Sedation Monitoring and Post-sedation Recovery and Discharge

Key Principles of Procedural Sedation and Analgesia

• Determine appropriate level of sedation desired

• Have appropriate monitoring and rescue equipment

• Administer analgesic before sedative• Titrate agents to desired level of sedation• Observe and monitor until recovery to

baseline mental status

Equipment and Supplies Recommendations

• Intravenous equipment• Basic & advance airway management

equipment• Pharmacologic antagonist• Emergency medication

Procedural Sedation Monitoring

• Interactive monitoring• Mechanical monitoring

Procedural Sedation Monitoring

• Interactive monitoring:Direct observation of patient to access

- Depth of sedation- Respiratory function & Hemodynamics

Unobstructed view of the patient’s face, mouth,

chest wall

In patients undergoing procedural sedation andanalgesia in the emergency department,

what is the minimum number of personnel necessary to manage complications?

• Mostly, one clinician performs the procedure while another (usually a nurse) observe and continuously monitor the patient

Level C recommendationsClinical Policy: Procedural Sedation and Analgesia in the Emergency Department Ann Emerg Med. 2014;63:247-258.

Monitoring Depth of sedation

• Check response to verbal commands• If verbal response is not possible, “thumbs up”• Deep sedation: response to a more profound

stimulus• Response limited to reflex withdrawal from a

painful stimulus is not considered a purposeful response

Scale monitoring depth of sedation

Moderate sedation: Do not exceed level 4Deep sedation score: Level 5

Regular patient monitoring is more important than the application of scales

Bispectral Index monitoring

• uses processed electroencephalogram signals to measure the depth of sedation

• 100 = complete alertness,• 0 = no cortical activity at all• 40 - 60 is believed to be consistent with GA

Monitoring

• Interactive monitoring• Mechanical monitoring

Mechanical Monitoring

• Arterial oxygenation• Ventilation• Vital sign• ECG monitoring

Arterial oxygenation

• Pulse oxymetry is not a substitute for monitoring ventilation

• Hypoventilation or apnea develop before oxygen saturation decreases especially “Patient who receive supplemental oxygen”

Ventilation

• Capnography• ETco2 correlates with arterial Pco2• ETco2 > 50 mmHg or ↑>10 mmHg

indicates hypoventilation

In patients undergoing procedural sedation and analgesia in the emergency department, Does the routine use of capnography reduce the incidence of adverse

respiratory events?

Level B recommendation

• Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED.

• Capnography includes all forms of quantitative exhaled carbon dioxide analysis.

Vital Signs

• Before the procedure• After each dose of sedative• Regular intervals during the procedure• During initial of recovery period• Before discharge

RecommendationsLevel of Sedation

LOC Heart Rate Respiratory Rate

BP O2 Saturation

Capnography

Minimal Observe frequently

q 15 min q 15 min q 15 min and after sedative boluses

Continuously -

Moderate or Dissociative

Observe constantly

Continuously Continuous direct observation

q 5 min & after sedative boluses

Continuously Consider continuously

Deep Observe constantly

Continuously Continuous direct observation

q 5 min & after sedative boluses

Continuously Recommend continuously

If recording is performed automatically, Device alarms should be set to alert

Cardiac monitoring

Recommended for:• Preexisting cardiac disease• Dysrhythmias• During procedures in which the cardiac

rhythm is of interest

• Recovery and discharge under supervision of operating practitioner or a licensed physician.

• A nurse or other individual should monitor until appropriate discharge criteria are satisfied

• Preparation for management of complications.

Post-Sedation Recovery

Observation Duration

• In most cases, prolong observation beyond 30 min is unlikely to be necessary

• Longer duration in patients who receive reversal agents

Discharge Criteria

• Low risk procedure that additional monitoring is un necessary.

• Symptoms should be well-controlled.• Stable V/S and respiratory and cardiac function• Alert and oriented or returned to baseline• A reliable person who can provide support and

supervision at least a few hours.• Scoring systems may assist in documentation.• Patient instruction

10/12 points required before discharge

Pediatric Discharge Criteria

• Young infants or children who are handicapped should return to the level of responsiveness observed before sedation

• Because of the significant risk of apnea after sedation, term infants with postconceptual ages (PCA) ≤45 weeks and former premature infants with PCA <60 weeks should undergo prolonged observation of respiratory status prior to discharge

Minimum Duration of Observation for Infants

• All infants with PCA ≤45 weeks – 12 hours • Pre-term infants with PCA 46 to 60 weeks and

significant comorbidities – 12 hours• Healthy pre-term infants with PCA 46 to 60

weeks – 6 hours (12 hours if given opioids or other medications with significant respiratory depressant effects)

• Patients, who develop apnea during observation, warrant prolonged observation until they are free of apnea for at least 12 hours.

• In some patients with frequent apneic episodes, caffeine administration may be appropriate.

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