CV-0590 Prodecural Sedation Record 12108145extcontent.covenanthealth.ca/Policy/vii-b-430 Procedural...
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Page 1 of CV-0590 (2016-09) 2 Side A Procedural Sedation Record Site Procedure Date Time Physician Ordering Sedation Physician Performing Procedure Time of Injury (hh:mm) NA Allergies Height(cm) Weight (kg) BMI: Time of Last Solids (hh:mm) Time of Last Liquids (hh:mm) Name of person to accompany patient at discharge: ___________________________________ Phone: _____________ NA Physician Documentation Patient, site and procedure confirmed Informed consent for the administration of procedural sedation obtained: verbal written Targeted Level of Sedation: Minimal Sedation/ Anxiolysis Deep Sedation/ Analgesia Dissociative Sedation Moderate Sedation/Analgesia General Anesthesia GERD or Hiatus Hernia Yes No Previous cardiac problem Yes No Describe: _______________________________________________ Previous respiratory problems Yes No Describe: _______________________________________________ Previous neurological problems Yes No Describe: _______________________________________________ Previous anesthesia problems Yes No Describe: _______________________________________________ Protruding teeth/dentures in Yes No Adequate opening of mouth Yes No (min. 3 cm or 2 fingers sideways) Uvula visualization All 1/2 1/4 None (no tongue depressor) Small Jaw Yes No (min. 3 fingers from chin to top of thyroid cartilage with neck extended) Adequate neck mobility Yes No (able to flex chin on chest & raise nose above horizontal when sitting) Abnormal baseline vitals Yes No Face or neck trauma Yes No Sleep apnea Yes No Neck circumference > 42.5cm for males / > 40.5 cm for females Yes No BiPAP/CPAP Yes No Smoker Yes No Pack Years ____ Alcohol use Yes No Average weekly ___ Last 12 hours ____ Narcotics &/or CNS/respiratory depressants within last 12 hrs Yes No Describe:________________________________________________ Last Menstrual Period _____________________ ASA Classification I Healthy patient II Mild systemic disease - no functional limitation III Severe systemic disease - definite functional limitation IV Severe systemic disease - constant threat to life V Moribund patient - survival unlikely without procedure Current Medications Physician Name (print) / Signature Nursing Documentation - Pre-Sedation Assessment Vital Signs See page 2 Contact Lenses In Out L.O.C. Alert & Oriented Altered Airway Patent Compromised Breathing Normal Shallow Rapid Laboured SpO 2 _______________ % on RA or Oxygen @ _______________ l/min Skin Normal Pale Cyanotic Moist Dry Warm Cool Other Time (hh:mm) Initials Equipment Checklist Adequate I.V. (if required) Oxygen Continuous SpO 2 Monitor Cardiac Monitor NIBP ETC0 2 (if available) BVM & Oral Airways present Crash cart readily available Suction available & working Reversal drugs available
Transcript of CV-0590 Prodecural Sedation Record 12108145extcontent.covenanthealth.ca/Policy/vii-b-430 Procedural...
Page 1 ofCV-0590 (2016-09) 2 Side A
Procedural Sedation Record
SiteProcedure Date TimePhysician Ordering SedationPhysician Performing ProcedureTime of Injury (hh:mm) NAAllergiesHeight(cm) Weight (kg) BMI: Time of Last Solids (hh:mm) Time of Last Liquids (hh:mm)Name of person to accompany patient at discharge: ___________________________________ Phone: _____________ NAPhysician Documentation Patient, site and procedure confirmedInformed consent for the administration of procedural sedation obtained: verbal written
Targeted Level of Sedation: Minimal Sedation/ Anxiolysis Deep Sedation/ Analgesia Dissociative Sedation Moderate Sedation/Analgesia General Anesthesia
GERD or Hiatus Hernia Yes No Previous cardiac problem Yes No Describe: _______________________________________________Previous respiratory problems Yes No Describe: _______________________________________________Previous neurological problems Yes No Describe: _______________________________________________Previous anesthesia problems Yes No Describe: _______________________________________________Protruding teeth/dentures in Yes No Adequate opening of mouth Yes No (min. 3 cm or 2 fingers sideways)Uvula visualization All 1/2 1/4 None (no tongue depressor) Small Jaw Yes No (min. 3 fingers from chin to top of thyroid cartilage with neck extended)Adequate neck mobility Yes No (able to flex chin on chest & raise nose above horizontal when sitting)Abnormal baseline vitals Yes No Face or neck trauma Yes No Sleep apnea Yes No Neck circumference > 42.5cm for males / > 40.5 cm for females Yes NoBiPAP/CPAP Yes No Smoker Yes No Pack Years ____Alcohol use Yes No Average weekly ___ Last 12 hours ____Narcotics &/or CNS/respiratory
depressants within last 12 hrs Yes No Describe:________________________________________________
Last Menstrual Period _____________________ASA Classification I Healthy patient II Mild systemic disease - no functional limitationIII Severe systemic disease - definite functional limitation
IV Severe systemic disease - constant threat to life V Moribund patient - survival unlikely without procedure
Current Medications
Physician Name (print) / Signature
Nursing Documentation - Pre-Sedation AssessmentVital Signs See page 2Contact Lenses In Out L.O.C. Alert & Oriented Altered Airway Patent Compromised Breathing Normal Shallow Rapid Laboured
SpO2 _______________ % on RA or Oxygen @ _______________ l/min Skin Normal Pale Cyanotic Moist Dry Warm Cool Other
Time (hh:mm) InitialsEquipment Checklist Adequate I.V. (if required) Oxygen Continuous SpO2 Monitor Cardiac Monitor NIBP ETC02 (if available) BVM & Oral Airways present Crash cart readily available Suction available & working Reversal drugs available
Procedural Sedation RecordProcedural Sedation Quick Reference
Note: Refer to Provincial or Zone Monographs for full reference information.
Drug
Route
InitialDose
(titrate to effect)
Special Consideration
Max Dose
Administer(X) Minutes
Prior to Procedure
PregnancyClass
LactationRecommendation
Midazolam IV Adult:0.5 -2.5mg
Direct IV (diluted or undiluted) over 2 minsReduce dose if age >55 yr, debilitated or chronically illUsual total dose 2.5-5 mg
1-5 min D *Caution.No breast feeding for the next 24 hr
Peds:0.05-0.2mg/kg
Direct IV (diluted or undiluted) over 2-5 minRepeat every 2-3 min as neededMax dose 5 mg
1-5 min
IN Peds:0.2-0.3 mg/kg/dose
½ dose to each nare over 15-30 secsMay repeat in 10-15 min if age greater than 6 monthsLarge volumes difficult to administer.
10-20 min
PO Peds:6 mos or older:0.25 to 0.5mg/kg
Give as a single dose (maximum 20mg)Higher doses (1mg/kg PO) can be used for uncooperative patients0.25mg/kg PO usually sufficient for cooperative or older children (6-16yo)
30-45 mins
FentaNYL IV Adult:0.5 to 1.5 mcg/kg IV
Direct IV (50 mcg/mL Concentration) over 1-3 min up toMAX of 100 mcg/minuteAdjust dosing in elderly
1-5 min B **NotRecommended
Peds: 1-3 mcg/kg Direct IV (50 mcg/mL concentration) over 2-5 min 1-5 min
IN Neonates:1 to 2 mcg/kg/dose
Give every 30-60 min as neededMax: 5mcg/kg/dose
5-15 min C
Infants:1 to 2 mcg/kg/dose
Give every 30-60 min as neededMax: 5mcg/kg/dose
Peds: 1 to 12years:1-3mcg/kg/dose
Give every 30-60 min as needed
12 years and older:0.5 to 1 mcg/kg/dose
Give every 30-60 min as needed
Ketamine IV Adult:0.2-0.75 mg/kgPeds: 0.5–2 mg/kg
Slow direct IV over 1-3 minDilute 50 mg/mL – with equal volume diluent. 10 mg/mLdoes not require further dilutionContraindications: Children less than 3 months of age; Pulmonary infections.
1-2 min B **NotRecommended
IM Adult: 2-4 mg/kgPeds: 3-6 mg/kg
7-10 min C
Propofol IV Adult: 0.5-1.5 mg/kg Direct IV (undiluted) over 3-5 minTitrate slowly to desired effect – i.e. every 30 secUse with caution in elderly, debilitated or ASA 3 and 4 patients; Contraindicated if allergy to eggs or soybeans No known reversal agent
1-3 min C **NotRecommended
Peds:1 mg/kg Not recommended less than 3 years of ageDirect IV (undiluted) over 1-2 min to MAX dose 40 mg. Repeat dose of 0.5 mg/kg to maximum of 20 mg may be given
Antagonist Note: If used, Patient must be Observed for an Additional 2 hours.Naloxone IV Adult:
0.1-0.4 mg/doseDirect IV (diluted or undiluted) over 15 -30 secRepeat every 2-3 minutes as needed. MAX dose 0.8 mg
1-2 min *Caution
Peds(0.01-0.1 mg/kg)
Direct IV (diluted or undiluted) over 30 secRepeat every 2-3 minutes as needed0.01 mg/kg dosing probably adequate for procedural sedation depending on dose of opioid administered
Flumazenil IV Adult: 0.2 mg Direct IV over 15 secs. Can repeat every 60 secs. MAXdose 1 mg
1-3 min *Caution
Peds: 0.01 mg/kg Direct IV (diluted or undiluted) over 15-30 secMay repeat every 60 sec. MAX total dose 0.05 mg/kg or1 mg (whichever is less)
*Caution = use in the breastfeeding patient may be considered but caution is advised**Not recommended = use in the breast feeding patient is not recommendedAdapted from Provincial, Calgary, South Edmonton and North Zone Parenteral manuals July 2015
Page 2 of 2 Side B
Procedural Sedation Record
Page 1 of 2 Side B
Monitoring
Baseline vital signs Intra-procedural monitoring:
• Continuous oximetry• Vital signs every 15 minutes for moderate sedation and immediately following• Vital signs every 5 minutes for deep sedation and immediately following.
Post procedure: Vital signs every 15 minutes for at least 30 minutes, and:• Aldrete score of 8 or greater is achieved, and/or• Patient returns to baseline
Patients who experience a procedural complication or require a reversal agent must be monitored for a minimum of2 hours post procedure and achieve an appropriate Aldrete score prior to being discharged.
Note: Monitor ETCO2 (if available) in patients targeted for deep sedation. It is optional for patients targeted for light or moderate sedation. Electrocardiogram monitoring is strongly advised in patients where underlying cardiopulmonary disease (e.g. previous myocardial infarction or dysrhythmia) may impact the patient outcomes during or post-procedure. Document in patient care record.Refer to Covenant Health Corporate Policy & Procedure #VII-B-430 Procedural Sedation for more information.
*Aldrete ScoreColor
2 - Normal
1 - Pale, blotchy, dusky
0 - Cyanotic
LOC
2 - Awake & oriented.
1 – Arousable
0 - Not responding
Ventilation
2 - Can cough & deep breathe
1 - Labored or limited
0 - Apneic
Circulation
2 - BP ± 20% of pre-op
1 - BP ± 20-50% of pre-op
0 - BP greater than or equal to 50% of pre-op
Activity
Able to move voluntarily or on command
2 – 4 extremities
1 – 2 extremities
0 – 0 extremities
Page 2of 2 Side A
Procedural/ Post- Procedural RecordingOngoing Assessment/ Treatment/ Response
Time(hh:mm)
P R BP Sp02 ETCO2 AldreteScore
Initials Notes
Baseline Pre-Sedation Vital Signs
See Patient Care Record Vital Sign Record
Medications Time Med/Dose Route Initial Time Med/Dose Route Initial Post- Procedure Assessment Complications (Check all that apply) Level of Sedation Achieved Tolerated procedure without apparent complications Minimal Sedation/Anxiolysis Required advanced airway maintenance Moderate Sedation/Analgesia intubation laryngeal mask Deep Sedation/Analgesia Required administration of reversal agent
General Anesthesia
Hypotension requiring intervention Dissociative Sedation Patient vomited Discharge/Transfer Discharge Transfer to: __________________________________________ Criteria for discharge/ transfer met (Aldrete score of 8 or greater and/or patient’s baseline)Time(hh:mm) ________ Written discharge instructions given to: Patient Parent/guardian Other _______________________ NAStaff Name (print) / Designation Initials Staff Name (print) / Designation Initials
Procedural Sedation Record
Procedural Sedation Record
Page 1 of 2 Side B
Monitoring
Baseline vital signs Intra-procedural monitoring:
• Continuous oximetry• Vital signs every 15 minutes for moderate sedation and immediately following• Vital signs every 5 minutes for deep sedation and immediately following.
Post procedure: Vital signs every 15 minutes for at least 30 minutes, and:• Aldrete score of 8 or greater is achieved, and/or• Patient returns to baseline
Patients who experience a procedural complication or require a reversal agent must be monitored for a minimum of2 hours post procedure and achieve an appropriate Aldrete score prior to being discharged.
Note: Monitor ETCO2 (if available) in patients targeted for deep sedation. It is optional for patients targeted for light or moderate sedation. Electrocardiogram monitoring is strongly advised in patients where underlying cardiopulmonary disease (e.g. previous myocardial infarction or dysrhythmia) may impact the patient outcomes during or post-procedure. Document in patient care record.Refer to Covenant Health Corporate Policy & Procedure #VII-B-430 Procedural Sedation for more information.
*Aldrete ScoreColor
2 - Normal
1 - Pale, blotchy, dusky
0 - Cyanotic
LOC
2 - Awake & oriented.
1 – Arousable
0 - Not responding
Ventilation
2 - Can cough & deep breathe
1 - Labored or limited
0 - Apneic
Circulation
2 - BP ± 20% of pre-op
1 - BP ± 20-50% of pre-op
0 - BP greater than or equal to 50% of pre-op
Activity
Able to move voluntarily or on command
2 – 4 extremities
1 – 2 extremities
0 – 0 extremities
Page 2of 2 Side A
Procedural/ Post- Procedural RecordingOngoing Assessment/ Treatment/ Response
Time(hh:mm)
P R BP Sp02 ETCO2 AldreteScore
Initials Notes
Baseline Pre-Sedation Vital Signs
See Patient Care Record Vital Sign Record
Medications Time Med/Dose Route Initial Time Med/Dose Route Initial Post- Procedure Assessment Complications (Check all that apply) Level of Sedation Achieved Tolerated procedure without apparent complications Minimal Sedation/Anxiolysis Required advanced airway maintenance Moderate Sedation/Analgesia intubation laryngeal mask Deep Sedation/Analgesia Required administration of reversal agent
General Anesthesia
Hypotension requiring intervention Dissociative Sedation Patient vomited Discharge/Transfer Discharge Transfer to: __________________________________________ Criteria for discharge/ transfer met (Aldrete score of 8 or greater and/or patient’s baseline)Time(hh:mm) ________ Written discharge instructions given to: Patient Parent/guardian Other _______________________ NAStaff Name (print) / Designation Initials Staff Name (print) / Designation Initials
Procedural Sedation Record
Page 1 ofCV-0590 (2016-09) 2 Side A
Procedural Sedation Record
SiteProcedure Date TimePhysician Ordering SedationPhysician Performing ProcedureTime of Injury (hh:mm) NAAllergiesHeight(cm) Weight (kg) BMI: Time of Last Solids (hh:mm) Time of Last Liquids (hh:mm)Name of person to accompany patient at discharge: ___________________________________ Phone: _____________ NAPhysician Documentation Patient, site and procedure confirmedInformed consent for the administration of procedural sedation obtained: verbal written
Targeted Level of Sedation: Minimal Sedation/ Anxiolysis Deep Sedation/ Analgesia Dissociative Sedation Moderate Sedation/Analgesia General Anesthesia
GERD or Hiatus Hernia Yes No Previous cardiac problem Yes No Describe: _______________________________________________Previous respiratory problems Yes No Describe: _______________________________________________Previous neurological problems Yes No Describe: _______________________________________________Previous anesthesia problems Yes No Describe: _______________________________________________Protruding teeth/dentures in Yes No Adequate opening of mouth Yes No (min. 3 cm or 2 fingers sideways)Uvula visualization All 1/2 1/4 None (no tongue depressor) Small Jaw Yes No (min. 3 fingers from chin to top of thyroid cartilage with neck extended)Adequate neck mobility Yes No (able to flex chin on chest & raise nose above horizontal when sitting)Abnormal baseline vitals Yes No Face or neck trauma Yes No Sleep apnea Yes No Neck circumference > 42.5cm for males / > 40.5 cm for females Yes NoBiPAP/CPAP Yes No Smoker Yes No Pack Years ____Alcohol use Yes No Average weekly ___ Last 12 hours ____Narcotics &/or CNS/respiratory
depressants within last 12 hrs Yes No Describe:________________________________________________
Last Menstrual Period _____________________ASA Classification I Healthy patient II Mild systemic disease - no functional limitationIII Severe systemic disease - definite functional limitation
IV Severe systemic disease - constant threat to life V Moribund patient - survival unlikely without procedure
Current Medications
Physician Name (print) / Signature
Nursing Documentation - Pre-Sedation AssessmentVital Signs See page 2Contact Lenses In Out L.O.C. Alert & Oriented Altered Airway Patent Compromised Breathing Normal Shallow Rapid Laboured
SpO2 _______________ % on RA or Oxygen @ _______________ l/min Skin Normal Pale Cyanotic Moist Dry Warm Cool Other
Time (hh:mm) InitialsEquipment Checklist Adequate I.V. (if required) Oxygen Continuous SpO2 Monitor Cardiac Monitor NIBP ETC02 (if available) BVM & Oral Airways present Crash cart readily available Suction available & working Reversal drugs available
Procedural Sedation RecordProcedural Sedation Quick Reference
Note: Refer to Provincial or Zone Monographs for full reference information.
Drug
Route
InitialDose
(titrate to effect)
Special Consideration
Max Dose
Administer(X) Minutes
Prior to Procedure
PregnancyClass
LactationRecommendation
Midazolam IV Adult:0.5 -2.5mg
Direct IV (diluted or undiluted) over 2 minsReduce dose if age >55 yr, debilitated or chronically illUsual total dose 2.5-5 mg
1-5 min D *Caution.No breast feeding for the next 24 hr
Peds:0.05-0.2mg/kg
Direct IV (diluted or undiluted) over 2-5 minRepeat every 2-3 min as neededMax dose 5 mg
1-5 min
IN Peds:0.2-0.3 mg/kg/dose
½ dose to each nare over 15-30 secsMay repeat in 10-15 min if age greater than 6 monthsLarge volumes difficult to administer.
10-20 min
PO Peds:6 mos or older:0.25 to 0.5mg/kg
Give as a single dose (maximum 20mg)Higher doses (1mg/kg PO) can be used for uncooperative patients0.25mg/kg PO usually sufficient for cooperative or older children (6-16yo)
30-45 mins
FentaNYL IV Adult:0.5 to 1.5 mcg/kg IV
Direct IV (50 mcg/mL Concentration) over 1-3 min up toMAX of 100 mcg/minuteAdjust dosing in elderly
1-5 min B **NotRecommended
Peds: 1-3 mcg/kg Direct IV (50 mcg/mL concentration) over 2-5 min 1-5 min
IN Neonates:1 to 2 mcg/kg/dose
Give every 30-60 min as neededMax: 5mcg/kg/dose
5-15 min C
Infants:1 to 2 mcg/kg/dose
Give every 30-60 min as neededMax: 5mcg/kg/dose
Peds: 1 to 12years:1-3mcg/kg/dose
Give every 30-60 min as needed
12 years and older:0.5 to 1 mcg/kg/dose
Give every 30-60 min as needed
Ketamine IV Adult:0.2-0.75 mg/kgPeds: 0.5–2 mg/kg
Slow direct IV over 1-3 minDilute 50 mg/mL – with equal volume diluent. 10 mg/mLdoes not require further dilutionContraindications: Children less than 3 months of age; Pulmonary infections.
1-2 min B **NotRecommended
IM Adult: 2-4 mg/kgPeds: 3-6 mg/kg
7-10 min C
Propofol IV Adult: 0.5-1.5 mg/kg Direct IV (undiluted) over 3-5 minTitrate slowly to desired effect – i.e. every 30 secUse with caution in elderly, debilitated or ASA 3 and 4 patients; Contraindicated if allergy to eggs or soybeans No known reversal agent
1-3 min C **NotRecommended
Peds:1 mg/kg Not recommended less than 3 years of ageDirect IV (undiluted) over 1-2 min to MAX dose 40 mg. Repeat dose of 0.5 mg/kg to maximum of 20 mg may be given
Antagonist Note: If used, Patient must be Observed for an Additional 2 hours.Naloxone IV Adult:
0.1-0.4 mg/doseDirect IV (diluted or undiluted) over 15 -30 secRepeat every 2-3 minutes as needed. MAX dose 0.8 mg
1-2 min *Caution
Peds(0.01-0.1 mg/kg)
Direct IV (diluted or undiluted) over 30 secRepeat every 2-3 minutes as needed0.01 mg/kg dosing probably adequate for procedural sedation depending on dose of opioid administered
Flumazenil IV Adult: 0.2 mg Direct IV over 15 secs. Can repeat every 60 secs. MAXdose 1 mg
1-3 min *Caution
Peds: 0.01 mg/kg Direct IV (diluted or undiluted) over 15-30 secMay repeat every 60 sec. MAX total dose 0.05 mg/kg or1 mg (whichever is less)
*Caution = use in the breastfeeding patient may be considered but caution is advised**Not recommended = use in the breast feeding patient is not recommendedAdapted from Provincial, Calgary, South Edmonton and North Zone Parenteral manuals July 2015
Page 2 of 2 Side B
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