Pre sedation phase

Wesam Farid Mousa

Assist prof Anesthesia & ICUDammam University , KSA

Informed Consent, Levels of Sedation, Getting Started, Equipment Needs, Standard Monitoring, Timeout

Informed Consent

Needed from all patients undergoing procedural sedation

Consent will be obtained by the physician:Consent is a process not a signature

- Options for care

- Explanation of risks

Levels of Sedation

Understanding the various depths of sedation is essential to provide safe and effective sedation

The American Society of Anesthesiologists (ASA) has defined the various sedation depths, as follows:

Levels of Sedation

Patency of the Airway

Response to tactile stimulation and verbal commands

Co-ordination

Cognitive function

Ventilatory function

Cardiovascular function

Minimal sedation (anxiolysis)

The patient retains ability to independently and continually maintain an airway and respond normally to tactile stimulation and verbal command.

Although cognitive function and coordination may be modestly impaired, ventilatory and cardiovascular functions are unaffected.

The key word here is the ability of the patient to remain in a conscious state. Even though there may be a modest impairment of cognitive ability, they can still respond to you in a normal manner

For example, I can ask them a question or lightly tap them on the shoulder and they can respondSwallowing reflexes are intact and they have no problem breathing on their own

The individual who is minimally sedated is still able to function in a somewhat normal fashion. Maybe we can say the patient is awake but drowsy

Patients at this level of sedation would be given a drug in an

amount equal to or less than the minimal recommended dose

(MRD)



Co-ordination

Cognitive function



The patient’s retains ability to independently and continually maintain an airway and respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

Their cognitive function and co-ordination are noticeably influenced. Ventilatory and Cardiovascular function are usually maintained.

Moderate sedation (Conscious sedation)

The key word here is purposeful. This person may be asleep, but he can be easily aroused. The patient can respond in a purposeful manner to verbal commands or light tactile stimulation. I can still ask the patient a question or tap them on the shoulder and they can respond, but it is purposeful. What does purposeful mean?

He can respond, but has to think about what he is

saying.

متأنيdedicated

This person would be obviously sedated, but still able to function. They should not be allowed to drive home. They would endanger themselves and others.

All swallowing reflexes are intact and they have no trouble breathing on their own.

For those who have had received a colonoscopy, with moderate sedation. They would probably describe it as a pleasant experience, in which they remembered very little, if anything.

The starting dose would be the MRD increased in increments



Co-ordination

Cognitive function



Deep sedation

The patient may lose the ability to maintain an airway and breath on their own. The patient is unable to respond purposefully to physical stimulation or verbal command. You have to shake him or arouse him with a painful stimulus to awaken him.

They are asleep but difficult to arouse Their cognitive function and co-ordination are no longer preserved. Ventilatory and Cardiovascular function are usually maintained.

There is partial or complete loss of protective reflexes particularly the swallowing reflex. If they were to regurgitate, they could very well asphyxiate on their own vomit.



Co-ordination

Cognitive function



this is an induced state of unconsciousness that's accompanied by partial or complete loss of protective reflexes, including the inability to continually maintain an airway independently or respond purposefully to verbal commands or physical stimulus.

General Anesthesia

The key word here is unconsciousness. The patient cannot be aroused by shaking or painful stimulation. You can cut a patient with a scalpel and they will not respond.

Protective reflexes such as swallowing are obviously impaired and the patient may not be able to

breathe on their own.

Key words:

Minimal sedation: Normally

Moderate sedation: Purposefully

Deep sedation: Asleep

General Anesthesia: Unconsciousness

Dynamic Sedation Level

The patient’s level of sedation may be dynamic.

Patients may suddenly or gradually experience an increased or decreased level of sedation than intended.

The response to procedural sedation medications is directly related to

the type of drug administered,

the dose, and

the individual’s own response.

Over-sedatedrisk of ventilatory and cardiovascular impairment and loss of protective reflexes

Under-sedated• anxiety and agitation• awareness and recall

Without a means to objectively titrate

the level of sedation,

patients may be:

Incidence of Inappropriate Sedation

Over-sedation

On Target

Under-sedation

54%

15.4%

30.6%

Kaplan L and Bailey H. Critical Care. 2000; 4(1):S110.

Olson D et al. NTI Proceedings. 2003; CS82:196.

10%20%

70%

Kaplan L. and Bailey H. 2000

Olson D. et al.2003

Components of Comfort

Analgesia Muscle Relaxation

Consciousness/Sedation

COMFORT

Autonomic & Somatic Response + Pain Scales

Movement + Nerve Stimulator

Vital Signs + Sedation Scales + BIS Monitoring

Assessment of Sedation Level Ramsay Scale

The goal of moderate (conscious) sedation is to have the patient at level 2 or 3 on the scale

Assessment of Sedation Level

Richmond Agitation and Sedation Scale

Bispectral Index (BIS)

A practical, processed EEG parameter that measures the direct effects of sedatives on the brain

Frontal montage

Numerical scale correla that is patient independent and it is drug independent. It requires no calibration for either the patient or the drugs that are being used.

Provides objective information about an individual patient’s response to sedation

BIS Display / BIS Sensor

BIS Display

BIS Sensor

BIS Range Guidelines

Titration of sedatives to BIS ranges should be dependent upon the individual goals for sedation that have been established for each patient.

These goals and associated BIS ranges may vary over time, in the context of patient status and treatment plan.

BIS in Deep Sedation

Jaspers et al. Intensive Care Medicine. 1999;25(Suppl 1):S67.

• Titration to maximal Ramsay Score of 6 (unarousable)• Blinded BIS monitoring

Results:• Ramsay Score remains the same, with significant decrease of BIS values over time. • Data suggest possible accumulation of sedatives and inherent risks of over-sedation.

0

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Day 1 Day 3 Day 5

BIS

Val

ue

BIS

Ram

say Score*

68

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31

6 6 6

23

4

56

* Mondello et al. Minerva Anestesiology. 2002;68(102):37-43.

Ramsay

BIS in Deep Sedation

Riker. AJRCCM 1999De Deyne. Int Care Med 1998

Unarousable

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100B

isp

ectr

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nd

ex (

BIS

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SAS 1 Ramsay 6

• Titration to unarousable state by subjective scale• Blinded BIS monitoring

Results: • Patients were unarousable at maximal sedation score. • All patients appeared similar clinically, but displayed wide variation in

sedation level as measured objectively with BIS monitoring.SAS=sedation agitation scale

The bispectral index (BIS)

Although the latest recommendations from the

ACEP state that “There is insufficient evidence

to advocate the routine use of BIS in procedural

sedation and analgesia", future studies will

likely assess its utility

The two basic requirements for all procedural sedation are

The continuous monitoring of vital signs by a combination of clinical methods and monitoring devices

The continuous presence of a qualified person who is responsible for patient monitoring and not involved in any other procedures

Equipment Needs, Standard Monitoring,

Be Prepared!

Nothing is more expensive than the missed opportunity

Pre sedation phase

Health & Medicine

Transcript of Pre sedation phase