Michael R. "Ron" Eslinger
CAPT, USN, NC, RETIRED
RN, CRNA, APN, MA
Course Director

Ron Eslinger, Captain USN Nurse Corps Retired.  His positions included Chief CRNA and Assistant Department Head. He was Assistant Officer and Chief Nurse on the Navy Hospital Ship USNS Mercy. He also served as Officer-in-Charge Branch Medical Clinic, Parris Island, Marine Corps Recruit Depot, Director of Patient Services and Senior Executive Nurse Beaufort Navy Hospital.

Ron was instrumental in the development of the IV Conscious Sedation Certification Training for five Navy Hospitals.  He is currently owner of Healthy Visions Wellness Center, Oak Ridge, Tennessee.

Queston:
WHAT IS SEDATION?

MINIMAL SEDATION (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

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

DEEP SEDATION/ANALGESIA is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

GENERAL ANESTHESIA is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired. Because sedation is a continuum, it is not always possible to predict how an individual patient will respond. Hence, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. Individuals administering Moderate Sedation/Analgesia ("Conscious Sedation") should be able to rescue patients who enter a state of Deep Sedation/Analgesia, while those administering Deep Sedation/Analgesia should be able to rescue patients who enter a state of general anesthesia.

Question:
WHO CAN ADMINISTER Conscious Sedation?

Answer:
Conscious sedation is extremely safe when administered by qualified providers. Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, other physicians, dentists, and oral surgeons are qualified providers of conscious sedation. Specifically trained Registered Nurses may assist in the administration of conscious sedation.

Question:
WHO SHOULD MONITOR Conscious Sedation?

Answer:
Because patients can slip into a deep sleep, proper monitoring of conscious sedation is necessary. Healthcare providers monitor patient heart rate, blood pressure, breathing, oxygen level and alertness throughout and after the procedure. The provider who monitors the patient receiving conscious sedation should have no other responsibilities during the procedure and should remain with the patient at all times during the procedure.

Question:
WHAT ARE THE SIDE EFFECTS OF Conscious Sedation?

Answer:
A brief period of amnesia after the procedure may follow the administration of conscious sedation. Occasional side effects may include headache, hangover, nausea and vomiting or unpleasant memories of the surgical experience.

Question:
WHAT SHOULD PATIENTS EXPECT IMMEDIATELY FOLLOWING THE SURGICAL OR DIAGNOSTIC PROCEDURE?

Answer:
A qualified provider monitors the patient immediately following the procedure. Written postoperative care instructions should be given to the patient to take home. Patents should not drive a vehicle, operate dangerous equipment or make any important decisions for at least 24 hours after receiving conscious sedation. A follow-up phone call usually is made by the healthcare provider to check on the patient’s condition and answer any remaining questions.

QUESTIONS TO ASK ABOUT CONSCIOUS SEDATION

The following is a list of questions patients should ask prior to the surgical or diagnostic procedure:

Will a trained and skilled provider be dedicated to monitoring me during conscious sedation?

Will my provider monitor my breathing, heart rate, and blood pressure?

Will oxygen be available and will the oxygen content of my blood be monitored?
Are personnel trained to perform advanced cardiac life support?

Is emergency resuscitation equipment available on-site and immediately accessible in the event of and emergency?

Will a trained and skilled provider stay with me during my recovery period and for how long?

Should a friend or family member take me home?

Question:
Does my Facility have to stock Dantrolene?

Answer:
Yes, if you are using Triggering Agents.

Inhaled anesthetic agents such as halothane, enflurane, isoflurane and desflurane are known triggering agents for MH; by implication other inhaled agents, except nitrous oxide, are also considered triggers. The muscle relaxant succinylcholine is also a known trigger for MH.

Answer:
No, if you are using a Non-triggering Agents.

Non-triggering agents include all local anesthetics, nitrous oxide, benzodiazepines, no-depolarizing muscle relaxants, propofol barbiturates, ketamine and etomidate.

JCAHO Standard

Question:
Does the person administering sedation have to be qualified to monitor the patient if other staff who are present are qualified? 

Answer:
Standard PC.13.20 requires a sufficient number of staff, in addition to the person performing the procedure, be present to perform the procedure, monitor and recover the patient.

JCAHO Policy

The person administering the medication must be qualified to manage the patient at whatever level of sedation or anesthesia is achieved, either intentionally or unintentionally.
Must be able to manage one level deeper
There may be a need for additional monitoring personnel, but the person administering the sedation must be qualified to monitor the patient.

JCAHO Policy – Permission to Administer Moderate Sedation

Question:
Are specific privileges to administer moderate sedation required?

Answer:
The anesthesia care standards require that the individuals who are "permitted" to administer sedation are able to perform airway & cardiac rescue.

JCAHO Policy – Permission to Administer Moderate Sedation

Each organization is free to define how it will determine that the individuals are able to perform the required types of rescue. 
  
Acceptable examples include, but are not limited to, ACLS certification, a satisfactory score on a written examination developed in concert with the department of anesthesiology, a mock rescue exercise evaluated by an anesthesiologist.

With regard to non-Licensed Independent Providers (LIPs), such as nurses, who are permitted to administer the sedation, the permission could be found in the individual’s job description, or other documentation in their personnel file.

VA SEDATION DIRECTIVE
 
QUESTION
Would an LPN present in a room where moderate sedation is in use need to have special sedation training training?

ANSWER
The VA requires that those individuals, ordering, administering, and supervising moderate sedation in support of patient care must be qualified and have appropriate credentials.  Individuals administering, monitoring, and/or supervising moderate sedation must have had competency-based education, training, and experience.  If the LPN is administering, monitoring and/or supervising moderate sedation then training is required.  Otherwise training is not manditory.

QUESTION
Does use of inhalational Nitrous Oxide/Oxygen in a dental clinic setting fall under the moderate sedation directive?

ANSWER
No.  It should not be considered moderate sedation as there is no risk of deep sedation resulting as long as not combined with other agents.

QUESTION
What is the VA position on nurse administered Propofol for endoscopy?

ANSWER
It is not permitted, per the Directive.  Propofol can be adminstered only by people trained to rescue the patient from general anesthesia.  This could include an oral surgeon, for instance, since their training requires 3-6 months of anesthesia training.  If your LIP practitioners can document training and competence in general anesthesia, then they can use it.  This must be specifically stated in your hospital policy.

The VA policy on this is based on FDA approval -- Propofol is approved only for those trained in general anesthesia or for patients who are already intubated (ICU sedation).  The links below will take you to additional discussion of this issue.

http://www.ismp.org/newsletters/acutecare/articles/20051103.asp

http://www.medicalnewstoday.com/medicalnews.php?newsid=40846