sedation and anesthesia represent different points on a continuum of responses. degree of response is dependent on: 1. 2. 3. patient factors also influence patient response: 1. 2. 3.

1. dose 2. route and rate 3. synergy of drugs patient factors also influence patient response: 1. age 2. weight 3. medical conditions

Knowledge of drugs necessary to provide effective conscious sedation without progression to anesthesia. Defined by _____________ effect and NOT by ______________.

defined by INTENDED EFFECT not by ROUTE OF ADMINISTRATION.

1980s: only 3 types of anesthesia: general, regional, and local/standby TEFRA: tax equity and fiscal responsibility act of 1982: acknowledged standby anesthesia as a physician anesthesia service and thus supported its reimbursement under Medicare part B “Standby” was interpreted variably- to eliminate the confusion: ASA developed concept: __________________________

MONITORED ANESTHESIA CARE (1986)

1998: MAC redefined: with introduction of SEDATION CONTINUUM - MAC specifically involves the administration of medication in doses which may result in: ____________________________________________________ And if for an extended time the patient is unconscious or loses protective reflexes the anesthesia care shall be considered General Anesthesia.

LOSS OF PROTECTIVE REFLEXES OR CONSCIOUSNESS

2003: propofol use blurred lines: further differentiated by 4 components: 1. 2. 3. 4.

1. Responsiveness to stimuli 2. Airway maintenance 3. Spontaneous ventilation 4. Cardiovascular effects

MAC: monitored anesthesia care - “the administration of drugs with anxiolytic, hypnotic, analgesic and amnestied properties, either alone or as a supplement to a local or regional technique” – usually just not MAC alone - Describes a specific anesthesia service in which an anesthetist has been requested to participate in the care of a patient undergoing a diagnostic or therapeutic procedure…if you’re in the room its considered MAC - It does not describe THE CONTINUUM OF ___________________

It does not describe THE CONTINUUM OF DEPTH OF SEDATION

Goals of MAC/Conscious Sedation: 1. 2. 3.

1. comfort- anxiolysis, amnesia, analgesia (not pain free) 2. safety- continuous monitoring 3. satisfaction

Moderate/Conscious Sedation 1. responsiveness: 2. airway: 3. spontaneous ventilation: 4. caridovascular function:

1. responsiveness: purposeful response to verbal or tactile stimuli 2. airway: no intervention 3. spontaneous ventilation: adequate 4. caridovascular function: usually maintained

Minimal Sedation (anxiolysis): 1. responsiveness: 2. airway: 3. spontaneous ventilation: 4. caridovascular function:

1. responsiveness: normal response to verbal stimuli 2. airway: unaffected 3. spontaneous ventilation: unaffected 4. caridovascular function: unaffected

Deep Sedation: 1. responsiveness: 2. airway: 3. spontaneous ventilation: 4. caridovascular function:

1. responsiveness: purposeful response to REPEATED OR PAINFUL stimuli 2. airway: intervention may be required: ORAL/NASAL AIRWAY 3. spontaneous ventilation: may be inadequate 4. caridovascular function: usually maintained

General Anesthesia: 1. responsiveness: 2. airway: 3. spontaneous ventilation: 4. caridovascular function:

1. responsiveness: UNAROUSABLE even to painful stimuli 2. airway: intervention often REQUIRED 3. spontaneous ventilation: FREQUENTLY INADEQUATE 4. caridovascular function: may be IMPARIED

Minimal Sedation: Unaffected: 1. responsiveness 2. airway 3. spontaneous ventilation 4. caridovascular function Affected: 1. 2.

1. cognitive function 2. coordination

drug induced depression of consciousness:

Moderate/Conscious

drug induced state

minimal

REAL drug induced depression of consciousness

deep

drug induced loss of consciousness

general

respiratory function may be diminished but no intervention other than noninvasive oxygen required:

moderate/conscious

Requries qualified anesthesia provider:

deep

What does managing the continuum mean?

• Managing the Continuum o Not always possible to predict how an individual will respond o Individual administering > “rescue” abilities o Moderate sedation > deep sedation o Deep sedation > general anesthesia

Our role as a Consultant for RN administer conscious sedation: 1. develop policies 2. 3. 4. 5.

Consultant for RN administer conscious sedation: 1. Develop policies 2. Provide emergency training 3. Teach pharm principles 4. Ensure adequate monitoring/safety precautions 5. Conduct quality assurance surveillance

Joint Commision: Requries hospital or facility to 1. 2. JC does NOT tell us: Staffing requirement:

1. Requires hospital to have clear policies for administration of moderate/deep sedation and that the provider has credentials to manage whatever level of sedation occurs Standards are also 4 levels Staffing, monitory, documentation 2. Facility must have education/credentialing mechanism which provides a process to evaluate and document the providers competency JC does NOT tell us: what medications to use, but any medication used that results in moderate sedation be subjected to the standards for anesthesia instead of those for just sedation- AKA if you go and give moderate sedation to a GI clinic- you must give the patient a full anesthesia work up Must be sufficient number of staff, one person qualified to monitor and recover the patient and one person performing the procedure

ASA/AANA Joint Statement: 1. 2. 3.

1. Difference between sedation/analgesia vs conscious sedation 2. Suggests limitations on propofol 3. Non-anesthesia provider requirements  Demonstrate knowledge of A&P, pharm, cardiac arrhythmia, complications related to sedation and analgesia, medications including reversal agents.  Manage compromised airway  Provide adequate oxygenation and ventilation  Sate and competent operation of emergence equipment  BLS, ACLS  Documentation of competency

Patient Requirements prior to sedation/analgesia: 1. 2. 3. 4. 5.

1. Consent for sedation and analgesia 2. Documentation of TWO patient exams -One at time before procedure -One immediately prior to starting procedure (include complete vital signs) 3. Airway exam, clerical ROM, dentition, mallampati 4. ASA status 5. NPO appropriate

Routine Equipment:

o Positive pressure oxygen delivery system capable of giving 100% oxygen with backup supply o Variety of oxygen masks, airways (ETT, LMA, oral, nasal) o Reliable source of adequate suction o Continuous ECG o Pulse oximetry o BP cuff o Crash cart- with supplies o Emergency meds and reversals (naloxone/flumazenil) o Communication device- phone o IV access- must have continuous IV access if receiving sedation

Patient Evaluation:

o Abnormalities of major organ systems o Previous adverse effects from sedation/anesthesia o Current medications o drug allergies o History of ETOH, tobacco, drugs o Last oral intake o Focused physical exam  Auscultation of heat and lungs

MAC- why not conscious sedation? 1. 2. 3.

1. surgeon request (in conjunction with local, regional, blocks) 2. patient medical condition/history indicates 3. in conjunction with neuraxial or extremity block

MAC procedure selection: 1 2 3 4 5 6 7 8

o Duration less than 2 hours o Minimal risk of bleeding o Low incidence of postoperative pain o Minimal physiologic derangement o Gentle surgeon o Cooperative patient- remain immobile o Ease of converting to plan B o Supplement blocks by surgeon or anesthesia  Eyes, dental, vascular, orthopedic/podiatry, urology

MAC Failure: 1 2 3 4 5

o Inadequate/excessive local o Painful position o Uncooperative patients o Paradoxical effects from sedation- propofol o Medication choices: high doses, multiple sedating agents, rapid IV administration

Patients Increased Risk of complications with sedation: 1 2 3 4 5

o Young and elderly o Obesity o Multiple allergies o OSA o Cardiac disease and metabolic derangements o Hemodynamic compromise o Pulm: COPD, asthma o GERD: impaired GI motility o Coagulopathy o Anatomical structure abnormalities in face and neck o Neurological abnormalities- epilepsy o Severe hepatic or renal dysfunction

MAC meds: categories 1. 2. 3. 4.

1. supplemental oxygen- required if you plan to alter consciousness 2. inhaled agents- nitrous oxide 3. sedative/anxiolytic/hypnotic 4. narcotic

Required if you plan to alter consciousness:

oxygen

Midazolam (Versed) causes: 1. 2. 3. 4. 5.

1. anterograde amnesia 2. anxiolysis 3. profound sedation 4. synergistic with narcotics 5. mild decrease BP and increase HR reduce dose with elderly and hepatic dysfunction 2-7.5mg alone or 1-2mg with propofol

Chloral Hydrate OD Symptoms: 1. 2. 3. 4. 5.

1. hypothermia 2. pinpoint pupil 3. hypotension 4. coma 5. shallow breathing

Flumazenil dose:

0.2 mg over 15 seconds (repeat 60 second intervals until 1mg)

Synergistic with narcotics: 1. 2.

1. midazolam (versed) 2. propofol

Propofol produces: 1. BP and HR 2. 3. 4. 5. 6.

1. BP/HR 30% decrease 2. antiemetic 3. antipruritic 4. myoclonus 5. anaphylaxis (egg allergy) 6. bacterial contamination

Katamine: hypnotic: 1. 2. 3. 4. dose:

1. dissociate state with profound analgesia 2. copious secretions 3. emergence delirium 4. 20-40mg

Adverse Effects of Fentanyl: 1. 2. 3. 4.

1. chest wall rigidity 2. cough reflex 3. N/V 4. pruritus

Remifentanil: 1. 2. ideal: 3. not ideal: 4. adverse: 5. synergistic with:

1. rapid on/off 2. ideal: blocks, no chance of pain after 3. not ideal: pain control 4. adverse: muscle wall ridigity, pruritis, headache, N/V 5. synergistic with sedatives and hypnotics

Narcan dose:

0.1-0.4mg slowly

Special Preparation of Ketamine and Propofol: 1. 2.

1. 1mg ketamine per mL propofol 2. give versed FIRST o Wider range of safety when given together  Propofol= respiratory depression and bradycardia  Ketamine= respiratory intact and tachycardia

o Wider range of safety when given together  Propofol= respiratory _____________  Ketamine= respiratory __________

o Wider range of safety when given together  Propofol= respiratory depression and bradycardia  Ketamine= respiratory intact and tachycardia

ASA regarding MAC: If the patient __________________________, it is considered GENERAL ANESTHESIA whether the airway ___________________.

If the patient loses consciousness and the ability to respond purposefully, it is considered GENERAL ANESTHESIA whether the airway is instrumented or not.

DC home criteria: 1 2 3 4 5 6 7 8 9 10

• DC home criteria o Alert and oriented to baseline o Vital signs within 20% baseline and stable for 30 min o Spo2 94% room air (or baseline) o No significant pain or bleeding o Minimal N/V o At least 2 hours since reversal dose o Ambulate unassisted o Voiding o No apparent complication o Document attainment of criteria

why do we clearly define MAC: 1. 2.

1. money: Medicare requirement for reimbursement 2. safety: sedation conducted by someone capable of managing possible risks of respiratory depression and airway compromise

Most common damaging mechanism of MAC:

respiratory depression by sedative/opioid overdose

supplemental oxygen can delay _____________ as dangerous levels of ________ build up.

desaturation CO2

__________ may be the initial signals event of hypoxemia.

cardiac arrest