1. IV Moderate Sedation

2. Definition
I.V. moderate sedation should produce
an altered sensory condition in which
the patient exhibits an altered
(depressed) level of consciousness
while maintaining the ability to
independently and continuously
maintain a patent airway and respond
appropriately to verbal stimuli.

3. Protective Reflexes
Loss of reflexes, including the
inability to maintain a patent airway
and/or purposeful response to
physical and/or verbal stimulation as
a result of a systemically
administered drug.

4. Location
Operating Room
PACU
Endoscopy
Outpatient Center
Critical Care Unit (ICU)
Emergency Department

5. Scope
All moderate sedation will be ordered
and directly supervised by the
physician performing the procedure.
Administration and/or monitoring of
monitored sedation may be performed
by a qualified physician privileged
or a registered nurse trained in
administering or monitoring conscious
sedation.

6. Scope
A physician may waive NPO guidelines
under any emergency conditions, which
will be noted in the medical record
Patients with severe systemic disease
present on the day a procedure under
monitored sedation is scheduled may
require a sub-specialty consultation
and/or anesthesia provider

7. Scope
Patients with severe systemic disease
present on the day a procedure under
monitored sedation is scheduled may
require a sub-specialty consultation
and/or anesthesia provider

8. Scope
Any Patient Receiving Propofol or
Ketamine
Patients under 60 years of age who
receive intravenously >5mg of Versed
or >20mg of Valium.
Patients 60 years of age and older
who receive intravenously >2mg of
Versed or >10mg of Valium

9. Scope
Patients receiving any combination of
IV narcotic and Versed or Valium.

10. Pediatric Patients
Demerol combined with Phenergan or
Thorazine.
Chloral Hydrate
PO Fentanyl
PO Versed
Rectal Brevital

11. Physician
Responsibilities
Providing the level of monitoring
specified in these guidelines and to
manage complications.
The practitioner should be trained in
and capable of providing basic life
support (ACLS Recommended)

12. Physician
Responsibilities
Being present when medications for
moderate sedation are administered.
Be within immediate reach and
available on the hospital premises if
problems or emergencies arise.

13. Physician
Responsibilities
Authorizing the administration of the
sedation within the recommended
sedation dosage guidelines.
Writing a post-procedure note and
discharge orders.
Determining that the patient is an
appropriate candidate for the
sedative agent to be administered.

14. Pre-Procedure
Evaluation
Patient’s age
Chief complaint
Current medications
History of medication allergies/
reactions
Overall physical status

15. Pre-Procedure
Evaluation
Concurrent medical problems
History of substance abuse
Verification of patient compliance
with pre-procedure instructions
(Informed Consent for the procedure
to be performed)

16. Pre-Procedure
Evaluation
Discussion of risks, benefits, and
alternatives
Physical examination pertinent to the
history and procedure to be performed

17. ASA Classification
Class I normal healthy patient
Class II patient with mild systemic
disease
Class III patient with severe
systemic disease with functional
limitations
Class IV patient with severe
systemic disease that is constant
threat to life

18. RN Responsibilities
Adequate transportation and
postoperative care arrangements made
for discharge.
History and Physical present in the
medical record.
Proper consent(s) signed for the
procedure.

19. RN Responsibilities
Verify the patient has been NPO
Verify allergies.
Verify pregnancy status
Assure recent lab results are
available in the medical record.
Document baseline vital signs

20. RN Responsibilities
Document baseline SaO2 (room air if
O2 therapy not being implemented)
Complete a pre-procedure assessment.
Assure a patent IV access
Verify equipment is functioning
properly prior to use.

21. RN Responsiblities
Document emotional state.
Document level of consciousness.
Document skin signs
Verify perceptions regarding
procedures and level of sedation.

22. Goals And Obectives
Allay patient fears and anxiety
regarding the planned procedure(s)
Alteration in mood
Maintenance of consciousness
Cooperation
Elevation in pain threshold

23. Goals And Objectives
Minimum variation of vital signs
Amnesia
Rapid, safe return to ambulation

24. RN Responsibilities
Administer medications as directed by
the privileged physician present.
Notify physician of any significant
change in the patient’s physiologic
status.

25. RN Responsibilities
The nurse managing the sedation of
the patient shall have no other
responsibilities that would interfere
with continuing monitoring care,
physical care, and emotional support.

26. Equipment
Oxygen delivery in place
Pulse oximetry equipment in place
An I.V. access line established and
patency maintained
Cardiac and blood pressure monitoring
in place

27. Equipment (Present &
Available)
There shall be an emergency code cart
immediately available with emergency
resuscitative drugs and
defibrillator.
Oxygen and appropriate O2 delivery
systems
Suction and appropriate suction
equipment

28. Equipment (Present &
Available)
Bag, valve, mask breathing devices
Oral/nasopharyngeal airways and
endotracheal tubes of various sizes
Sphygmomanometer and/or non-invasive
blood pressure monitor
EKG monitor

29. Equipment (Present &
Available)
Pulse oximeter
Pharmacologic antagonists: Narcan
and Romazicon (Flumazenil)

30. Monitoring
Respiratory rate
O2 saturation
Blood pressure
Cardiac rate and rhythm
Level of consciousness (Aldrette
score)
Skin condition

31. Aldrette Score
Activity
Able to move 4 extremities……………2
Able to move 2 extremities………….1
Able to move 0 extremities……………0

32. Aldrette Score
Respiration
Deeply breathes, coughs freely………2
Dyspnea or limited breathing…………1
Apneic………………………………………………….......0

33. Aldrette Score
Circulation
Systolic BP +/- 20 mmHg pre-procedure
level………2
Systolic BP +/- 20 mmHg–50mmH Pre-
procedure level……………………………1
Systolic BP +/- 50 mmHg pre-procedure
level………… 0

34. Aldrette Score
Consciousness
Fully awake……………………………………………. 2
Arises on calling…………………………………1
Unresponsive…………………………………………… 0

35. Aldrette Score
Color
Pink………………………………………………...........2
Pale, dusky, blotchy, jaundiced……1
Cyanotic……………………………………………........0

36. Continuous
Monitoring
Desired therapeutic effects
Adverse effects with appropriate
intervention/prevention of these
adverse effects.
Early detection of non-preventable
adverse effects
Patient’s response

37. Continuous
Monitoring
Assess and document vital signs at a
minimum of every 5 minutes or more
frequently during drug administration
and during the procedure.

38. Post Procedure
Monitoring
Vital signs (BP, EKG/HR, RR)
Oxygenation (SaO2)
Level of consciousness and Return to
pre-sedation status

39. Post Procedure
Monitoring
Assess and document vital signs at a
minimum of every 15 minutes x 2, then
every 30 minutes x 2, then every hour
x 2, then every 2 hours x 4
Continuous SaO2 monitoring for a
minimum of 30 minutes, recheck and
document SaO2 immediately prior to
discharge

40. Transfer
Requirements
O2 saturation maintained at pre-
procedure level or >92%, with or
without oxygen, at a respiratory rate
of 12 or greater
Intact protective reflexes, muscular
strength
Able to cough and/or demonstrate gag
reflexes

41. Transfer
Requirements
Respond to verbal commands
Maintain patent airway, independently
and continuously
Absence of restlessness, cyanosis,
pallor, flushing, diaphoresis, or
palpitation
No evidence of bleeding

42. Discharge Criteria
Consciousness: Awake and responding
appropriately, > 1 hour post reversal
drug
Circulation: BP within acceptable
pre-operative levels
Oxygen saturation > or = to 95% in
the unstimulated patient on room air
or equal to pre-procedure saturation.

43. Discharge Criteria
Fluid intake: Taking P.O. fluids
without nausea
Activity level: Ambulate with
minimal assistance with stable BP
Body functions: Patients who have
undergone regional anesthesia,
urological, gynecological, or hernia
procedures must be able to void

44. Discharge Criteria
Stable wound site
Pain within tolerable limits with/
without P.O. medication
Adequate neurovascular status of
operative extremity (if applicable)
Modified Aldrette score of 8 or
greater

45. Dishcarge Criteria
If the patient does not meet the
above criteria, a discharge order
must be obtained from the surgeon
and/or consulting Anesthesiologist/
CRNA.
If the above criteria are not met
after four hours, the attending
physician should be notified.

46. Documentation
The Local/ Moderate Sedation
Operative Record will be utilized for
all patients receiving conscious
sedation in every patient care area.

47. Documentation
The Emergency and Critical Care
Departments may utilize only the
graph portion of the Local/ Monitored
Sedation Operative Record if all
other pertinent information is
documented on the Emergency
Department Clinical Record or the
Critical Care Flow Sheets.

48. Documentation
Shall reflect evidence of continuous
assessment, diagnosis, outcome,
identification, planning,
implementation, and evaluation of
care

49. Documentation
Patient care management immediately
before administration of monitored
sedation drugs, during the sedation
phase, and immediately post-procedure
(recovery).
Dosage, route, time and effects of
drugs used
Type and amounts of fluids

50. Documentation
Physiologic data from continuous
monitoring at a minimum of 5 minute
intervals and with any significant
event during the procedure.
Level of consciousness

51. Documentation
Significant adverse patient events
with corrective action taken and
effects of action taken.
Condition at transfer in the event
the patient is transferred to another
patient care area

52. Reportable
Conditions
Deep sedation (unintended)
Unexpected Phase I recovery
Assisted Ventilation is required.
There is an unanticipated hospital
admission and/or an increased level
of care required

53. Reportable
Conditions
Any case in which the SaO2 remains <
90% or 3% less than baseline for more
than three (3) minutes after O2
administration.
Any case in which SaO2 is 80% or less
at any time.

54. Reportable
Conditions
Any case in which there is
hemodynamic instability (defined as a
20% change from baseline blood
pressure or heart rate) requiring
medications and/or medical
interventions.
A reversal agent is administered

55. Reportable
Conditions
Lack of adherence to hospital policy
on Moderate Sedation.
ET intubation
Cardiac arrest
Adverse medication reaction

56. Reportable
Conditions
Prolonged recovery from sedation (> 2
hours post procedure)
Patient, family, or staff complaint
regarding quality of sedation/
analgesia.
Unexpected need for Anesthesiologist/
CRNA

57. Qualifications
Physicians intending to use agents
for the purpose of monitored sedation
must be specifically privileged.
Anesthesiologists, CRNAs, Board
Certified Physicians in Critical Care
(Adult & Pediatric) and Board
Certified Physicians in Emergency
Medicine will be granted privileges.

58. RN Qualifications
RNs who monitor patients receiving
I.V. moderate sedation will have
completed competencies in Moderate
Sedation.
The nurse monitoring the patient care
shall be aware of the desirable and
undesirable effects of I.V. moderate
sedation.

59. RN Qualifications
The nurse shall have the knowledge
and skills to intervene in the event
of a complication.

60. Desirable Effects
Intact protective reflexes
Relaxation
Cooperation
Diminished verbal communication
Easy arousal from sedation

61. Undesirable Effects
Nystagmus
Unarousable sleep/sedation
Hypotension
Agitation
Combativeness
Hypoventilation

62. Undesirable Effects
Respiratory Depression
Airway obstruction
Apnea

63. RN Qualifications
The nurse monitoring the patient
shall have a working knowledge of
resuscitation equipment and the
function and use of monitoring
equipment and should be able to
interpret the data obtained.

64. RN Qualifications
The nurse shall demonstrate skills in
basic life support and have Current
BLS recognition. ACLS is
recommended.

65. RN Qualifications
Anatomy and physiology
Pharmacology of drugs used
Cardiac arrhythmia interpretation

66. RN Qualifications
Complications related to the use of
I.V. conscious sedation
Principles of oxygen delivery and
respiratory physiology
Demonstrate knowledge of proper
dosages, administration, adverse
reactions, and interventions for
adverse reactions and overdoses.

67. RN Qualifications
Assess total patient care
requirements or parameters, including
but not limited to respiratory rate,
oxygen saturation, blood pressure,
cardiac rate and rhythm, and level of
consciousness.

68. Benzodiazepines
Most common are midazolam (Versed®),
diazepam (Valium®), and lorazepam
(Ativan®)
Most often administered for sedation
and amnesia or as adjuncts to general
anesthesia (usually a pre op med)

69. Benzodiazepines
CNS – amnestic, anticonvulsant,
hypnotic, muscle relaxant, and
sedative effects in a dose dependent
manner.
Cardiovascular – mild systemic
vasodilatation and reduction in
cardiac output (more pronounced with
added narcotic)

70. Benzodiazepines
Respiratory – mild decrease in RR and
tidal volume (more pronounced with
added narcotic)
Reversal of benzodiazepines is
accomplished with flumazenil if
needed (antagonist)
May cause venous irritation

71. Narcotics
Fentanyl and sufentanil are the major
narcotics used intraoperatively.
Morphine, demerol, and fentanyl are
the major narcotics used
postoperatively.
In high doses, narcotics are
occasionally employed as the sole
anesthetic (e.g. cardiac surgery)

72. Narcotics
Primary effect is analgesia, and
therefore they are used primarily to
supplement other anesthetics during
induction or maintenance of general
anesthesia.

73. Narcotics CNS
Sedation and analgesia
Euphoria also common.
In large doses amnesia and loss of
consciousness.
Demerol can cause Seizures

74. Narcotics
Cardiovascular
SVR moderately reduced
Demerol a direct myocardial
depressant.
Enhance myocardial depressant effects
of other anesthetics
Bradycardia in a dose-dependent
manner (eg fentanyl)
Morphine and Demerol can cause
histamine release

75. Narcotics
Respiratory depression in a dose-
dependent manner.
Miosis may be a useful guide in the
assessment of narcotic effect
Muscle rigidity
Nausea and vomiting
Urinary retention

76. Narcotics
Fentanyl Quick onset...goes away
quick (peak effect 5-7 minutes)
Morphine peak effect 30 min
Demerol peak effect 15 min

77. Propofol
Used for induction and/or maintenance
of general anesthesia.
Also used in lower doses for sedation

78. Propofol
Rapidly induces unconsciousness with
rapid recovery due to redistribution
of the drug.
Decreases in arterial blood pressure
and cardiac output in a dose-
dependent manner (cardiovascular
depressant).
Dose-dependent decrease in
respiratory rate and tidal Volume.