Achieving a minimal level of sedation with the smallest possible dose of anesthetic is the ideal course of conscious sedation. When done correctly, it maintains patients' protective reflexes, relaxes them enough to facilitate cooperation and causes a decrease in pain perception ' all factors leading to an easily aroused patient who's ready for a timely discharge.

But problems lurk with every push of the syringe. Patients may become agitated or combative. They may experience hypotension, hypoventilation, respiratory depression or airway obstruction and become difficult to arouse. The difference between an uneventful discharge and an unwanted event can be as slight as the targeted sedation level. Your staff must understand the properties of common anesthetics and must master each step of the sedation process by understanding the latest guidelines for monitoring the sedated patient.[1]

Down but not out
The Joint Commission, the American Association of Nurse Anesthetists and the American Society of Anesthesiologists collaborated to establish guidelines for administering intravenous sedation in 2003.[2] These guidelines are the foundation of the training staffers need to know before they can be considered qualified to administer IV sedation.

You must have the appropriate institutional credentials and privileges, such as state boards of nursing, professional associations and hospital staff and committee recognition, to administer conscious sedation. Each facility must develop a relevant protocol of definitions and regulations for sedation and anesthesia care, certification in basic life support and advanced cardiac life support. These rules should be focused on minimizing the risk of compromised airways during IV sedation.[3]

Patients should receive a pre-sedation assessment to be sure they're healthy enough for the procedure. The basis for this assessment is the history and physical examination and the patient's medication and allergy history. For sedation, you specifically want to look for:

• the patient's NPO status;
• baseline physiologic parameters such as LOC, BP, HR, EKG, RR and oxygen saturation;
• the state of the patient's airways; and
• a history of snoring or sleep apnea, which puts the patient at risk for respiratory complications.[2]

Sleep apnea tends to be common in obese patients because they hyperextend their necks and constrict their airways while sleeping. But now that the public is becoming more aware of sleep disorders, you may see thinner patients presenting with this condition.

With information gleaned from the pre-op assessment, anesthesia providers can determine the patient's appropriateness for sedation by finding her rank on the ASA's system for physical status classifications. This scale is arranged by the letter 'P' and a corresponding number between one and six. So a P1 patient is considered normal and healthy, while a P2 patient is considered to have a mild systemic disease that doesn't limit normal activities, such as controlled hypertension. Both of these patients would be suitable candidates for sedation in an outpatient setting. If the patient meets the criteria for P3 (she has a severe systemic disease that limits activities, such as stable angina) or a higher number, it's best to consult with an anesthesiologist to assess the risks versus the benefits of conscious sedation.

It's also crucial to be sure you have the right patient before you administer intravenous sedation. The Joint Commission requires two patient safety checks, such as looking at the patient's birth date and medical record number. After this, it's time to explain the procedure with its benefits and risks so the patient can comfortably provide informed consent.

What to watch for
After you consider the patient's age, body mass and overall health, it's still difficult to predict how an individual receiving medication will respond. Chronic alcohol use or certain medications may activate the patient's liver enzymes, meaning she could require higher doses. In contrast, patients with a history of smoking or pulmonary disease may have lower blood saturation rates, meaning anesthetic doses will have more effect.

That considered, when the needle is inserted, the responsibility shifts from assessment to monitoring. It's best to push the chosen anesthetic and assess the patient's response before pushing again. You should document the medications administered (noting the agent's name, dose and route) and the patient's vital signs and level of physiologic parameters every 5 minutes. Part of the routine should include checking the patient's response to verbal commands.

This sort of monitoring doesn't prevent a clinician from participating in the procedure (some anesthesiologists and nurse anesthetists may disagree with that), but it does mean the anesthetist or RN needs to have a clear view of the patient. The IV sedation nurse does not need to be scrubbed or sterile, but opening catheters and handling instruments may be permitted as long as she can still perform her monitoring duties. All monitoring documentation must be done in writing to identify trends and to ensure timely interventions are made; any circumstances that prevent periodic written monitoring and patient assessment are unacceptable.

The ASA practice guidelines state that healthcare providers administering intravenous sedation must be prepared to rescue patients from any level of sedation, including general anesthesia.[2] This means you must never give an elective anesthetic with the potential for airway loss without the presence of both a designated physician and nurse who has successfully demonstrated competence in the administration of intravenous sedation and cardiac monitoring. It is absolutely necessary to have a physician supervising efforts to provide emergent intervention if the patient slips into deep sedation; if this role is served by a non-anesthesia specialized physician, he should be capable of assessing the need to consult an anesthesiologist for support.

In addition to the right personnel, you need the right equipment. Make sure the following emergency equipment is onhand and working:

• crash cart,
• suction equipment,
• emergency medications,
• reversal agents, and
• additional intravenous fluids.

If an adverse event escalates to a situation requiring the use of reversal agents, such as naloxone for opiates or flumazenil for benzodiazepines, the Joint Commission requires you to continuously monitor the patient's vital signs for at least an hour afterwards. These reversal agents are fast-acting, but it's impossible to tell how the patient will react. If the patient does not wake up after an hour and still has irregular vital signs, the anesthesiologist must re-evaluate the reasons for this outcome.

After adverse situations are resolved, physicians should write out a quality variance report to describe what happened and try to determine what went wrong. This can help pinpoint the problem and reduce the future risk of oversedation.

Ready to go home
The post-procedure assessment and documentation for IV sedation consists of using the same physiologic parameters you've monitored every five minutes for the first 30 minutes after sedation agents are administered. In recovery, a modified Aldrete system is used to assess the patient's vital signs, oxygen saturation (which should be back at the patient's baseline level), orientation to person, place and time and ability to voluntarily move her extremities.[4] Before clearing a patient for discharge, also check the patient's ability to swallow fluids, cough or otherwise demonstrate a gag reflex, verbalize a level of comfort and walk as well as she did before the procedure.

If the patient has an Aldrete score of nine or greater, she has adequately recovered from sedation. If this isn't the case, consult with the anesthesiologist for treatment protocols. Only the very worst cases will call for CPR, but it's important to make sure the staff is trained in this technique.

Each facility has its own criteria for post-sedation discharge. The Joint Commission's regulations are a great foundation, and from there your anesthesia committee can develop protocols for determining when a patient is ready to go home. Once they leave your facility, patients should rest, avoid driving or drinking alcohol and start eating again with soup or other light foods.

References:
1. Dlugose D. Strategies for Safe and Effective Sedation. Gastroenterology Nursing. 2007;30(2):147.
2. Bragg K, O'Donnnell JM, Sell S. Procedural sedation: Safely navigating the twilight zone. Nursing. 2003;33:36-44.
3. Moon M, Sporton S. Nurse administration of intravenous (IV) moderate sedation. Nursing in Critical Care. 2001;6:285-292.
4. Aldrete JA. The post-anesthesia recovery score revisited. Journal of Clinical Anesthesia. 1995;7:89'91.