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CRNA Practice
American Association of Nurse Anesthetists

Introduction
Although the safest care for the patient receiving sedation and analgesia is provided by a qualified anesthesia provider, a large number of registered nurses are involved in the administration of sedation and analgesia. To promote safe care during sedation and analgesia and to address questions which have been raised by nursing organizations and healthcare institutions with respect to the necessary qualifications of registered nurses involved in this care, the American Association of Nurse Anesthetists suggests the following policy considerations. These considerations do not supersede or give the effect to more restrictive relevant laws, regulations, judicial and administrative decisions and interpretations, accepted standards and scopes of practice established by professional nursing organizations, or institutional policies applicable to registered nurses, which should be reviewed prior to the development of any sedation and analgesia policy.

Definition
Sedation and analgesia describes a medically controlled state of depressed consciousness that allows protective reflexes to be maintained. The patient retains the ability to independently maintain his or her airway and to respond purposefully to verbal commands and/or tactile stimulation. The American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia has developed Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists which states "sedation and analgesia describes a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardio respiratory function and the ability to respond purposefully to verbal command and tactile stimulation. The Task Force decided that the term sedation and analgesia more accurately defines this therapeutic goal than does the more commonly used but imprecise term of ‘conscious sedation.’ Those patients whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than encompassed by sedation/analgesia."

The Joint Commission on Accreditation for Healthcare Organizations has introduced to their standards definitions for four levels of sedation and anesthesia. Minimal sedation where the patient responds normally; moderate sedation/analgesia (conscious sedation), where an airway and cardiovascular function is maintained; deep sedation/analgesia, in which the patient is not easily aroused; and, anesthesia, in which patients require assisted ventilation. Sedation and analgesia may easily be converted to deep sedation and the loss of consciousness because of the agents used and the physical status and drug sensitivities of the individual patient. The administration of sedation and analgesia requires constant monitoring of the patient and ability of the administrator to respond immediately to any adverse reaction or complication. Vigilance of the administrator and the ability to recognize and intervene in the event complications or undesired outcomes arise are essential requirements for individuals administering sedation and analgesia.

A. Qualifications

1. The registered nurse is allowed by state law and institutional policy to administer sedation and analgesia.
2. The health care facility shall have in place an educational/credentialing mechanism which includes a process for evaluating and documenting the individual’s competency relating to the management of patients receiving sedation and analgesia. Evaluation and documentation occur on a periodic basis.
3. The registered nurse managing and monitoring the care of patients receiving sedation and analgesia is able to:

• Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmia recognition and complications related to sedation and analgesia sedation and medications.
• Assess the total patient care requirements before and during the administration of sedation and analgesia, including the recovery phase.
• Understand the principles of oxygen delivery, transport and uptake, respiratory physiology, as well as understand and use oxygen delivery devices.
• Recognize potential complications of sedation and analgesia sedation for each type of agent being administered.
• Posses the competency to assess, diagnose, and intervene in the event of complications and institute appropriate interventions in compliance with orders or institutional protocols.
• Demonstrate competency, through ACLS or PCLS, in airway management and resuscitation appropriate to the age of the patient.
• The registered nurse administering sedation and analgesia understands the legal ramifications of providing this care and maintains appropriate liability insurance.

1. Guidelines for patient monitoring, drug administration, and protocols for dealing with potential complications or emergency situations, developed in accordance with accepted standards of anesthesia practice, are available.
2. A qualified anesthesia provider or attending physician selects and orders the agents to achieve sedation and analgesia.
3. Registered nurses who are not qualified anesthesia providers should not administer agents classified as anesthetics, including but not limited to Ketamine, Propofol, Etomidate, Sodium Thiopental, Methohexital, Nitrous oxide and muscle relaxants.
4. The registered nurse managing and monitoring the patient receiving and analgesia sedation shall have no other responsibilities during the procedure.
5. Venous access shall be maintained for all patients having sedation and analgesia.
6. Supplemental oxygen shall be available for any patient receiving sedation and analgesia, and where appropriate in the post procedure period.
7. Documentation and monitoring of physiologic measurements including but not limited to blood pressure, respiratory rate, oxygen saturation, cardiac rate and rhythm, and level of consciousness should be recorded at least every 5 minutes.
8. An emergency cart must be immediately accessible to every location where and analgesia sedation is administered. This cart must include emergency resuscitative drugs, airway and ventilatory adjunct equipment, defibrillator, and a source for administration of 100% oxygen. A positive pressure breathing device, oxygen, suction and appropriate airways must be placed in each room where and analgesia sedation is administered.
9. Back-up personnel who are experts in airway management, emergency intubations, and advanced cardiopulmonary resuscitation must be available.
10. A qualified professional capable of managing complications is present in the facility and remains in the facility until the patient is stable.
11. A qualified professional authorized under institutional guidelines to discharge the patient remains in the facility to discharge the patient in accordance with established criteria of the facility.

Barr J, Donner A: Optimal Intravenous Dosing Strategies for Sedatives and Analgesics in the Intensive Care Unit. Critical Care Clinics. 1995;1 1:4:827-847.

Finnie G: Conscious sedation and plastic surgery. Specialty Nursing Forum. 1990;2:8.

Gunn IP: The many issues regarding IV conscious sedation. Specialty Nursing Forum. 1990;2:2.

Harvard minimal monitoring standards. JAMA. 1986;256:8.

Holzman RS, Cullen DJ, Eichhorn JK Philip JH: Guidelines for Sedation by Non-anesthesiologists during Diagnostic and Therapeutic Procedures. Journal of Clinical Anesthesia. 1994;6

Joint Commission on Accreditation of Health Care Organizations. Care of Patients-Examples for Use of Anesthesia and Conscious Sedation. JCAHO Accreditation Manual for Hospitals. 1996; 194-201.

Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals, The Official Handbook. 2000;

Kallar SK- Conscious sedation for outpatient surgery. Wellcome Trends in Anesthesiology. 1991;9:3-5, 8-9.

Kingsbury JA: IV Conscious sedation: JCAHO and hospital issues. Specialty Nursing Forum. 1990;2:7- 8.

Nemiroff MS: IV Conscious Sedation: Essential Techniques of Monitoring. Trends in Health Care, Law & Ethics. 1993;8-1:87-94

Nursing Care of the Patient Receiving Conscious Sedation in the Gastrointestinal Endoscopy Setting. Society of Gastroenterology Nurses and Associates, Inc. Rochester, New York. 1991.

Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 1996; 84;459-71.

Qualified Providers of Conscious Sedation. American Association of Nurse Anesthetists Position Statement. Park Ridge, IL: American Association of Nurse Anesthetists. 1996; 2.2

Position Statement on the Role of the Registered Nurse (RN) in the Management of Patients Receiving IV Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures. ANA Collaborative Statement. Washington, DC. American Nurses Association. 1991.

Spry CC: Perioperative nurses should keep monitoring within their specialty. AORN Journal. 1990;51:1071-1072.

Watson DS: Recommended practices for monitoring and administering IV conscious sedation. Specialty Nursing Forum. 1990;2:3.

Council for Public Interest in Anesthesia

See the state-by-state regulations governing RNs in regards to administering sedation and analgesia: http://www.ncsbn.org/news/stateupdates_state_sedation.asp