedure may not leave the patient unattended at any time; they cannot assist with any procedure that distracts them from the monitoring of the patient  Monitoring includes: observing skin color, level of consciousness, rate and depth of respiratory rate  Patients are at a higher risk of respiratory depression within 5 to 20 minutes after receiving IV sedation  Oxygen saturation monitor on throughout  Cardiologist performing the test is responsible for sedation dosage and writing the order for administration  Should start with the lowest dose of sedation and repeat to achieve patient comfort  Cardiologist performing the test must be made aware of the patient’s status throughout the test  Staff should always be aware of length of test and patient comfort level  Appropriate recovery time with continuous monitoring and IV site, until patient stabilized  If Flumazenil or Naloxone required to reverse the effects of the sedation, the patient should continue to be monitored for an additional 2 hours  Patient must be discharged with an accompanying adult who takes responsibility for them

Recovery: To assess the recovery status of the patient after discontinuation of the sedation.

Example: Aldrete Score

Score 2 1 0 Respirations Able to take a deep Dyspnea/shallow apnea breath and cough breathing Oxygen saturation Maintains > 92% on Needs oxygen Saturation < 90% even with room air inhalation to supplemental oxygen maintain > 90 % Consciousness Fully awake Arousable on Not responding calling Circulation B/P +/- 20 mmhg B/P +/- 20 to 50 B/P +/- 50 mmhg pre test pre test mmhg pre test Activity Able to move all Able to move 2 Able to move 0 extremeties extremeties extremeties

The Aldrete score should be completed every 15 minutes until the patient reaches a score of 8 to 10 prior to discharge. There are different scoring methods available on line:

2 of 2  Modified Observers Assessment of Alertness  Ramsey Score

3 of 2