OVERVIEW OF ANESTHESIA SCORING SYSTEMS, SEDATION AND ANALGESIA CONSCIOUS MODERATE SEDATION JASSIN M. JOURIA Dr. Jassin M. Jouria is a practicing Emergency Medicine physician, professor of academic medicine, and medical author. He graduated from Ross University School of Medicine and has completed his clinical clerkship training in various teaching hospitals throughout New York, including King’s County Hospital Center and Brookdale Medical Center, among others. Dr. Jouria has passed all USMLE medical board exams, and has served as a test prep tutor and instructor for Kaplan. He has developed several medical courses and curricula for a variety of educational institutions. Dr. Jouria has also served on multiple levels in the academic field including faculty member and Department Chair. Dr. Jouria continues to serve as a Subject Matter Expert for several continuing education organizations covering multiple basic medical sciences. He has also developed several continuing medical education courses covering various topics in clinical medicine. Recently, Dr. Jouria has been contracted by the University of Miami/Jackson Memorial Hospital’s Department of Surgery to develop an e-module training series for trauma patient management. Dr. Jouria is currently authoring an academic textbook on Human Anatomy & Physiology. ABSTRACT As noninvasive and minimally invasive procedures become more common outside of operating rooms, the use of conscious moderate sedation to induce a state in which patients can tolerate unpleasant procedures while maintaining airway control and oxygenation independently has had corresponding growth. Conscious moderate sedation, with or without analgesia, creates a depressed level of consciousness with minimal risk to the patient. With the proper understanding of moderate sedation techniques and monitoring requirements, health clinicians can offer patients an alternative to more invasive sedation options. 1 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. It is the policy of NurseCe4Less.com to ensure objectivity, transparency, and best practice in clinical education for all continuing nursing education (CNE) activities. Continuing Education Credit Designation This educational activity is credited for 3 hours. Nurses may only claim credit commensurate with the credit awarded for completion of this course activity. Pharmacology content is 0.5 hour (30 minutes). Statement of Learning Need Clinicians need to know the procedures for conscious moderate sedation, and the special attention and procedures that are needed for high-risk patients who undergo sedation. Because individuals will respond differently to standard medication doses used during sedation, clinicians need to be prepared to reverse sedation when necessary and to return patients to a desired state. Course Purpose To provide clinicians with knowledge of conscious moderate sedation techniques offered for procedures scheduled in various hospital and outpatient settings. 2 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Target Audience Advanced Practice Registered Nurses and Registered Nurses (Interdisciplinary Health Team Members, including Vocational Nurses and Medical Assistants may obtain a Certificate of Completion) Course Author & Planning Team Conflict of Interest Disclosures Jassin M. Jouria, MD, William S. Cook, PhD, Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC – all have no disclosures Acknowledgement of Commercial Support There is no commercial support for this course. Please take time to complete a self-assessment of knowledge, on page 4, sample questions before reading the article. Opportunity to complete a self-assessment of knowledge learned will be provided at the end of the course. 3 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com 1. When a patient’s level of sedation becomes deeper than the clinician intended to produce, the clinician should a. be able to return the patient to the original intended level of sedation. b. proceed with the deeper sedation since sedation is a continuum. c. proceed with the deeper sedation unless an adverse physiologic event, i.e., hypoventilation, occurs. d. return the patient to baseline and abort the procedure. 2. Procedural sedation and analgesia (PSA) is defined as a. a state where a patient cannot maintain unassisted oxygenation. b. a continuum. c. intended to result in a depressed level of consciousness. d. a state where a patient is at baseline values. 3. True or False: Loss of consciousness is the primary goal for conscious or procedural sedation. a. True b. False 4. A patient receiving sedation using an anxiolysis is likely needing relief for a. severe pain. b. convulsions. c. anxiety. d. pain associated with a fracture. 5. Procedural sedation and analgesia (PSA) may NOT be used a. in an emergency department setting. b. for imaging or minor procedures. c. dentistry. d. None of the above 4 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Introduction A proper understanding of sedation techniques and monitoring requirements for conscious moderate sedation is needed by clinicians in order to establish safe alternatives for patients undergoing potentially uncomfortable procedures. Clinicians need to know the recommendations for patient assessment prior to sedation, during sedation, and as the patient reaches the post-sedation recovery phase. In general, drug dosages for sedation and analgesia are highly variable based on the patient’s medical condition, concurrent medications, and age. Drugs for mild to moderate sedation must be used only in a setting that provides for continuous monitoring of patient response to medication, including respiratory and cardiac function. Other requirements include the immediate availability of resuscitative drugs and equipment and health personnel experienced with the use of sedation and reversal agents and equipment. Sedation And Analgesia The American Society of Anesthesiologists provides definitions for various levels of sedation. Minimal sedation or moderate sedation is used for various outpatient procedures and is often combined with analgesia. Minimal sedation (anxiolysis) allows for normal patient response to verbal stimulation and for ventilation and cardiovascular functions that are unaffected. Cognitive function and coordination may become impaired. Moderate sedation or analgesia (formerly called conscious sedation) results in the patient having depression of consciousness that is drug-induced, purposeful response to verbal commands, an airway that is patent, as well as spontaneous ventilation that is adequate, and cardiovascular function that is usually unaffected.13-16 5 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com Deep sedation/analgesia involves the following patient responses: • Depression of consciousness that is drug-induced. • Patient is not easily aroused but responds purposefully following repeated or painful stimulation. • Independent maintenance of ventilatory function may be impaired. • Patient may require assistance in maintaining a patent airway. • Spontaneous ventilation may be inadequate. • Cardiovascular function is usually maintained. Patients who become overly sedated may show features of general anesthesia, such as drug-induced 1) loss of consciousness where the patient is not able to be aroused, even by painful stimulation, 2) impaired independent ventilatory function, 3) depression of spontaneous ventilation or of neuromuscular function requiring assistance if patients to maintain a patent airway, and positive pressure ventilation, and 4) impaired cardiovascular function.13-16 A summary of the American Society of Anesthesiologists’ Continuum of Depth of Sedation and Definition of General Anesthesia and Levels of Sedation/Analgesia is shown below.13-16 Quality Moderate Sedation/Analgesia (Conscious Sedation) Responsiveness Purposeful response to verbal or tactile stimulation Airway No intervention needed Spontaneous Adequate Ventilation Cardiovascular Usually maintained Function 6 nursece4less.com nursece4less.com nursece4less.com nursece4less.com nursece4less.com While under minimal sedation, the patient will respond normally to verbal commands. Physical coordination and cognitive function could be impaired. Airway reflexes plus ventilator and cardiovascular function are unaffected. Moderate sedation/analgesia also known as conscious sedation is a drug- induced depression of consciousness. In this state, a patient responds purposefully to verbal commands either alone or accompanied by light tactile stimulation. Spontaneous ventilation is adequate and no intervention is needed to maintain a patent airway. Cardiovascular function is usually maintained. Deep sedation/analgesia is a drug-induced depression of consciousness. In this state, a patient cannot be aroused easily but responds purposefully following painful or repeated stimulation. What could be impaired is the ability to independently maintain ventilatory function. A patient could require assistance in maintaining a patent airway. Spontaneous ventilation could be inadequate. Cardiovascular function is usually maintained. General anesthesia