Conscious sedation

Prof.Med. Nabil H. Mohyeddin
Board certified�Intensive care &Anesthesiology
Meeqat General Hospital,Medinah

1. Prof.Med. Nabil H. MohyeddinProf.Med. Nabil H. Mohyeddin
Board certifiedBoard certified
Intensive care &AnesthesiologyIntensive care &Anesthesiology
Rostock UniversityRostock University
Academic College, Berlin, Germany Academic College, Berlin, Germany
E-mail: [email protected]: [email protected]
Conscious sedationConscious sedation

2. Objectives & Sedation Objectives & Sedation
DefinitionsDefinitions

3. GoalsGoals
•To provide safe sedation/analgesia To provide safe sedation/analgesia
((Guard patient safety)Guard patient safety)
•To decrease adverse psychological To decrease adverse psychological
responsesresponses
•To facilitate procedural ease through:To facilitate procedural ease through:
1.1. Minimize pain of procedure.Minimize pain of procedure.
2.2. Minimize fear and anxiety.Minimize fear and anxiety.
3.3.Control behavior.Control behavior.
4.4.Provide amnesia.Provide amnesia.

4. Minimal Sedation (AnxiolysisMinimal Sedation (Anxiolysis((
•A drug-induced state during which A drug-induced state during which
patients respond normally to verbal patients respond normally to verbal
commands. Although cognitive commands. Although cognitive
function and coordination may be function and coordination may be
impaired, ventilatory and impaired, ventilatory and
cardiovascular functions are cardiovascular functions are
unaffected.unaffected.

5. Moderate SedationModerate Sedation
•A drug induced depression of A drug induced depression of
consciousness during which patients consciousness during which patients
cannot be easily arouse, but respond cannot be easily arouse, but respond
purposefully following repeated or purposefully following repeated or
painful stimulation. No interventions painful stimulation. No interventions
are required to maintain a patent are required to maintain a patent
airway, and spontaneous ventilation is airway, and spontaneous ventilation is
adequate. Cardiovascular function is adequate. Cardiovascular function is
usually maintained.usually maintained.

6. Deep SedationDeep Sedation
•A drug-induced depression of consciousness A drug-induced depression of consciousness
during which patients cannot be easily during which patients cannot be easily
aroused, but respond purposefully following aroused, but respond purposefully following
repeated or painful stimulation. The ability to repeated or painful stimulation. The ability to
independently maintain ventilatory function independently maintain ventilatory function
may be impaired. Patient may require may be impaired. Patient may require
assistance in maintaining a patent airway and assistance in maintaining a patent airway and
spontaneous ventilation may be inadequate. spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained. Cardiovascular function is usually maintained.

7. Level of
Consciousness
Awake
Analgesia
Anxiolysis
Hypnosis
“Conscious
Sedation”
Deep
Sedation
General
Anesthesia
The Spectrum of Sedation
Patients may travel quickly in either direction along this spectrum!
Protective
Reflexes
Potential
Loss
Potential
Loss
Present Total LossPresent
ED/Transport Mgmt

10. Pharmacology Pharmacology
ofof
SedativesSedatives

11. Common Medications forCommon Medications for
Sedation & Analgesia Sedation & Analgesia
•BenzodiazepinesBenzodiazepines
•OpioidsOpioids
•Sedative-hypnoticsSedative-hypnotics
•Neuroleptics Neuroleptics
•Anaesthetic agentsAnaesthetic agents

12. Common Medications forCommon Medications for
SedationSedation & Analgesia & Analgesia
•Desired actions of drugs used for sedation:Desired actions of drugs used for sedation:
•Short duration of actionShort duration of action
•Lack of cumulative effectsLack of cumulative effects
•Promote rapid recoveryPromote rapid recovery
•Minimal side-effectsMinimal side-effects
•Residual analgesiaResidual analgesia
•UnfortunatelyUnfortunately, no single pharmacological , no single pharmacological
agent satisfies all requirements. Generally agent satisfies all requirements. Generally
have to combine medications.have to combine medications.

13. List of TermsList of Terms
•Because of the wide range Because of the wide range
of settings in which this of settings in which this
presentation will be presentation will be
viewed, a list of generic viewed, a list of generic
and proprietary drug and proprietary drug
names is presented. names is presented.
Please refer to this slide as Please refer to this slide as
necessary throughout the necessary throughout the
presentation.presentation.
•Alprazolam = XanaxAlprazolam = Xanax
•Diazepam = ValiumDiazepam = Valium
–Lorazepam = AtivanLorazepam = Ativan
•Midazolam = VersedMidazolam = Versed
•Propofol = DiprivanPropofol = Diprivan
•Ketamine= ketalarKetamine= ketalar
•FentanylFentanyl
•Mepiridine = pethidineMepiridine = pethidine
•Naloxone = NarcanNaloxone = Narcan
•Flumazinil = RomaziconFlumazinil = Romazicon
–Methohexital = BrevitalMethohexital = Brevital
•Sodium Thiopental = Sodium Thiopental =
Sodium PentothalSodium Pentothal

14. BenzodiazepinesBenzodiazepines
•Actions:Actions:
•Potentiate the effects of the neuroinhibitor Potentiate the effects of the neuroinhibitor
GABA.This creates anticonvulsant, amnesic and GABA.This creates anticonvulsant, amnesic and
sedative effects.sedative effects.
•Mimic inhibitory actions of Glycine. Causing Mimic inhibitory actions of Glycine. Causing
muscle relaxation and anxiolysis.muscle relaxation and anxiolysis.
•Benzodiazepines affect the limbic system, Benzodiazepines affect the limbic system,
thalamus and hypothalamus.thalamus and hypothalamus.

15. BenzodiazepinesBenzodiazepines
•Indicated for:Indicated for:
•AnxietyAnxiety
•InsomniaInsomnia
•SeizuresSeizures
•Muscle relaxationMuscle relaxation
•Induction of general anaesthesiaInduction of general anaesthesia
•Preoperative sedationPreoperative sedation
•Conscious sedationConscious sedation
•Alcohol withdrawalAlcohol withdrawal
•Most commonly used types:Most commonly used types:
•Diazepam, Lorazepam and Diazepam, Lorazepam and MidazolamMidazolam

16. BenzodiazepinesBenzodiazepines
•Benzodiazepines have no analgesic properties.Benzodiazepines have no analgesic properties.
•Combining sedatives and opoids creates a Combining sedatives and opoids creates a
synergistic action.synergistic action.
•Recommended to reduce dose of benzodiazepine Recommended to reduce dose of benzodiazepine
and opiod by 1/3 when giving concurrently.and opiod by 1/3 when giving concurrently.

17. Watch OutWatch Out!!
•Contraindications:Contraindications:
•Acute narrow angle glaucomaAcute narrow angle glaucoma
•Untreated open angle glaucomaUntreated open angle glaucoma
•ShockShock
•ComaComa
•Acute alcohol intoxicationAcute alcohol intoxication
•Children<6 months oldChildren<6 months old

18. Benzodiazepines : Adverse Benzodiazepines : Adverse
effectseffects
•Respiratory:Respiratory:
•Respiratory depression,apnoea,respiratory arrest Respiratory depression,apnoea,respiratory arrest (especially (especially
Midazolam)Midazolam)
•CV:CV:
•Diazepam-SVR and CODiazepam-SVR and CO
•Midazolam-hypotension and bradycardiaMidazolam-hypotension and bradycardia
•CNS:CNS:
•Diazepam-drowsiness, confusion,slurred speech, syncopeDiazepam-drowsiness, confusion,slurred speech, syncope
•Midazolam-agitation, hyperactivity, involuntary movement, Midazolam-agitation, hyperactivity, involuntary movement,
combativenesscombativeness

19. Midazolam (VersedMidazolam (Versed((
•Rapid onset.Rapid onset.
•Short duration 20 - 30 minutes.Short duration 20 - 30 minutes.
•Dose Dose
•IV 0.1mg/kg max. 5mg., onset 2 - 3 min.IV 0.1mg/kg max. 5mg., onset 2 - 3 min.
•Oral 0.5mg/kg, onset 20 - 25 min.Oral 0.5mg/kg, onset 20 - 25 min.
•Intranasal 0.4mg/kg, onset 15 - 20 min.Intranasal 0.4mg/kg, onset 15 - 20 min.
•Rectal 0.5mg/kg, onset 5 - 10 min.Rectal 0.5mg/kg, onset 5 - 10 min.

20. OpioidsOpioids
•The opioids provide analgesia and The opioids provide analgesia and
some sedation, as well as some sedation, as well as
alterations of mood and perception alterations of mood and perception
of surroundings. They may also of surroundings. They may also
depress cough reflexes.depress cough reflexes.
•Examples includeExamples include
–morphinemorphine
–hydromorphone hydromorphone
–meperidinemeperidine
–fentanylfentanyl depicted at rightdepicted at right
•Some opioids like meperidine and Some opioids like meperidine and
fentanyl are synthetic substances, fentanyl are synthetic substances,
while others are natural.while others are natural.

21. Mepiridine (pethidineMepiridine (pethidine((
•MeperidineMeperidine should be used cautiously in should be used cautiously in
patients with renal/hepatic disease, those at patients with renal/hepatic disease, those at
risk for seizure due to accumulation of its risk for seizure due to accumulation of its
active metabolite, normeperidine, and in active metabolite, normeperidine, and in
those with little cardiac reserve.those with little cardiac reserve.
•0.5-2 mg/kg iv bolus, may repeat as 0.5-2 mg/kg iv bolus, may repeat as
necessary.necessary.
•Not used in pediatric patients.Not used in pediatric patients.

22. FentanylFentanyl
•FentanylFentanyl may cause chest wall and glottic may cause chest wall and glottic
rigidity, particularly when administered rigidity, particularly when administered
rapidly. This may make manual rapidly. This may make manual
ventilation very difficult.ventilation very difficult.
•Route: IVRoute: IV
•Onset: 1-3 minOnset: 1-3 min
•Duration: 30-60 minDuration: 30-60 min
•Adult dose: 25-50 mcg/doseAdult dose: 25-50 mcg/dose

23. •Propofol is widely Propofol is widely
distributed in the body distributed in the body
and is eliminated via and is eliminated via
hepatic & pulmonary hepatic & pulmonary
systems. systems.
•No dosage adjustments No dosage adjustments
necessary in patients with necessary in patients with
hepatic/renal disease.hepatic/renal disease.
•To prevent hypotension To prevent hypotension
consider reduced doses consider reduced doses
in the elderly, in the elderly,
hypovolemic, or patients hypovolemic, or patients
receiving other receiving other
narcotics/sedatives.narcotics/sedatives.
•Supports rapid bacterial Supports rapid bacterial
growth; discard 6 hrs growth; discard 6 hrs
after opening.after opening.

24. Propofol (DiprivanPropofol (Diprivan((
•Experience in emergency department Experience in emergency department
limited.limited.
•Short acting, nonopioid sedative Short acting, nonopioid sedative
hypnotic.hypnotic.
•Dose, 1 - 2 mg/kg IV over 1 - 2 min Dose, 1 - 2 mg/kg IV over 1 - 2 min
followed by infusion of 6mg/kg/hour.followed by infusion of 6mg/kg/hour.
•Duration, 8 - 10 min.Duration, 8 - 10 min.
•Side effectsSide effects
•Deeper sedation.Deeper sedation.
•Cardiorespiratory depression. (hypotension 3-10%)Cardiorespiratory depression. (hypotension 3-10%)
•Pain at injection site.Pain at injection site.
•Contraindicated in patients with hypersensitivity Contraindicated in patients with hypersensitivity
to eggs.to eggs.

25. KetamineKetamine
•SedativeSedative
•AmnesiaAmnesia
•Powerful analgesicPowerful analgesic
•General anaesthesiaGeneral anaesthesia

26. Ketamine: Adverse effectsKetamine: Adverse effects
•CNS: muscle tone, emergence reaction:e.g CNS: muscle tone, emergence reaction:e.g
hallucinations, delirium, tremors, increase hallucinations, delirium, tremors, increase
intracranial pressureintracranial pressure
•CV: increase BP, tachycardia, decrease BP CV: increase BP, tachycardia, decrease BP
in hypovolaemic patientsin hypovolaemic patients
•Respiratory: copious secretions (pre-treat Respiratory: copious secretions (pre-treat
with atropine)with atropine)

27. Ketamine: Ketamine:
Contra-indicationsContra-indications
•Hypertension, heart failure, recent Hypertension, heart failure, recent
MI, history of cardiovascular diseaseMI, history of cardiovascular disease
•Increased intracranial pressureIncreased intracranial pressure
•Increased intraocular pressureIncreased intraocular pressure
•Acute psychiatric illnessAcute psychiatric illness
•ThyrotoxicosisThyrotoxicosis

28. BarbituratesBarbiturates
•Barbituates include Barbituates include
sodium pentothal and sodium pentothal and
methohexital. methohexital.
•Barbiturates provide Barbiturates provide
sedation but no sedation but no
analgesia.analgesia.

29. Reversal AgentsReversal Agents
•Naloxone:Naloxone:
–Dose for reversal. IV or IM or SC.Dose for reversal. IV or IM or SC.
•Titrate 0.01 - 0.1 mg/kg to desired effect.( 1-Titrate 0.01 - 0.1 mg/kg to desired effect.( 1-
2 mcg/kg over less than 30 seconds to 2 mcg/kg over less than 30 seconds to
reverse sedation. reverse sedation.
•May need multiple doses.( repeat every 2-3 May need multiple doses.( repeat every 2-3
min. )min. )
•Onset of action 1 - 2 min.Onset of action 1 - 2 min.
•Duration of action 20 - 60 min.Duration of action 20 - 60 min.

30. •Flumazenil (Anxat)Flumazenil (Anxat)
–Dose IV or IMDose IV or IM
•Pediatrics 0.01 - 0.2 mg/kg (max. Pediatrics 0.01 - 0.2 mg/kg (max.
0.2mg) May be repeated. Half dose q 1 0.2mg) May be repeated. Half dose q 1
min. min.
•Adults 0.2 mg bolus to total 1mg. May Adults 0.2 mg bolus to total 1mg. May
repeat q 10 min.repeat q 10 min.
•Onset of action 1 - 5 min.Onset of action 1 - 5 min.
•Duration of action 20 - 60 min.Duration of action 20 - 60 min.

31. Reversal AgentsReversal Agents
-,

32. Indications of conscious sedationIndications of conscious sedation::
–Fracture, dislocation reduction.Fracture, dislocation reduction.
–F.B. removalF.B. removal
–Laceration repairLaceration repair
–EndoscopyEndoscopy
–Pediatric Gyne .ExamPediatric Gyne .Exam
–Invasive procedure.Invasive procedure.
–OthersOthers

33. Complication of Complication of
SedationSedation

34. High risk patientsHigh risk patients
•The elderlyThe elderly
•Hepatic disordersHepatic disorders
•Renal disordersRenal disorders
•Respiratory disordersRespiratory disorders
•Cardiac disordersCardiac disorders
•Drug abusersDrug abusers
•Obese patientsObese patients

35. MonitoringMonitoring
•Vigilant monitoring is the Vigilant monitoring is the
key to prevention of overdose key to prevention of overdose
and other potential and other potential
complicationscomplications

36. SedationSedation
•Sedation failure:Sedation failure:
–Could be due to unsuitability of the patient , orCould be due to unsuitability of the patient , or
–Problems with medicationsProblems with medications
•Excessive sedationExcessive sedation
–Can be avoided by:Can be avoided by:
•Monitoring level of consciousness(i.e Ramsey Monitoring level of consciousness(i.e Ramsey
score)score)
•Titration of medicationsTitration of medications

37. Respiratory depression & Respiratory depression &
hypoventilationhypoventilation
•Detected by:Detected by:
•Decrease in oxygen saturationDecrease in oxygen saturation
•Decrease in rate and depth of respirationsDecrease in rate and depth of respirations
•Treatment:Treatment:
•Stimulate patientStimulate patient
•Open airwayOpen airway
•Give oxygenGive oxygen
•If the above steps are unsuccessful,ventilate with If the above steps are unsuccessful,ventilate with
ambu-bag. If the condition does not improve or ambu-bag. If the condition does not improve or
the patient stops breathing, intubate.the patient stops breathing, intubate.

38. Cardiac complications & Cardiac complications &
hypotensionhypotension
•Cardiac arrythmias:Cardiac arrythmias:
•Must be recognized and treated quickly for Must be recognized and treated quickly for
positive patient outcomespositive patient outcomes
•Hemodynamic instability, caused Hemodynamic instability, caused
by a variety of factors:by a variety of factors:
•HypovolaemiaHypovolaemia
•Myocardial ischaemiaMyocardial ischaemia
•MedicationsMedications
•AcidosisAcidosis
•Parasympathetic stimulationParasympathetic stimulation

39. Cardiac complications & Cardiac complications &
hypotensionhypotension
•Treatment:Treatment:
•IV fluidsIV fluids
•OxygenOxygen
•Vasopressors or specific Vasopressors or specific
agonists(avoid if possible)agonists(avoid if possible)

40. In conclusionIn conclusion
•If patient and medication If patient and medication
selection is appropriate and the selection is appropriate and the
patient is monitored adequately, patient is monitored adequately,
then the incidence of then the incidence of
complications due to complications due to
sedation/analgesia will be very sedation/analgesia will be very
low.low.

41. Staff Qualification & Staff Qualification &
PrivilegingPrivileging

42. Sedation policies & procedure Sedation policies & procedure
identifyidentify::
•Special qualifications or Special qualifications or
skills of staff involved in skills of staff involved in
sedation processsedation process

44. Sedation ProviderSedation Provider
•Any physician who is privileged.Any physician who is privileged.
•Anesthesiologists by nature of their Anesthesiologists by nature of their
specialty.specialty.
•Physician or dentist who is Physician or dentist who is
credentialed or privileged.credentialed or privileged.

45. The Sedation Provider should be The Sedation Provider should be
competent incompetent in::
•Techniques of various modes of sedationTechniques of various modes of sedation
•Appropriate monitoringAppropriate monitoring
•Response to complicationsResponse to complications
•Use of reversal agentsUse of reversal agents
•At least basic life supportAt least basic life support

46. Privileging of non-Privileging of non-
AnesthesiologistsAnesthesiologists
•Valid BLS Certification.Valid BLS Certification.
•Documented attendance and successful Documented attendance and successful
completion of an approved completion of an approved
Sedation/Analgesia Course.Sedation/Analgesia Course.
•Training curriculum clearly indicating that Training curriculum clearly indicating that
competency in providing Sedation/Analgesia competency in providing Sedation/Analgesia
is part of the qualification process for his/her is part of the qualification process for his/her
degree.degree.

47. Privileging of non-Privileging of non-
AnesthesiologistsAnesthesiologists
•Certificates of experience from his/her Chairman or Certificates of experience from his/her Chairman or
previous employer documenting that provision of previous employer documenting that provision of
Sedation/Analgesia is part of his/her clinical Sedation/Analgesia is part of his/her clinical
practice for a minimum of 5yrs.practice for a minimum of 5yrs.
•Attending and passing the Basic Competency Attending and passing the Basic Competency
Course provided by the Hospital Sedation Course provided by the Hospital Sedation
Committee.Committee.

48. Privileging of non-Privileging of non-
AnesthesiologistsAnesthesiologists
•Re-evaluation of Privileging on individual Re-evaluation of Privileging on individual
basis is mandated if:basis is mandated if:
•Invalid BLS.Invalid BLS.
•Less than 10 sedation/procedures per year.Less than 10 sedation/procedures per year.
•Failure to pass the basic competency course Failure to pass the basic competency course
provided by the Hospital Sedation provided by the Hospital Sedation
Committee.Committee.

49. Responsibilities of Sedation Responsibilities of Sedation
ProviderProvider
•Obtain ConsentObtain Consent
•Evaluate patient prior to procedureEvaluate patient prior to procedure
•Document the assessmentDocument the assessment
•Refer to Anesthesia Department if needed Refer to Anesthesia Department if needed
•Prescribe or administer medications as per his/her Prescribe or administer medications as per his/her
privilegeprivilege
•Ensure monitoring of patient’s progressEnsure monitoring of patient’s progress
•Present in procedure area throughout the entire Present in procedure area throughout the entire
procedure and remain on the premises of recovery area procedure and remain on the premises of recovery area
during recovery.during recovery.
•Ensure appropriate discharge of patient.Ensure appropriate discharge of patient.

50. Competencies required for Registered Competencies required for Registered
NurseNurse
•The nurse is competent in patient The nurse is competent in patient
monitoring, drug administration, and monitoring, drug administration, and
protocols for dealing with emergency protocols for dealing with emergency
situationssituations
•The nurse will have NO other The nurse will have NO other
responsibilities that would leave the responsibilities that would leave the
patient unattended or compromise patient unattended or compromise
continuous monitoring. continuous monitoring.

51. Competencies required for Registered Competencies required for Registered
NurseNurse
•The Nurse is able to demonstrate the The Nurse is able to demonstrate the
required knowledge of Pharmacology, and required knowledge of Pharmacology, and
complications related to medications.complications related to medications.
•Demonstrate monitoring requirements Demonstrate monitoring requirements
during sedation and recovery.during sedation and recovery.
•Understand the principles of oxygen delivery, Understand the principles of oxygen delivery,
respiratory physiology, transport and uptake, respiratory physiology, transport and uptake,
and demonstrate the ability to use oxygen and demonstrate the ability to use oxygen
delivery devices.delivery devices.

52. Competencies required for Registered Competencies required for Registered
NurseNurse
•Anticipate and recognize potential Anticipate and recognize potential
complications of sedation in relation to the complications of sedation in relation to the
type of medication being administered.type of medication being administered.
•Possess the requisite knowledge and skills Possess the requisite knowledge and skills
to assess, diagnose and intervene in the to assess, diagnose and intervene in the
event of complications or undesired event of complications or undesired
outcomes and to institute nursing outcomes and to institute nursing
interventions in compliance with orders.interventions in compliance with orders.

53. Competencies required for Competencies required for
Registered NurseRegistered Nurse
•Demonstrate skill in airway management and Demonstrate skill in airway management and
resuscitation principles.resuscitation principles.
•The Nursing Education Department will maintain The Nursing Education Department will maintain
an educational/competency validation mechanism an educational/competency validation mechanism
that includes demonstration of the knowledge, skill that includes demonstration of the knowledge, skill
and abilities related to the management of patients and abilities related to the management of patients
receiving sedation/analgesia.receiving sedation/analgesia.

54. Privileging for Privileging for
Registered NurseRegistered Nurse
•The Registered Nurse needs to have a The Registered Nurse needs to have a
valid: valid:
•BLS certificate BLS certificate
•IV Cannulation workshopIV Cannulation workshop
•ECG workshopECG workshop
•Sedation and Analgesia workshopSedation and Analgesia workshop

55. The Registered Nurse is Responsible The Registered Nurse is Responsible
forfor::
•Providing uninterrupted Providing uninterrupted
monitoring of the patient’s monitoring of the patient’s
physiological parametersphysiological parameters
•Assisting in supportive or Assisting in supportive or
resuscitation measures.resuscitation measures.

56. DocumentationDocumentation

57. Responsibilities of Sedation Responsibilities of Sedation
ProviderProvider
•
Obtain Consent (new requirement)Obtain Consent (new requirement)
•
Evaluate patient prior to procedureEvaluate patient prior to procedure
•
Document the assessmentDocument the assessment
•
Refer to Anesthesia if needed Refer to Anesthesia if needed
•
Prescribe or administer medications as per his/her Prescribe or administer medications as per his/her
privilegeprivilege
•
Ensure monitoring of patient’s progressEnsure monitoring of patient’s progress
•
Present in procedure area throughout the entire Present in procedure area throughout the entire
procedure and remain on the premises of recovery area procedure and remain on the premises of recovery area
during recovery.during recovery.
•
Ensure appropriate discharge of patient.Ensure appropriate discharge of patient.

58. DocumentationDocumentation
•
ASA ClassificationASA Classification
•
Airway classificationAirway classification
•
Physical examinationPhysical examination
•
Lab resultsLab results

59. ASA Classification of Physical StatusASA Classification of Physical Status
•
Class I Class I 
–
The patient has no organic, physiological, The patient has no organic, physiological,
biochemical or psychiatric disturbance. The biochemical or psychiatric disturbance. The
pathological process for which surgery is to be pathological process for which surgery is to be
performed is localized and does not entail a performed is localized and does not entail a
systemic disturbance. Examples: a fit patient systemic disturbance. Examples: a fit patient
with an inguinal hernia, a fibroid uterus in an with an inguinal hernia, a fibroid uterus in an
otherwise healthy woman. otherwise healthy woman. 

60. •
Class II Class II 
–
Mild to moderate systemic disturbance caused Mild to moderate systemic disturbance caused
either by the condition to be treated surgically or either by the condition to be treated surgically or
by other pathophysiological process. Examples: by other pathophysiological process. Examples:
Non-limiting organic heart disease, mild diabetes, Non-limiting organic heart disease, mild diabetes,
essential hypertension or anaemia (i.e. controlled essential hypertension or anaemia (i.e. controlled
systemic disease). Extreme obesity and chronic systemic disease). Extreme obesity and chronic
bronchitis may be included in this category. bronchitis may be included in this category. 
ASA Classification of Physical StatusASA Classification of Physical Status

61. •
Class III Class III 
–
Severe systemic disturbance or disease whatever Severe systemic disturbance or disease whatever
cause, even though it may not be possible to define cause, even though it may not be possible to define
the degree of disability with finality. Examples: the degree of disability with finality. Examples:
Severe limiting organic heart disease, severe Severe limiting organic heart disease, severe
diabetes with vascular complications, moderate to diabetes with vascular complications, moderate to
server degrees of pulmonary insufficiency, angina server degrees of pulmonary insufficiency, angina
pectoris or healed myocardial infarction (i.e. pectoris or healed myocardial infarction (i.e.
controlled systemic disease).controlled systemic disease).
ASA Classification of Physical StatusASA Classification of Physical Status

62. •Class IV Class IV
–Severe systemic disorders that are Severe systemic disorders that are
already life threatening, not always already life threatening, not always
correctable by operation. Examples: correctable by operation. Examples:
Patient with organic heart disease Patient with organic heart disease
showing marked signs of cardiac showing marked signs of cardiac
insufficiency, persistent angina, or insufficiency, persistent angina, or
active myocarditis, advanced degrees of active myocarditis, advanced degrees of
pulmonary hepatic, renal or endocrine pulmonary hepatic, renal or endocrine
insufficiency. insufficiency.
ASA Classification of Physical StatusASA Classification of Physical Status

63. •Class V Class V 
–The moribund patient who has little chance of survival The moribund patient who has little chance of survival
but is submitted to operation in desperation. Examples: but is submitted to operation in desperation. Examples:
Burst of aortic aneurysm with profound shock, major Burst of aortic aneurysm with profound shock, major
cerebral trauma with rapidly increasing intracranial cerebral trauma with rapidly increasing intracranial
pressure, massive pulmonary embolus. Most of these pressure, massive pulmonary embolus. Most of these
patients require operations as a resuscitative measure. patients require operations as a resuscitative measure.
(i.e. patients who are not expected to live more than 24 (i.e. patients who are not expected to live more than 24
hours). hours). 
ASA Classification of Physical StatusASA Classification of Physical Status

64. •
Class E Class E 
–
Any emergency procedure, is labelled E Any emergency procedure, is labelled E
in addition to one of the above classes in addition to one of the above classes
according to patient’s condition, e.g. II E according to patient’s condition, e.g. II E
or I E.or I E.
ASA Classification of Physical StatusASA Classification of Physical Status

65. Anesthesia ConsultationAnesthesia Consultation
•
Adult patient ASA III or above. Adult patient ASA III or above.
•
Pediatric patient ASA IV or above. Pediatric patient ASA IV or above.
•
Patients with complex airway problems. Patients with complex airway problems.
•
Previous failure of sedation / analgesia.Previous failure of sedation / analgesia.
•
Patient ASA I or above undergoing a diagnostic Patient ASA I or above undergoing a diagnostic
and / or therapeutic procedure(s) performed by a and / or therapeutic procedure(s) performed by a
physician / dentist who is not privileged to perform physician / dentist who is not privileged to perform
sedation / analgesia. sedation / analgesia.

67. HOW TO IMPLEMENT THE STANDARDSHOW TO IMPLEMENT THE STANDARDS

68. The BeginningThe Beginning
•Formulate a Task force for evaluation.Formulate a Task force for evaluation.
•Review the policy.Review the policy.
•Identify and Inspect the sedation areas.Identify and Inspect the sedation areas.
•Review the process of conduct of sedation, Review the process of conduct of sedation,
monitoring, record keeping.monitoring, record keeping.
•Review of departments policies.Review of departments policies.

69. GoalGoal
•Formulation of Hospital Policy.Formulation of Hospital Policy.
•Formulation of unified record Formulation of unified record
keeping.keeping.
•Formulation of a sedation Formulation of a sedation
committee.committee.
•Define the charges of the Define the charges of the
committee.committee.

70. Committee MembersCommittee Members
•Chairman: Chairman:
AnesthesiologistAnesthesiologist
•Members:Members:
•Physician Representative from major clinical departments.Physician Representative from major clinical departments.
•Nursing representative from Nursing education department.Nursing representative from Nursing education department.
•QM representative.QM representative.
•Clinical pharmacist.Clinical pharmacist.
•Admin AssisstantAdmin Assisstant

71. Committee ChargesCommittee Charges
•Survey & Certify Location(s) within the hospital meeting Survey & Certify Location(s) within the hospital meeting
the criteria of your policy.the criteria of your policy.
•Review & update the policy.Review & update the policy.
•Conduct and prepare a sedation/analgesia course for Conduct and prepare a sedation/analgesia course for
physician and nurses.physician and nurses.
•Certify physicians requesting sedation privileges.Certify physicians requesting sedation privileges.
•Certify nurses to monitor patients during sedation.Certify nurses to monitor patients during sedation.
•Monitor the practice and come up with recommendation Monitor the practice and come up with recommendation
to improve the quality of care.to improve the quality of care.

72. Committee ChargesCommittee Charges
•Receive quarterly reports and statistics from various Receive quarterly reports and statistics from various
clinical departments in relation to the practice of clinical departments in relation to the practice of
sedation.sedation.
•Receive and review quality indicator forms forwarded Receive and review quality indicator forms forwarded
from various departments in relation to the practice of from various departments in relation to the practice of
sedation.sedation.
•Submit a quarterly report to the hospital Q.I committee.Submit a quarterly report to the hospital Q.I committee.
•Forward an annual report to medical director about the Forward an annual report to medical director about the
practice of sedation/analgesia.practice of sedation/analgesia.

74. Audit & Quality ImprovementsAudit & Quality Improvements

75. how do we audit our practicehow do we audit our practice

76. Quality IndicatorsQuality Indicators
Used for monitoring of sedation/analgesia Used for monitoring of sedation/analgesia
performanceperformance
Completed by Sedation Assistant at the end Completed by Sedation Assistant at the end
of procedureof procedure
Sent to Quality Management Department Sent to Quality Management Department
for review and analysisfor review and analysis

77. why do we need to audit our why do we need to audit our
practicepractice

78. Adverse events or patterns of adverse Adverse events or patterns of adverse
events during moderate or deep sedation events during moderate or deep sedation
are analyzed.are analyzed.
Use information from data analysis to Use information from data analysis to
identify improvements or reduce (or identify improvements or reduce (or
prevent) adverse events.prevent) adverse events.

79. Hospital Sedation Hospital Sedation
CommitteeCommittee

80. RationaleRationale
•Maintain the quality of care.Maintain the quality of care.
•Maintain patient safety.Maintain patient safety.
•Central committee responsible Central committee responsible
about the practice of sedation. about the practice of sedation.

81. Hospital Sedation CommitteeHospital Sedation Committee
•A committee that is called and A committee that is called and
approved by the Hospital Director, or approved by the Hospital Director, or
equivalent, to be responsible about equivalent, to be responsible about
the practice of sedation/analgesia by the practice of sedation/analgesia by
non anaesthesiologist.non anaesthesiologist.

82. Committee MembersCommittee Members::
•Chairman: chair of the Anesthesiology Department, or an Chairman: chair of the Anesthesiology Department, or an
Anesthesiologist Nominated by the chair of the Anesthesia Department.Anesthesiologist Nominated by the chair of the Anesthesia Department.
•Nursing division representative: Director of Nursing Education.Nursing division representative: Director of Nursing Education.
•Quality management representative: quality management specialist.Quality management representative: quality management specialist.
•Department of Medicine representative: Chair or any physician Department of Medicine representative: Chair or any physician
nominated by the chair of the department.nominated by the chair of the department.
•Department of Surgery representative: Chair or any physician nominated Department of Surgery representative: Chair or any physician nominated
by the chair of the department.by the chair of the department.
•Department of Paediatrics/Paediatric Oncology representative.Department of Paediatrics/Paediatric Oncology representative.
•Department of Emergency & family medicine representative: Chair or Department of Emergency & family medicine representative: Chair or
any physician nominated by the chair of the department.any physician nominated by the chair of the department.
•Administrative Assistant.Administrative Assistant.

83. Committee Committee
ChargesCharges
•Survey and certify location(s) within the institute meeting the criteria of the hospital Survey and certify location(s) within the institute meeting the criteria of the hospital
policy.policy.
•Review and update that policy.Review and update that policy.
•Conduct and prepare a sedation/analgesia course for physicians and nurses.Conduct and prepare a sedation/analgesia course for physicians and nurses.
•Certifications of physicians requesting the privilege to administer sedation.Certifications of physicians requesting the privilege to administer sedation.
•Certifications of nurses to monitor patients during sedation.Certifications of nurses to monitor patients during sedation.
•Monitor the practice of sedation/analgesia in the hospital and come up with Monitor the practice of sedation/analgesia in the hospital and come up with
recommendation to improve the quality of care as deemed necessary.recommendation to improve the quality of care as deemed necessary.
•Receive quarterly reports and statistics forwarded from various clinical departments in Receive quarterly reports and statistics forwarded from various clinical departments in
relation to the practice of sedation/analgesia.relation to the practice of sedation/analgesia.
•Receive and review quality indicator forms forwarded from various departments in Receive and review quality indicator forms forwarded from various departments in
relation to the practice of sedation/analgesia.relation to the practice of sedation/analgesia.
•Forward an annual report to the Hospital Director, or equivalence about the practice of Forward an annual report to the Hospital Director, or equivalence about the practice of
sedation/analgesia.sedation/analgesia.
•To conduct research in the field of sedation/analgesia for the purpose of improvement To conduct research in the field of sedation/analgesia for the purpose of improvement
of the quality of care.of the quality of care.

84. •overover