Conscious SedationConscious Sedation

台中榮民總醫院台中榮民總醫院 內科部 加護中心內科部 加護中心 李博仁醫師李博仁醫師

Case PresentationCase Presentation

吳吳 xx, 74 year-old age man. xx, 74 year-old age man. C.C:C.C:PET whole body PET whole body scan:The area of increased FDG uptake at the scan:The area of increased FDG uptake at the hepatic flexure of the colon can be due tumor hepatic flexure of the colon can be due tumor involvement or normal bowel activityinvolvement or normal bowel activity

Further evaluation with CT scan is recommended Further evaluation with CT scan is recommended CREAT. 4.3 mg/dl CREAT. 4.3 mg/dl

S-SCOPE + BX: 91/06/27 S-SCOPE + BX: 91/06/27 unpleasantunpleasant

Unpleasant endoscopyUnpleasant endoscopy

Unsedated endoscopy (43% refusal rate for upper GI enUnsedated endoscopy (43% refusal rate for upper GI endoscopy with no sedation, 65-83% refusal rate for unseddoscopy with no sedation, 65-83% refusal rate for unsedated colonoscopy ) ated colonoscopy )

Whereas other patients will need prolonged, more stimulWhereas other patients will need prolonged, more stimulating therapeutic endoscopic procedures that require totating therapeutic endoscopic procedures that require total patient compliance.al patient compliance.

Zaman A. A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin vidZaman A. A randomized trial of peroral versus transnasal unsedated endoscopy using an ultrathin videoendoscope. Gastrointest Endosc 1999; 49:279-284eoendoscope. Gastrointest Endosc 1999; 49:279-284

Early DS:Patient attitudes toward undergoing colonoscopy without sedation. Am J Gastroenterol 1999;Early DS:Patient attitudes toward undergoing colonoscopy without sedation. Am J Gastroenterol 1999;

94:1862-1865 94:1862-1865

Patient factors affecting tolerance oPatient factors affecting tolerance of unsedated endoscopyf unsedated endoscopy

509 patients undergoing unsedated diagnostic g509 patients undergoing unsedated diagnostic gastroscopy aided by topical pharyngeal anaesthastroscopy aided by topical pharyngeal anaesthesia esia

Gag reflex, young age, a high level of anxiety, pGag reflex, young age, a high level of anxiety, poor tolerance of previous examinations and femaoor tolerance of previous examinations and female sexle sex

Rex DK: Patients willing to try endoscopy without sedation: associated clinical factors and results Rex DK: Patients willing to try endoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc 1999; 49:554-559. of a randomized controlled trial. Gastrointest Endosc 1999; 49:554-559.

GI endoscopy complicationGI endoscopy complication

Bleeding, perforation, and infectionBleeding, perforation, and infection0.1% for upper endoscopy 0.1% for upper endoscopy 0.2% for colonoscopy0.2% for colonoscopyCardiopulmonary complications :21,011 procedures :5.4 per 1Cardiopulmonary complications :21,011 procedures :5.4 per 1000 procedures 000 procedures AspirationAspirationOversedationOversedationHypoventilationHypoventilationVasovagal episodesVasovagal episodesAirway obstruction Airway obstruction

Rankin GB. Indications, contraindications and complications of colonoscopy. In Rankin GB. Indications, contraindications and complications of colonoscopy. In Gastroenterologic EndoscGastroenterologic Endosc

opyopy 19891989

Endoscopic design and intubation rEndoscopic design and intubation routeoute

Ultrathin (5-6 mm) endoscopes Ultrathin (5-6 mm) endoscopes

Less traumatic and easier to tolerate for pLess traumatic and easier to tolerate for patients having UGIE without sedation atients having UGIE without sedation

Nasal route provides a direct route to the eNasal route provides a direct route to the esophagus avoiding sensitive oropharyngeasophagus avoiding sensitive oropharyngeal structures with less stimulation of the gag l structures with less stimulation of the gag reflex reflex

Routine administration of sedation , The Routine administration of sedation , The incidence of unplanned absence from work the incidence of unplanned absence from work the day after outpatient colonoscopy has been day after outpatient colonoscopy has been shown to be 4%shown to be 4%

What is Conscious Sedation?What is Conscious Sedation?

Altered state of consciousness Altered state of consciousness

Minimizes pain and discomfort through the use Minimizes pain and discomfort through the use of pain relievers and sedatives of pain relievers and sedatives

Able to speak and respond to verbal cues Able to speak and respond to verbal cues throughout the procedure throughout the procedure

Communicating any discomfort they experience Communicating any discomfort they experience to the provider. to the provider.

Amnesia may erase any memory of the Amnesia may erase any memory of the procedure. procedure.

Depth of Sedation: Definition of General Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/AnalgesiaAnesthesia and Levels of Sedation/Analgesia

Non-Anest Practice Guidelines foNon-Anest Practice Guidelines for Sedation and Analgesia byr Sedation and Analgesia by

Non-Anesthesiologists hesiologiNon-Anesthesiologists hesiologistssts

Anesthesiology 2002; 96:1004–17Anesthesiology 2002; 96:1004–17

Who Can Administer Conscious Who Can Administer Conscious Sedation?Sedation?

Qualified providersQualified providersCertified Registered Nurse Anesthetists (CCertified Registered Nurse Anesthetists (CRNAs)RNAs)AnesthesiologistsAnesthesiologistsPhysiciansPhysiciansDentistsDentistsOral surgeons are qualified providers of coOral surgeons are qualified providers of conscious sedation nscious sedation

When is Conscious Sedation When is Conscious Sedation Administered?Administered?

In hospitals, outpatient facilities, e.g., ambulatory In hospitals, outpatient facilities, e.g., ambulatory surgery centers, doctors offices surgery centers, doctors offices Breast biopsy Breast biopsy Vasectomy Vasectomy Minor foot surgery Minor foot surgery Minor bone fracture repair Minor bone fracture repair Plastic/reconstructive surgery Plastic/reconstructive surgery Dental prosthetic/reconstructive surgery Dental prosthetic/reconstructive surgery Endoscopy (example: diagnostic studies and treEndoscopy (example: diagnostic studies and treatment of stomach, colon and bladder )atment of stomach, colon and bladder )

Definition of TermsDefinition of Terms Sedation and AnalgesiaSedation and Analgesia describes a state that allows patients to tolerate describes a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory fununpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and/or tction and the ability to respond purposefully to verbal command and/or tactile stimulation.actile stimulation.MonitoringMonitoring is the measurement of physiologic parameters, including the is the measurement of physiologic parameters, including the use of mechanical devices as well as clinical observations. The RN may use of mechanical devices as well as clinical observations. The RN may delegate this function.delegate this function.AssessmentAssessment is the continuous, systematic collection, validation, and co is the continuous, systematic collection, validation, and communication of patient data for the purpose of planning, implementing, ammunication of patient data for the purpose of planning, implementing, and evaluating nursing care. Assessment is directed toward the attainmend evaluating nursing care. Assessment is directed toward the attainment of specific patient outcomes. The RN should nt of specific patient outcomes. The RN should notnot delegate this function. delegate this function.Assistive personnelAssistive personnel are staff without a nursing license (e.g., GI assistant are staff without a nursing license (e.g., GI assistants, medical technicians, respiratory therapists) who have direct patient cas, medical technicians, respiratory therapists) who have direct patient care responsibility and are supervised by an RN.re responsibility and are supervised by an RN.

Preprocedure evaluationPreprocedure evaluationPatient EvaluationPatient Evaluation

strongly agree:history, physical examination increases the strongly agree:history, physical examination increases the likelihood of satisfactory sedation and decreases the likelihood of satisfactory sedation and decreases the likelihood of adverse outcomes for both moderate and likelihood of adverse outcomes for both moderate and deep sedationdeep sedation(1) abnormalities of the major organ systems(1) abnormalities of the major organ systems(2) previous adverse experience with sedation/analgesia as (2) previous adverse experience with sedation/analgesia as well as regional and general anesthesiawell as regional and general anesthesia(3)drug allergies, current medications, and potential drug (3)drug allergies, current medications, and potential drug InteractionsInteractions(4) time and nature of last oral intake; and(4) time and nature of last oral intake; and(5) history of tobacco, alcohol, or substance use or abuse(5) history of tobacco, alcohol, or substance use or abuse

Preprocedure PreparationPreprocedure Preparation

Strongly agree that appropriate Strongly agree that appropriate preprocedure counseling of patpreprocedure counseling of patients regarding risks, benefits, ients regarding risks, benefits, and alternatives to sedation anand alternatives to sedation and analgesia increases patient sd analgesia increases patient satisfactionatisfactionGuidelines for Preoperative FaGuidelines for Preoperative Fastingsting(1) the target level of sedation(1) the target level of sedation(2) whether the procedure sho(2) whether the procedure should be delayeduld be delayed(3) whether the trachea should (3) whether the trachea should be protected by intubationbe protected by intubation

Preprocedure Fasting GuidelinesPreprocedure Fasting Guidelines

Problems with sedation (sedation and Problems with sedation (sedation and procedure-related complications )procedure-related complications )DesaturationDesaturationArrhythmiasArrhythmiasMyocardial ischemic episodesMyocardial ischemic episodesO2 saturation less than 95% O2 saturation less than 95% premorbid cardio-respiratory disease premorbid cardio-respiratory disease Continuous electronic monitoring (oxygen saturation, eleContinuous electronic monitoring (oxygen saturation, electrocardiogram (ECG), non-invasive blood pressure (NIBctrocardiogram (ECG), non-invasive blood pressure (NIBP)P)

Froelich F, Thorens J, Schwizer W -- Gastrointest Endosc 1997; 45:1-9Froelich F, Thorens J, Schwizer W -- Gastrointest Endosc 1997; 45:1-9Alcain G, Guillen P. Predictive factors of oxygen desaturation during upper gastrointeAlcain G, Guillen P. Predictive factors of oxygen desaturation during upper gastrointestinal endoscopy in nonsedated patients. Gastrointest Endosc 1998; 48:143-147stinal endoscopy in nonsedated patients. Gastrointest Endosc 1998; 48:143-147

Airway Assessment Procedures for Sedation andAirway Assessment Procedures for Sedation andAnalgesiaAnalgesia

MonitoringMonitoring

strongly agree : monitoring level of consciousnesstrongly agree : monitoring level of consciousness reduces risks for both moderate and deep seds reduces risks for both moderate and deep sedationationbe avoided if adverse drug responses are detectbe avoided if adverse drug responses are detected and treated in a timely manner ed and treated in a timely manner i.e.i.e., before the , before the development of cardiovascular decompensation development of cardiovascular decompensation or cerebral hypoxiaor cerebral hypoxiaPulmonary VentilationPulmonary VentilationOxygenationOxygenationHemodynamicsHemodynamics

Recording of Monitored Recording of Monitored ParametersParameters

(1) before the beginning of the procedure(1) before the beginning of the procedure

(2) after administration of sedative– (2) after administration of sedative–

analgesic agentsanalgesic agents

(3) at regular intervals ( 5-min) during the(3) at regular intervals ( 5-min) during the

procedureprocedure

(4) during initial recovery(4) during initial recovery

(5) just before discharge(5) just before discharge

Pulmonary VentilationPulmonary Ventilation

Capnography, measurement of carbon Capnography, measurement of carbon dioxide retention, may be useful in proldioxide retention, may be useful in prolonged casesonged cases

OxygenationOxygenation

strongly agree : early detection of through thstrongly agree : early detection of through the use of oximetrye use of oximetry

hypoxemia more likely to be detected by oxihypoxemia more likely to be detected by oximetry than by clinical assessment alonemetry than by clinical assessment alone

pitch “beep”alarmspitch “beep”alarms

Supplemental OxygenSupplemental Oxygen

HemodynamicsHemodynamics

Blunt the appropriate autonomic compensation for hBlunt the appropriate autonomic compensation for hypovolemia and procedure-related stresses or inadeypovolemia and procedure-related stresses or inadequate (hypertension, tachycardia)quate (hypertension, tachycardia)Response to verbal commands :control his airway aResponse to verbal commands :control his airway and take deep breathsnd take deep breathsyoung children, mentally impaired or uncooperative young children, mentally impaired or uncooperative patients, oral surgery, upper endoscopypatients, oral surgery, upper endoscopyContinously EKGContinously EKGBlood pressureBlood pressure

Arrhythmias -- sedation in the enArrhythmias -- sedation in the endoscopydoscopy

five- to sixfold higher in patients with pre-efive- to sixfold higher in patients with pre-existing cardiac disease xisting cardiac disease

endoscope sizeendoscope size

the presence of hypoxemiathe presence of hypoxemia

premorbid cardiorespiratory disease premorbid cardiorespiratory disease

Emergency Equipment for Sedation andEmergency Equipment for Sedation andAnalgesiaAnalgesia

(1) (1)

Emergency Equipment for Sedation andEmergency Equipment for Sedation andAnalgesiaAnalgesia

(2)(2)

Availability of Emergency Availability of Emergency EquipmentEquipment

Suction, appropriately sized airway Suction, appropriately sized airway equipment, means of positive- pressure equipment, means of positive- pressure ventilationventilation

Intravenous equipment, pharmacologic Intravenous equipment, pharmacologic antagonists, and basic resuscitative antagonists, and basic resuscitative medicationsmedications

Defibrillator immediately available for Defibrillator immediately available for patients with cardiovascular diseasepatients with cardiovascular disease

Training of PersonnelTraining of Personnel

Strongly agree :education and trainingStrongly agree :education and training(1) potentiation of sedative-induced respiratory(1) potentiation of sedative-induced respiratory

depression by concomitantly administered opioidsdepression by concomitantly administered opioids(2)inadequate time intervals between doses of seda(2)inadequate time intervals between doses of sedative or analgesic agents, resulting in a cumulative otive or analgesic agents, resulting in a cumulative overdoseverdose(3) inadequate familiarity with the role of pharmacol(3) inadequate familiarity with the role of pharmacologic antagonists for sedative and analgesic agentsogic antagonists for sedative and analgesic agentsACLS,BLSACLS,BLS

Combinations of Sedative–Combinations of Sedative–Analgesic AgentsAnalgesic Agents

Equivocal regarding :moderate sedationEquivocal regarding :moderate sedationDeep sedation, satisfactory: Intravenous Deep sedation, satisfactory: Intravenous ccombinations of sedative–analgesic agentombinations of sedative–analgesic agentFixed combinations of sedative and Fixed combinations of sedative and analgesic agents may not allowanalgesic agents may not allowAppropriately titrated: strongly agree that Appropriately titrated: strongly agree that incremental drug administration improves incremental drug administration improves patient comfort and decreases riskspatient comfort and decreases risks

Drugs used in conscious sedation fDrugs used in conscious sedation for endoscopyor endoscopy

BenzodiazepinesBenzodiazepines

the majority of endoscopic procedures the majority of endoscopic procedures relaxation , cooperation and anterograde amnesia relaxation , cooperation and anterograde amnesia titrated titrated respiratory depression respiratory depression synergistically increased with the use of intravenous opiasynergistically increased with the use of intravenous opiates, the midazolam dose should be reduced by 30%tes, the midazolam dose should be reduced by 30%0.5-2 mg given slowly intravenously 0.5-2 mg given slowly intravenously repeating doses every 2 to 3 minutes repeating doses every 2 to 3 minutes total dose is 2.5 to 5 mg total dose is 2.5 to 5 mg

Midazolam-Induced Sedation for Upper GastrMidazolam-Induced Sedation for Upper Gastrointestinal Endoscopy: Assessment of Endosointestinal Endoscopy: Assessment of Endos

copist and Patient Satisfactioncopist and Patient Satisfaction 352 patients upper gastrointestinal endoscopy were sedated with mi352 patients upper gastrointestinal endoscopy were sedated with midazolam given dazolam given Ages of the patients ranged between 16 and 79 years (average: 41.Ages of the patients ranged between 16 and 79 years (average: 41.6 ± 12.7 years). 6 ± 12.7 years). Anterograde memory was found in 310 (88.0%) Anterograde memory was found in 310 (88.0%) 342 patients (98.0%) cooperated well 342 patients (98.0%) cooperated well Side effects were rarely seen (3.6%), and included nausea, vertigo, Side effects were rarely seen (3.6%), and included nausea, vertigo, and vomiting and vomiting Acceptability of further endoscopy in 338 (96.0%) Acceptability of further endoscopy in 338 (96.0%)

No significant cardiopulmonary problemsNo significant cardiopulmonary problems

Gastroenterology Nursing: Volume 26(4) July/August 2003 pp 164-167Gastroenterology Nursing: Volume 26(4) July/August 2003 pp 164-167

Most patients and endoscopists prefer some form of premedication Most patients and endoscopists prefer some form of premedication be given (Bell, 1990)be given (Bell, 1990)

Intravenous diazepam or midazolam have been used by the majoritIntravenous diazepam or midazolam have been used by the majority of endoscopists (Wille et al., 2000)y of endoscopists (Wille et al., 2000)

Midazolam quickly gained popularity after it was introduced in the mMidazolam quickly gained popularity after it was introduced in the mid-1980s (Zakko, Seifert, & Gross, 1999)id-1980s (Zakko, Seifert, & Gross, 1999)

Many endoscopists prefer midazolam for conscious sedation becauMany endoscopists prefer midazolam for conscious sedation because it has short duration of action and efficient amnesic effect (Whitwse it has short duration of action and efficient amnesic effect (Whitwam, Al-Khudhairi, & McCloy, 1983;Wille et al., 2000)am, Al-Khudhairi, & McCloy, 1983;Wille et al., 2000)

Midazolam was accused of more than 40 sedation-related deaths, wMidazolam was accused of more than 40 sedation-related deaths, which made its safety in the setting of conscious sedation questionablhich made its safety in the setting of conscious sedation questionable (Zakko et al., 1999). These adverse events may have been relatee (Zakko et al., 1999). These adverse events may have been related to the fact that when midazolam was first used d to the fact that when midazolam was first used

Opiates --FentanylOpiates --Fentanyl

Pain threshold, alters pain reception, and inhibits Pain threshold, alters pain reception, and inhibits ascending pain pathwaysascending pain pathways

Sedation is 25 to 50 µg, repeated every 1 to 2 Sedation is 25 to 50 µg, repeated every 1 to 2 minutes minutes

Total dose is 50 to 200 µg Total dose is 50 to 200 µg

Half-life is 2 to 4 hoursHalf-life is 2 to 4 hours

Opiates --MeperidineOpiates --Meperidine

pain threshold, alters pain reception, and inhibits pain threshold, alters pain reception, and inhibits ascending pain pathwaysascending pain pathways

sedation is routine procedures is 50 to 100 mgsedation is routine procedures is 50 to 100 mg

Reversal AgentsReversal Agents

Naloxone and flumazenil available wheNaloxone and flumazenil available whenever opioids or benzodiazepines adminever opioids or benzodiazepines administerednistered

Special ConsiderationsSpecial Considerations

* Age >60 years* Age >60 years

* Inability to cooperate* Inability to cooperate

* Significant development* Significant developmental delayal delay

* Severe comorbidity (e.g.,* Severe comorbidity (e.g., cardiac, pulmonary, hepa cardiac, pulmonary, hepatic, renal, or central nervotic, renal, or central nervous system disease)us system disease)

* Morbid obesity* Morbid obesity

* History of sleep apnea* History of sleep apnea

* History of drug or alcoh* History of drug or alcohol abuseol abuse

* Pregnancy* Pregnancy

* Emergency procedure w* Emergency procedure with lack of patient preparatith lack of patient preparationion

* Airway anomalies* Airway anomalies

Recovery Criteria after SedationRecovery Criteria after Sedationand Analgesiaand Analgesia

1. Medical supervision of recovery and discharge after 1. Medical supervision of recovery and discharge after moderate or deep sedation is the responsibility of the operating moderate or deep sedation is the responsibility of the operating practitioner or a licensed physician.practitioner or a licensed physician.

2. The recovery area should be equipped with, or have direct 2. The recovery area should be equipped with, or have direct access to, appropriate monitoring and resuscitation equipmentaccess to, appropriate monitoring and resuscitation equipment

3. Patients receiving moderate or deep sedation should be 3. Patients receiving moderate or deep sedation should be monitored until appropriate discharge criteria are satisfied .The monitored until appropriate discharge criteria are satisfied .The duration and frequency of monitoring should be individualized duration and frequency of monitoring should be individualized depending on the level of sedation achieved .the overall depending on the level of sedation achieved .the overall condition of the patient, and the nature of the intervention for condition of the patient, and the nature of the intervention for which sedation/analgesia was administered. Oxygenation which sedation/analgesia was administered. Oxygenation should be monitored until patients are no longer at risk for should be monitored until patients are no longer at risk for respiratory depressionrespiratory depression

Recovery Criteria after SedationRecovery Criteria after Sedationand Analgesiaand Analgesia

4.Recovery area once vital signs are stable and 4.Recovery area once vital signs are stable and the patient has reached an appropriate level of the patient has reached an appropriate level of consciousness. Level of consciousness, vital consciousness. Level of consciousness, vital signs, and oxygenation (when indicated) should signs, and oxygenation (when indicated) should be recorded at regular intervals.be recorded at regular intervals.5. A nurse or other individual trained to monitor 5. A nurse or other individual trained to monitor patients and recognize complications should be in patients and recognize complications should be in attendance until discharge criteria are fulfilled.attendance until discharge criteria are fulfilled.6. An individual capable of managing 6. An individual capable of managing complications (complications (e.g. e.g. establishing a patent airway establishing a patent airway and providing positive pressure ventilation) and providing positive pressure ventilation) should be immediately available until discharge should be immediately available until discharge criteria are fulfilledcriteria are fulfilled

Guidelines for dischargeGuidelines for discharge1. Patients should be alert and oriented; infants and patients whose m1. Patients should be alert and oriented; infants and patients whose mental status was initially abnormal should have returned to their baseliental status was initially abnormal should have returned to their baseline status. Practitioners and parents must be aware that pediatric patiene status. Practitioners and parents must be aware that pediatric patients are at risk for airway obstruction should the head fall forward while nts are at risk for airway obstruction should the head fall forward while the child is secured in a car seat.the child is secured in a car seat.2. Vital signs should be stable and within acceptable limits.2. Vital signs should be stable and within acceptable limits.3. Use of scoring systems may assist in documentation of fitness for dis3. Use of scoring systems may assist in documentation of fitness for discharge.charge.4. Sufficient time (up to 2 h) should have elapsed after the last adminis4. Sufficient time (up to 2 h) should have elapsed after the last administration of reversal agents (naloxone, flumazenil) to ensure that patienttration of reversal agents (naloxone, flumazenil) to ensure that patients do not become resedated after reversal effects have worn off.s do not become resedated after reversal effects have worn off.5. Outpatients should be discharged in the presence of a responsible a5. Outpatients should be discharged in the presence of a responsible adult who will accompany them home and be able to report any postprdult who will accompany them home and be able to report any postprocedure complications.ocedure complications.6. Outpatients and their escorts should be provided with written instru6. Outpatients and their escorts should be provided with written instructions regarding postprocedure diet, medications, activities, and a phoctions regarding postprocedure diet, medications, activities, and a phone number to be called in case of emergency.ne number to be called in case of emergency.

Discharge criteria after sedationDischarge criteria after sedation

Evidence-Based MedicineEvidence-Based Medicine

A focused history and physical is required prior to the administration A focused history and physical is required prior to the administration of moderate sedation. of moderate sedation. (C)(C) Routine monitoring of the patients pulse rate, blood pressure, oxygen Routine monitoring of the patients pulse rate, blood pressure, oxygen saturation are useful in identifying early problems. (saturation are useful in identifying early problems. (BB))Monitoring of EKG recordings may be helpful in selected cases. Monitoring of EKG recordings may be helpful in selected cases. (C)(C) Capnography, measurement of carbon dioxide retention, may be usefuCapnography, measurement of carbon dioxide retention, may be useful in prolonged cases. l in prolonged cases. (A)(A)

The use of benzodiazepines and/or opiates will result in a satisfactory The use of benzodiazepines and/or opiates will result in a satisfactory outcome in nearly all patients. outcome in nearly all patients. (B)(B) Endoscopists prefer the combination of these drugs, but it adds little Endoscopists prefer the combination of these drugs, but it adds little benefit from the patient's viewpoint. benefit from the patient's viewpoint. (A)(A)

(A)(A), Prospective controlled trials., Prospective controlled trials. (B)(B), Observational studies. , Observational studies. (C)(C), Expert opinion , Expert opinion

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