Moderate Sedation/ Analgesia (Conscious Sedation) Anuradha Patel M.B.B.S., M.D., D.A., F.R.C.A. ( I...

Moderate Sedation/ Moderate Sedation/ Analgesia (Conscious Analgesia (Conscious

Sedation)Sedation)Anuradha Patel

M.B.B.S., M.D., D.A., F.R.C.A. ( I ), D.A.B.A.

Assistant Professor, Department of Anesthesiology and

Perioperative MedicineUMDNJ, Newark

IntroductionIntroduction

These guidelines are designed to be applicable to These guidelines are designed to be applicable to procedures performed in a variety of settings by procedures performed in a variety of settings by practitioners who are not specialists in practitioners who are not specialists in anesthesiology.The purpose of these is to allow anesthesiology.The purpose of these is to allow clinicians to provide their patients with the clinicians to provide their patients with the benefits of sedation /analgesia, while minimizing benefits of sedation /analgesia, while minimizing associated risks.These guidelines are intended to associated risks.These guidelines are intended to be general in their application and broad in be general in their application and broad in scope.scope.

Depth of SedationDepth of Sedation

Minimal SedationMinimal Sedation (Anxiolysis)(Anxiolysis) - is a drug induced state during which - is a drug induced state during which

patients respond normally to verbal patients respond normally to verbal commands. Although cognitive function commands. Although cognitive function and coordination may be impaired, and coordination may be impaired, ventilatory and cardiovascular functions ventilatory and cardiovascular functions are unaffected.are unaffected.


Moderate Sedation/Analgesia Moderate Sedation/Analgesia (Conscious Sedation) (Conscious Sedation)

- is a drug induced depression of - is a drug induced depression of consciousness during which patients consciousness during which patients respond purposefully* to verbal commands respond purposefully* to verbal commands either alone or accompanied by light tactile either alone or accompanied by light tactile stimulation. No interventions are required to stimulation. No interventions are required to maintain a patent airway, and spontaneous maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular ventilation is adequate. Cardiovascular function is usually maintained.function is usually maintained.


Deep Sedation/AnalgesiaDeep Sedation/Analgesia - - is drug induced loss of consciousness during is drug induced loss of consciousness during

which patients cannot be easily aroused but which patients cannot be easily aroused but respond purposefully* following repeated respond purposefully* following repeated stimulation. The ability to independently stimulation. The ability to independently maintain ventilatory function is often maintain ventilatory function is often impaired.Patients may require assistance in impaired.Patients may require assistance in maintaining a patent airway and positive maintaining a patent airway and positive pressure ventilation may be required. pressure ventilation may be required. Cardiovascular function may be impaired.Cardiovascular function may be impaired.


General Anesthesia General Anesthesia - - is a drug induced loss of consciousness is a drug induced loss of consciousness

during which patients are not arousable, during which patients are not arousable, even by painful stimulation. The ability to even by painful stimulation. The ability to independently maintain ventilatory is often independently maintain ventilatory is often impaired. Patients often require assistance impaired. Patients often require assistance in maintaining a patent airway, and positive in maintaining a patent airway, and positive pressure ventilation may be required. pressure ventilation may be required. Cardiovascular function may be impaired.Cardiovascular function may be impaired.


• Protective airway reflexesProtective airway reflexes-includes the ability -includes the ability of an individual to counteract noxious events, of an individual to counteract noxious events, especially to defend breathing passages against especially to defend breathing passages against foreign material.foreign material.

• Reflex withdrawal from a painful stimulus is NOT Reflex withdrawal from a painful stimulus is NOT considered a purposeful responseconsidered a purposeful response

• Sedation is a continuum, it is not always possible Sedation is a continuum, it is not always possible to predict how an individual will respond.to predict how an individual will respond.

• Practitioners intending to produce a given level of Practitioners intending to produce a given level of sedation should be able to rescue patients whose sedation should be able to rescue patients whose level of sedation becomes deeper than initially level of sedation becomes deeper than initially intended.intended.

Locations of M.S./AnalgesiaLocations of M.S./Analgesia

• Radiology DepartmentRadiology Department• Medical Special Medical Special

ProceduresProcedures• Dental ClinicDental Clinic• Emergency Emergency

DepartmentDepartment• Progressive Care UnitsProgressive Care Units• Procedure Unit E-Procedure Unit E-

YellowYellow

• Critical Care UnitsCritical Care Units• Echocardiology LabEchocardiology Lab• Cardiac Cardiac

Catheterization LabCatheterization Lab• Clinics (Audiology, Clinics (Audiology,

Neurology)Neurology)• Pre-operative Pre-operative

holding areaholding area

Patient EvaluationPatient Evaluation• History/ Physical examHistory/ Physical exam

• Airway evaluationAirway evaluation

• Abnormalities of the major organ systemsAbnormalities of the major organ systems

• Previous adverse experience with sedationPrevious adverse experience with sedation

• Drug allergies, current meds.,potential Drug allergies, current meds.,potential interactioninteraction

• Focused physical exam- vital signs, auscultation Focused physical exam- vital signs, auscultation of heart and lungs, evaluation of the airwayof heart and lungs, evaluation of the airway

• NPO statusNPO status

• Lab data Lab data

Patient EvaluationPatient EvaluationAirway Evaluation

Mallampati Classification• Relates tongue size to pharyngeal size

• Performed with the patient in the sitting position, the head held in a neutral position, the mouth wide open, and the tongue protruding to the maximum

• May vary if the patient is in the supine position (instead of sitting)

• If the patients phonates, this falsely improves the view.

•If the patient arches his or her tongue, the uvula is falsely obscured.

Patient EvaluationPatient EvaluationAirway EvaluationMallampati

Classification Class I = visualization of the soft palate, fauces, uvula, anterior and posterior pillars.Class II = visualization of the soft palate, fauces and uvula.Class III = visualization of the soft palate and the base of the uvula.Class IV = soft palate is not visible at all.

ASA Physical StatusASA Physical Status

• Class I- normal, healthyClass I- normal, healthy• Class II- mild systemic disease Class II- mild systemic disease • Class III- severe systemic disease, Class III- severe systemic disease, e.g. e.g.

HTN COPD, HTN COPD,

• Class IV-severe systemic disease that is Class IV-severe systemic disease that is a constant threat to life, a constant threat to life, e.g. unstable e.g. unstable anginaangina

• Class V- moribund patient not expected Class V- moribund patient not expected to live with or without the procedureto live with or without the procedure

Patient EvaluationPatient EvaluationWhen an anesthesiologist or other When an anesthesiologist or other specialist may be needed.specialist may be needed.

• ASA class III or higherASA class III or higher

• Airway abnormalitiesAirway abnormalities

• Morbid obesityMorbid obesity

• Sleep apneaSleep apnea

• Previously failed Previously failed sedationsedation

• Major allergy or Major allergy or anaphylactic reactionanaphylactic reaction

• Complex procedureComplex procedure

• Prolonged sedation Prolonged sedation neededneeded

• New procedure New procedure

• Unusual positionUnusual position

• Unusual locationUnusual location

Pre procedure preparationPre procedure preparation

• Informed consentInformed consent

• Pre op fastingPre op fasting– Clear liquidsClear liquids 2h2h– Breast milkBreast milk 4h4h– Infant formulaInfant formula 6h6h– MilkMilk 6h6h– Light mealLight meal 6h6h

Equipment Equipment

• Self inflating bag and mask Self inflating bag and mask

• Oxygen – 2 outletsOxygen – 2 outlets

• Suction ( working )Suction ( working )

• Pulse oximeter, ECG monitor, BP. MonitorPulse oximeter, ECG monitor, BP. Monitor

• ? Capnometer? Capnometer

• Pharmacologic antagonistsPharmacologic antagonists

• Emergency equipment – airway kit (age Emergency equipment – airway kit (age appropriate) crash cart, defibrillatorappropriate) crash cart, defibrillator

Monitoring and Monitoring and DocumentationDocumentation• Pre-procedurePre-procedure

-V.S., SpO-V.S., SpO22 • ProcedureProcedure

-Continuous SpO-Continuous SpO22, E.C.G., E.C.G.-V.S. q 5 min.-V.S. q 5 min.-L.O.C. q 5 min.(level of consciousness)-L.O.C. q 5 min.(level of consciousness)

• Post ProcedurePost Procedure

-Continuous SpO-Continuous SpO22, V.S. q 5 min. for 15 min., , V.S. q 5 min. for 15 min., then q 15 min. until discharge criteria metthen q 15 min. until discharge criteria met

PersonnelPersonnel

1.1. The minimal number of available The minimal number of available personnel should be two:personnel should be two:

The operator (performs procedure) The operator (performs procedure) The monitor (administers drugs, The monitor (administers drugs, monitors airway and vital monitors airway and vital

signs.signs. The second individual may assist with The second individual may assist with

minor interruptible tasks.minor interruptible tasks.Both personnel must be credentialed in Both personnel must be credentialed in Moderate Sedation/ AnalgesiaModerate Sedation/ Analgesia

PersonnelPersonnel

Personnel who can administer Moderate Personnel who can administer Moderate Sedation/ Analgesia or monitor a patient, Sedation/ Analgesia or monitor a patient, include:include:

- A physician, or dentist who has been - A physician, or dentist who has been credentialed credentialed

Under the supervision of the above, the Under the supervision of the above, the following persons may administer M.S.following persons may administer M.S.

- CRNA, or a student CRNA, - CRNA, or a student CRNA,

- resident physician or resident dentist- resident physician or resident dentist

-registered nurse, under special situations.-registered nurse, under special situations.

Training of PersonnelTraining of Personnel

• Individuals responsible for patients should Individuals responsible for patients should understand the pharmacology of agents used understand the pharmacology of agents used for sedation and antagonists for opiates and for sedation and antagonists for opiates and benzodiazepines.benzodiazepines.

• Individuals monitoring patients should be Individuals monitoring patients should be able to recognize associated complications.able to recognize associated complications.

• One individual capable of estabilishing a One individual capable of estabilishing a patent airway and positive pressure patent airway and positive pressure ventilation should be present.ventilation should be present.

• All personnel must be ACLS certified. All personnel must be ACLS certified.

Discharge CriteriaDischarge Criteria

Patients will be discharged according Patients will be discharged according to the Aldrete score. The patients to the Aldrete score. The patients must have a score of ten.must have a score of ten.

Aldrete score is printed at the end of the Moderate Aldrete score is printed at the end of the Moderate sedation/Analgesia recordsedation/Analgesia record

Patients who receive reversal agents Patients who receive reversal agents need to remain in the procedure area need to remain in the procedure area for at least one hour after the last for at least one hour after the last dose.dose.

DrugsDrugsDrugs commonly used for M.SDrugs commonly used for M.S..Meperidine Meperidine

(Demerol)(Demerol)

MorphineMorphine

Fentanyl (Sublimaze)Fentanyl (Sublimaze)

Ketamine Ketamine

Diazepam (Valium)Diazepam (Valium)

Midazolam (Versed)Midazolam (Versed)

Droperidol (Inapsine)Droperidol (Inapsine)

Phenobarbital Phenobarbital

Naloxone (Narcan)Naloxone (Narcan)

Flumazenil Flumazenil (Romazicon)(Romazicon)

DrugsDrugs

Drugs EXCLUDED for M.S./ Analgesia Drugs EXCLUDED for M.S./ Analgesia by non-anesthesia staff are:by non-anesthesia staff are:

• Sodium ThiopentalSodium Thiopental• PropofolPropofol• Brevital (metho hexital)Brevital (metho hexital)• EtomidateEtomidate• SufentanilSufentanil• RemifentanilRemifentanil

Combinations of DrugsCombinations of Drugs

• IV.drugs should be given in small, IV.drugs should be given in small, incremental doses, titrated to end points of incremental doses, titrated to end points of analgesia/sedation.analgesia/sedation.

• Allow time for onset before repeatingAllow time for onset before repeating• Benzo. and opiates have synergistic effects Benzo. and opiates have synergistic effects • Non IV routes, eg. Oral,rectal,im.,tm.-allow Non IV routes, eg. Oral,rectal,im.,tm.-allow

adequate time for absorption. Repeat doses adequate time for absorption. Repeat doses not recommended(unpredictable absorption)not recommended(unpredictable absorption)

SynergySynergy

• Effects of Benzodiazepine and Opiate Effects of Benzodiazepine and Opiate are additive (synergistic)are additive (synergistic)

• For example, 2 mg. Midazolam or 10 For example, 2 mg. Midazolam or 10 mg. Morphine equals no apneamg. Morphine equals no apnea

• 1 mg Midazolam plus 5 mg morphine 1 mg Midazolam plus 5 mg morphine equals apneaequals apnea

Basic ConsiderationsBasic Considerations

• Low cardiac output equals slow onsetLow cardiac output equals slow onset

• Consider the age of the brain Consider the age of the brain

• Consider the physical condition of the Consider the physical condition of the patientpatient

• What effect is desired?What effect is desired?

• Is post-procedure pain control needed?Is post-procedure pain control needed?

• When in trouble, back outWhen in trouble, back out

• Titrate drugs to effect, wait for onset.Titrate drugs to effect, wait for onset.

Reversal agentsReversal agents

• Specific antagonists, naloxone/flumazenil should Specific antagonists, naloxone/flumazenil should be availablebe available

• May be administered if apnea or hypoxemia May be administered if apnea or hypoxemia develops, but routine use is strongly discouraged.develops, but routine use is strongly discouraged.

• Patients need to be observed longer in recovery Patients need to be observed longer in recovery (at least 2 hrs.) if reversal agents are used.(at least 2 hrs.) if reversal agents are used.

OpiatesOpiates

• Dose-dependent binding to opioid Dose-dependent binding to opioid receptors (especially mu) leads to:receptors (especially mu) leads to:– AnalgesiaAnalgesia– SedationSedation– Respiratory DepressionRespiratory Depression

• Side effects:Side effects:– Nausea/vomitingNausea/vomiting– Miosis Miosis – Decreased PeristalsisDecreased Peristalsis

MorphineMorphine

• Average Dose:Average Dose: 5-15 mg5-15 mg• Incremental Dose:Incremental Dose: 2.5 mg2.5 mg• Time Between Doses:Time Between Doses: 5-10 min5-10 min• Onset Time:Onset Time: 5-10 min5-10 min• Duration of Effect: Duration of Effect: 3-4 hrs3-4 hrs• Paradoxical ReactionParadoxical Reaction• PruritisPruritis• Anaphylactoid ReactionAnaphylactoid Reaction• Active MetabolitesActive Metabolites

Meperidine (Demerol)Meperidine (Demerol)

• Average Dose:Average Dose: 50-150 mg50-150 mg• Incremental Dose:Incremental Dose: 25 mg25 mg• Time Between Doses:Time Between Doses: 5 min5 min• Onset Time:Onset Time: 3-5 min3-5 min• Duration of Effect: Duration of Effect: 2-3 hrs2-3 hrs• Caution: Not used with MAO Inhibitors, Caution: Not used with MAO Inhibitors,

Antidepressants, Antiparkinsonian drugsAntidepressants, Antiparkinsonian drugs• Remember “Libby Zion”Remember “Libby Zion”• Active Metabolite can accumulate with renal Active Metabolite can accumulate with renal

dysfunctiondysfunction

BenzodiazepinesBenzodiazepines

• Enhance GABA transmission in CNSEnhance GABA transmission in CNS

• Most are lipid soluble only (except Most are lipid soluble only (except midazolam)midazolam)

• Effects:Effects:– AmnesiaAmnesia– AnticonvulsantAnticonvulsant– AnxiolyticAnxiolytic– Behavioral disinhibitionBehavioral disinhibition– Muscle relaxantMuscle relaxant

DiazepamDiazepam

• Average Dose:Average Dose: 5-20 mg5-20 mg

• Incremental Dose:Incremental Dose: 2.5 mg2.5 mg

• Time Between Doses:Time Between Doses: 2-3 min2-3 min

• Onset Time:Onset Time: 1-2 min1-2 min

• Duration of Effect: Duration of Effect: 0.5-2 hrs0.5-2 hrs

• Several active metabolites prolong Several active metabolites prolong effectseffects

• Elimination tElimination t1/21/2 15-21 hrs 15-21 hrs

Midazolam (Versed)Midazolam (Versed)

• Average Dose:Average Dose: 1-5 mg1-5 mg

• Incremental Dose:Incremental Dose: 0.5-1 mg0.5-1 mg




• Water and lipid solubleWater and lipid soluble

• Active metabolites, which are less potentActive metabolites, which are less potent

• Elimination tElimination t½½; 2-4 hrs; 2-4 hrs

DiphenydramineDiphenydramine

• Sedating antihistamine with Sedating antihistamine with anticholinergic propertiesanticholinergic properties

• PO/IV/IMPO/IV/IM

• Maximum sedative effect 1-3 hrs, Maximum sedative effect 1-3 hrs, duration; 4-7 hrsduration; 4-7 hrs

• Elimination tElimination t1/21/2: 2-8 hrs: 2-8 hrs

Fentanyl (Sublimaze)Fentanyl (Sublimaze)

• Average Dose:Average Dose: 0.025-0.15 mg0.025-0.15 mg




• Duration of Effect: Duration of Effect: 0.5- 1 hrs0.5- 1 hrs

• Elimination tElimination t1/21/2: : 3.1-6.6 hrs3.1-6.6 hrs

• May cause muscle rigidityMay cause muscle rigidity


• Reversal of opiatesReversal of opiates• Side effects:Side effects:

– PainPain– HypertensionHypertension– TachycardiaTachycardia– Ventricular dsyrhythmiasVentricular dsyrhythmias– Pulmonary EdemaPulmonary Edema

– Re-narcotization –Delayed respiratory Re-narcotization –Delayed respiratory depressiondepression


• Average Dose:Average Dose: 0.4 mg0.4 mg





Flumazenil (Romazicon)Flumazenil (Romazicon)

• Average Dose:Average Dose: 1 mg1 mg


• Time Between Doses:Time Between Doses: 1 min1 min


• Duration of Effect: Duration of Effect: 0.5-1.5 hrs0.5-1.5 hrs

• ResedationResedation

• SeizuresSeizures

Performance ImprovementPerformance Improvement

• All departments are responsible for PI activities All departments are responsible for PI activities related to moderate sedationrelated to moderate sedation

• Data collection monthly, quarterly reporting of Data collection monthly, quarterly reporting of complications on 6 PI indicators complications on 6 PI indicators

• All complications must be reported to All complications must be reported to Department of Anesthesiology PI Department of Anesthesiology PI representative A copy of the record needs to representative A copy of the record needs to be sent to Dr. A Patelbe sent to Dr. A Patel

• Moderate sedation data is presented at the Moderate sedation data is presented at the Invasive Procedure Committee and Hospital PI Invasive Procedure Committee and Hospital PI committeecommittee

P.I. IndicatorsP.I. Indicators

• Respiratory complications- Respiratory complications- need for oral need for oral airway, bag mask ventilation, intubation etc.airway, bag mask ventilation, intubation etc.

• Cardiovascular complications- Cardiovascular complications- hypotension, arrythmias, etc.hypotension, arrythmias, etc.

• Use of reversal drugsUse of reversal drugs

• Admission to hospital,if outpatientAdmission to hospital,if outpatient

• Pre sedation evaluation donePre sedation evaluation done

• Discharge criteria documentedDischarge criteria documented

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