moderate sedation review 2009 part 2: pharmacology

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Moderate Sedation Review 2009

Part 2: Pharmacology

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Pharmacology --Introduction

A variety of medications are used to induce the state of Moderate Sedation in the patient. These medications may be used alone, or in combination. It is important to remember that drugs used in combination may potentiate each other increasing the

effects of the combination to four to ten-times that of the same drugs used individually.

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Recall theGoals of Moderate

Sedation1.     Maintain adequate sedation with

minimal risk to the patient2.      Relieve anxiety and produce amnesia3.      Provide relief from pain and other

noxious stimuli

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Characteristics of Medications Used in MS

Agents used in moderate sedation will have:Short duration of actionRapid recoveryLack of cumulative effectsFew side effects

Desirable: analgesic effects last longer than sedative effects

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IMPORTANT!!Per policy CL.46.  All female patients age 9 (nine) and older must have a negative pregnancy test unless

menopausal surgically menopausal, or currently pregnant.  Before proceeding with moderate sedation....Is your patient pregnant?

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IMPORTANTThe medications used to cause moderate sedation have been shown to have adverse affects on the fetus!!

All female patients 9-years-old or older, that are not menopausal, MUST HAVE HCG TESTING DONE AND NEGATIVE RESULTS RECEIVED BEFORE THE PROCEDURE IS BEFORE THE PROCEDURE IS STARTED.STARTED.

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Clinical Endpoints of Moderate Sedation

Beginnings of slurred speechDecreased anxiety

Goal of Moderate Sedation IS NOT unconsciousness or unresponsiveness!

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End result of Moderate Sedation

To produce a:Pain-free amnesic,Sedated patient whoRecovers rapidly withFew side-effects due to medication.

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IMPORTANT!!Per policy CL.46.  All female patients age 9 (nine) and older must have a negative pregnancy test unless

menopausal surgically menopausal, or currently pregnant.  Before proceeding with moderate sedation....Is your patient pregnant?

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Medication Administration Key Points:

  Give only amount necessary to render the patient calm, cooperative, able to follow

commands   Administered according to Corporate medication

policies   When additional medication is ordered for sedation

after the initial dose: cumulative TOTAL dose will be communicated AUDIBLY to the practitioner (“I just gave 1-mg versed for a TOTAL dose of 2-mg given)

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IV AdministrationOnset is rapid (20-30 seconds)Titration: injection of small increments of drug until desired effects are achievedContinuously monitor patient’s response.

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RN must be knowledgeable about:

Drug names and classificationsAppropriate dosages for patient’s age and conditionIndicationsContraindicationsRecommended dilutionOnset and duration of action.

Expected actionsCompatibility with solutions, and other medicationsPossible side effects /adverse reactionsInterventions for side effectsEmergency management techniques

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Classes of AgentsSedatives

Opioids (morphine, Fentanyl®):

Benzodiazepines (Versed®, Valium®):

Reversal AgentsNarcan®

Romazicon®

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Opioids(e.g., morphine, Fentanyl)

Opioids (morphine, Fentanyl®):Alter the process of pain sensation, and emotional response to painSide effects:

CNS depressionRespiratory depressionNausea and vomitingHypotensionPruritis

Reversal Agent: Narcan®

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OpioidsDrug Dose

Range

IV Onset(minutes)

Clinical Duration(hours)

Comments

Morphine 2-3 mg 5 4

Inject slowly over 4 to 5 minutes

May be diluted with water for injectiondose by 30%if given with

another CNS depressant

Fentanyl 0.3 – 0.5mcg/kg

1-2 1

Has fewer side effectsTitrate in 25 mcg

increments every 2-3 minutes

Remifentanil

0.1-0.25 mcg/kg

1 10 minutes

Rapid induction with rapid elimination

Must be given SLOWLY (over 1 minute)

ReversalAgent Narcan®

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Benzodiazepines(e.g., Versed®, Valium®)

Depress CNS producing muscle relaxation, and anti-anxiety effects.Side effects:

Drowsiness, ataxia, confusionFatigue, headache, weaknessDizziness, vertigo, syncopeAntegrade amnesia

Reversal Agent: Romazicon®

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BenzodiazepinesDrug Dose

Range

IV Onset(minutes)

Clinical Duration(hours)

Comments

Midazolam(Versed®)

2.5 mg 1 1

Titrate SLOWLYInitial dose should not

exceed 2.5 mg administered over a min. of 2 minutes

DO NOT bolusWait 2 minutes between

doses to evaluate patient effects

Diazepam(Valium®)

1-2 mg 5 6

Titrate SLOWLY (over 1 min. for each 5 mg) until slurred speech occurs

Initial titration should not exceed 10 mg

If administered with a narcotic, dose of narcotic by 1/3 titrated slowly.

ReversalAgent

Romazicon(flumazeni

l)

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Reversal AgentsNarcan® (Naloxone)

Blocks effects of opiates

Romazicon® (Flumazenil)

Blocks effects of benzodiazepinesBoth may:

Precipitate withdrawal (seizures), cause increased sympathetic activities (tachycardia,

hypertension, arrhythmias, pulmonary edema)Allow re-sedation to occur (duration of action of

reversal agent is less than that of the sedatives they reverse)

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Reversal AgentsDrug Dose

Range

IV Onset(minutes)

Clinical Duration(hours)

Comments

Naloxone(Narcan®)

0.4 – 2 mg 2 1-4

Titrate slowly to desired effect

Dilute 1 ml ampoule (0.4mg/ml) in 10 ml normal saline

Give 1 ml (.04 mg) every 2-3 minutes until RESPIRATORY DEPRESSION is reversed

Patient must be monitored for up to 90 min. after time of administration

Flumazenil(Romazicon®

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Based on patient

response

1-2 (80% of patients

respond in 3 minutes)

45-90 minutes

Administer through LARGE vein

Give 0.2 mg increments (2 ml) over 15 seconds;

May repeat at 1 minute intervals

Total dose not to exceed 1 mg in 5 minutes

Maximum dose: 3 mg in any 1-hour period

Patient must be monitored for up to 90 min. after time of administration

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And now a word about PROPOFOL…

For years used in the ED as sedative for reducing fractures, in EP lab for procedures, etc.Used in some instances to bring about a state of Moderate SedationPlease note: THE RULES HAVE Please note: THE RULES HAVE CHANGED regarding the Nurse’s CHANGED regarding the Nurse’s role in its administrationrole in its administration

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Procedural Administration of Propofol

Urgent Nursing Practice Memo 12/7/07 issued by Nurse Executive Council, Quality and Patient

Safety states:As per As per Kaleida IV Administration Kaleida IV Administration PolicyPolicy TX.IV’s and MEDS_19, TX.IV’s and MEDS_19, Propofol may be titrated and Propofol may be titrated and administered by an RN administered by an RN only whenonly when a patient’s respiratory status is a patient’s respiratory status is supported by a mechanical supported by a mechanical ventilator.ventilator.

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What about for Moderate Sedation?

The same Nursing Practice memo states:

An RN may not participate in Moderate Sedation when propofol is utilized without active ventilator support

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What does participate mean?

The nurse MAY NOT be responsible for:Administering bolus of PropofolTitration of PropofolMaintenance of the airwayCare and monitoring of the patient

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The Nurse MAYAct as scribe, writing down information on the record formAct as “extra hands”, for example, by providing needed equipment, supplies

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What if I am asked to assist with propofol in a more

active patient monitoring role?

The short answer is to refuse.The longer answer is to discuss questions or concerns with your department manager.

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The reason to refuse….Nursing non-compliance with this New York State Department of Education and Licensure regulation is a NYS reportable event which places your license to practice nursing in jeopardy.

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If you need support for your refusal:

In a memo to the CMOs dated 12/6/07 it was stated:

An RN MAY NOT be the participant who is expected to push / titrate propofol OR assume the care / monitor the patient. It is the drug (propofol) which sets this situation apart.

In the case in ED, EP lab etc. where propofol is being used for moderate sedation:

A second provider (second ED attending, MOD) credentialed in moderate sedation will need to attend the patient, and provide monitoring, care, and documentation at the bedside.

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Remember!Moderate Sedation occurs on a

continuum:Awake Minimal Sedation

MODERATE SEDATIONMODERATE SEDATION

Deep Sedation General Anesthesia  

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Remember!Patients can slip from one level to the next without warning. Practitioners must be qualified to rescue the patient from a lower state, i.e. deep sedation, and be skilled in airway management.

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Remember!Avoid standard mixes (e.g., x-mg of medication A, and x-mg of medication B)Treat the specific symptom (e.g., treat pain with more local anesthetic or narcotic)Titrate medication carefully—more medication can always be given, however it can never be retrieved.

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Remember!Use reduced dose of agents in patients who are

DebilitatedAt extremes of ageHypovolemic

Patients with COPD are more susceptible to respiratory depressant effects Avoid using “recipes”—no two patients will react the same to a given doseGive only the medication that is needed

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Final NoteRegardless of:

Type of procedureType of drugs usedType of venue