If you offer endoscopy at your facility, chances are your physicians are employing some form of conscious sedation during upper and lower GI procedures. Conscious sedation is clinically defined by two critical factors: like other forms of sedation, it is a depressed level of consciousness; however, patients are able to breathe on their own, and they are also able to respond to physical stimulation and verbal commands.

In many cases, endoscopists elect to manage the anesthesia of these cases themselves. The question of whether they are qualified to do so without the help of an anesthesia provider has caused some controversy. The American Society of Anesthesiologists, recognizing that this practice will most likely continue to occur, recently assembled a team of non-anesthesiologists and anesthesia specialists and updated it's Guidelines for Sedation and Analgesia by Non-Anesthesiologists. The updates were published in October 2001 (available at www.asahq.org/practice/sedation/ sedation1017.pdf). The purpose of the guidelines is to help clinicians provide safe and effective anesthesia during diagnostic and therapeutic procedures.

We studied the ASA guidelines and talked to some endoscopists about how they ensure safety and effectiveness during conscious sedation, particularly when there is no anesthesia provider available. Four tips for doing so follow:

1. Select the right patients.
According to the ASA, there are five levels of patient classifications for evaluating a patient's physical status:

Class I: Normal, healthy patients;
Class II: Patients with mild systemic diseases;
Class III: Patients with severe systemic diseases;
Class IV: Patients with incapacitating diseases;
Class V: Patients suffering from life threatening illnesses, who are not expected to survive 24 hours.

The ASA recommends that non-anesthesiologists only administer conscious sedation to patients who fall in classes I through III; patients in classes IV and V require an anesthesia specialist's care.

"I only administer conscious sedation to class I, II, and III patients to avoid any unnecessary complications. I also avoid patients with a history of heart disease and pulmonary disease," says Jeffery Peters, MD, former president of the Society of American Gastrointestinal Endoscopic Surgeons. Some other conditions to watch out for include: abnormalities of the major organ systems; previous adverse experience with sedation as well as regional and general anesthesia; drug allergies, current medications and potential drug interactions; and history of tobacco, alcohol or substance use or abuse.

Myrna Mamaril, MS, RN, CPAN, CAPA, the former president of the American Society of PeriAnesthesia Nurses, recommends consulting with key surgeons and anesthesia specialists at your facility to develop standards for which patients require an anesthesia specialist's care (see sidebar).

No matter what the patient's status, careful pre-op screening and physical examination before the procedure are critical.

2. Designate a qualified individual, other than the practitioner performing the procedure, to monitor the patient throughout the procedure. "We have one nurse whose sole purpose is to monitor the patient during the procedure," notes Dr. Peters. Adds Ms. Mamaril, "The nurse monitoring the patient should have no other responsibilities. He or she should be ACLS trained and be able to recognize life threatening conditions, and he should understand the effects of the medications being used during the procedure." The three critical functions to monitor include: Patient's response to verbal commands: Monitoring a patient's response to verbal commands should be routine during conscious sedation to be sure the patient has not drifted into deeper levels of sedation. During procedures where a verbal response is not possible (such as upper endoscopy), the ability to give a "thumbs up" or any other indication of consciousness is sufficient indication that the patient will be able to control his airway and take deep breaths if necessary. Oxygen saturation: If available, it is best to use the variable pitch "beep" oximetry systems, according to the ASA. These devices give a continuous audible indication of the oxygen saturation reading. If the nurse is performing any other tasks during the surgery, she can still listen to the monitor without having to watch it. Breathing: The clinician who is monitoring the patient should continually check that the patient is breathing normally by either observation or listening to the patient's chest.

Developing or improving a conscious sedation policy To develop a standardized conscious sedation policy, first consult with yoursurgeons, anesthesia specialists, nurses, and if applicable, pharmacists. "It is very important to include your anesthesia specialists in this team," stresses Ms. Mamaril. "They are the specialists in this area, and they have the most knowledge about these drugs. They know what emergency situations might come up, how to handle them, and even better, how to prevent them." Ms. Mamaril also recommends consulting other similar facilities in your area for suggestions. The final policy should include the following: Define the levels of sedation and determine what the signs of each level are. Decide who is qualified to administer anesthesia, define each individual's specific duties during the procedure, and determine what sort of additional training, if any, the individual will need to perform these functions. Select your facility's pharmacological agents and establish what reversal agents you will need to keep on hand in case of an emergency. Establish a pre-operative fasting and prep protocol. Develop a pre-operative plan of care that includes a complete medical history and a standardized exam (ie. height, weight, and a review of systems) as well as standardized informed consent forms for both the procedure and the sedation/anesthesia. Determine what kinds of emergency equipment you should have on hand. Set up emergency contacts, such as anesthesiologists, or cardiovascular surgeons, who can be consulted in the case of an emergency. Develop standard discharge criteria. Once your policy is complete, involve everyone in its implementation. According to Ms. Mamaril, "When you have the surgeons and nurses involved from early on, they are much more receptive to the policy." You may want to put together worksheets or a video to help train your staff. At her facility, Ms. Mamaril has used an interactive approach for incorporating the conscious sedation policy by having annual competency days, where nurses do simulated scenarios where they have to demonstrate their critical thinking skills in emergency situations. She also provides the staff with self-learning packs containing current literature about conscious sedation to keep them up-to-date on the latest findings.

"We monitor the heart rate, respiratory rate, pulse oximetry, and blood pressure," says John H. Webb, MD, endoscopist with Gastroenterology Associates of North Mississippi and the Endoscopy Center of North Mississippi, Oxford, Miss. "We use monitors to check all of these signs , with the exception of respirations, which are monitored by the nurse."

3. Be prepared for an emergency.
The most common complications of sedation are related to respiratory or cardiovascular depression. All clinicians in the endoscopy suite should be trained to recognize symptoms of respiratory distress and be able to rescue patients who enter a state of deep sedation. One person in the suite should be trained in basic life support skills, including CPR and bag-valve-mask ventilation, and an individual with advanced life support skills, including tracheal intubation, defibrillation, and the use of resuscitation medications, should be in the immediate area (approximately one to five minutes away).

Keep emergency equipment in the suite to handle serious complications. "In our endoscopy suite we have a crash cart with suction, advanced airway equipment, and resuscitation medications, as well as a defibrillator," says Dr. Peters.

Ms. Mamaril stresses the need to think of all types of patients. "If you are performing a procedure on a child or a particularly obese or elderly patient you may need different equipment," she says.

4. Administer combinations of sedative agents with caution.
Although combinations of sedatives and opioids provide satisfactory moderate and deep sedation, these combinations may also increase the risk of ventilatory depression and hypoxemia. Combinations may be administered according to what the physician deems appropriate for the procedure and the condition of the patient. However, each component should be administered individually to achieve the desired effect. To decrease the risk of respiratory depression and airway obstruction, it's best to reduce the doses of each component and to continually monitor respiratory function.

"I have also found that it is safer to administer smaller incremental doses of the anesthesia," says Dr. Peters. "The physician must allow enough time between doses to allow the effect of each dose to be assessed before he administers more drugs. And when the sedatives are administered by non-intravenously, the physician should allow enough time for the drugs to be absorbed before more are administered."

"We basically use Demerol and Versed," Dr. Webb explains. "The nurses start with Versed and titrate to the patient's response. Demerol is used for pain control during the procedure. We do not use propofol at all. All of our patients are usually awake in the recovery area. We do have narcan and romazicon on hand for reversal if needed."