Q: Which medication is best to administer first, Versed or Fentanyl?

Answer: The standard regimens for moderate sedation which combine a benzodiazepines and an opioid usually involve the intermittent administration of alternate bolus doses of each type of drug until a desired level of sedation is achieved. (see Benzodiazepines and opioids). There is currently no evidence indicating an advantage of starting with one type of drug over the other. The choice of which drug to administer first is often based on personal or institutional preference.

Q: Are there any recommendations for pain assessment to be done during moderate sedation? SGNA mentions it. How to document? A non-verbal scale?

Answer: The SGNA offers no specific recommendations for pain assessment, however, JCAHO requires that guidelines for pain management, sedation and anesthesia care be comparable throughout a given hospital or facility using an institutional approved scale.  A variety of pain assessment tools are available including visual analog, numeric intensity scales, and descriptive scales as well as vehicles that combine multiple elements. For pediatric patients, the Wong-Baker FACES Pain Rating Scale is often used.  For non-verbal patients such as elders with dementia, infants and young toddlers, and individuals who are unconscious, the use of behavioral pain assessments may be appropriate. Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations published by the Society for Pain Management Nursing discusses the use of these tools.

Reference:
Herr K et al. Pain Assessment in the Nonverbal Patient: Position Statement with Clinical Practice Recommendations. Pain Management Nursing;7: 44-52.

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Q: Can you tell me about treatment of laryngospasm?

Answer:  Laryngospasm is defined as an occlusion of the glottis closure due to reflexive constriction of the laryngeal muscles. It can be caused by irritation of the vocal cords from mucus, blood, or saliva, usually in patients in whom the level of anesthesia is too light to prevent the laryngospasm reflex.  The problem occurs more often in children than in adults. Poor management of laryngospasm can result in severe hypoxemia, pulmonary aspiration, and post-obstructive pulmonary edema.

Currently there is no definitive protocol for the management of laryngospasm although algorithms have been proposed including ones by Roy and Lerman and Hampson-Evans, et al.  Treatment consists of physical interventions, pharmacological interventions, or a combination of the two.  The generally accepted steps as described in anesthesiology texts involve: 1) initial treatment using positive airway pressure and 100% oxygen with jaw thrust and chin lift to optimize the airway; if unsuccessful, 2) deepening sedation; and finally 3) administration of a muscle relaxant to relax the vocal cords. 

In an effort to provide clinical data on the optimal type and sequence of therapeutic interventions for pediatric laryngospasm, Burgoyne et al. examined of patient records for 21,452 anesthesias performed over a three and a half year period at St. Jude's Children's Hospital in Memphis, Tenn.  Twenty-one cases of laryngospasm were reported. Of these, 38 percent of patients responded to CPAP and airway repositioning; 47.6 percent were given muscle relaxants; and 23.8 percent were intubated.

A manual technique first reported by Guadagni more than 40 years ago and more recently described by Larson involves placing the middle finger of each hand in the notch behind the lobule of the pinna of each ear, the "larnygospasm notch."  The patient's mandible is then lifted at a right angle to the plane of the body ("jaw thrust"), while inward pressure toward the base of the skull is maintained with the index fingers. Done correctly, the author reports that the maneuver will convert laryngospasm to unobstructed breathing within a few breaths.

In addition to the interventions described above, case reports have been published which outline other methods for resolving laryngospasm. These include an infusion of doxapram, the administration of IV nitroglycerine, or performing a superior laryngeal nerve block. However, these procedures should not be attempted by a practitioner without previous training and experience with these interventions.  

For the non-anesthesiologist, an appropriate primary goal in treating laryngospasm is to be able to accurately identify the problem and understand when to get help. If laryngospasm cannot be resolved quickly with initial attempts at positive pressure ventilation and airway maneuvers, the endoscopist should call for emergency assistance immediately.

Sources:

Alalami A, Ayoub C, Baraka A, Laryngospasm: review of different prevention and treatment modalities. Pediatric Anesthesia. 2008;18:281-288.

Burgoyne L, Anghelescu D. Intervention steps for treating laryngospasm in pediatric patients. Pediatric Anesthesia. 2008;18:297-302. 

Hampson-Evans, Morgan P, Farrar M. Pediatric laryngospasm. Pediatric Anesthesia. 2008;18:303-7.

Larson P. Laryngospasm-The Best Treatment. Anesthesiology. 1998; 89:1293-4.

Roy W, Lerman J. Laryngospasm in paediatric anesthesia. Can J Aneseth. 1998;35:93-8.

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Q: What are SGNA's guidelines regarding pediatric sedation-ie age, wt, PAL's requirements for RN's, etc

Answer: SGNA's Statement on the Use of Sedation and Analgesia in the Gastrointestinal Endoscopy Setting recommends that registered nurses and physicians involved in the administration of deep sedation have additional training with emphasis on advanced airway management, including Pediatric Advanced Life Support (PALS) and advanced training on airway management and on medications that can be used to achieve deep sedation or can lead to or easily induce a state of general anesthesia.  A registered nurse should be present to monitor the patient throughout the procedure and should have no other responsibilities.  The SGNA statement includes pediatrics in patient populations that may need special considerations, and provides additional resources, including the American Academy of Pediatrics Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.

For additional information on sedation in the pediatric population, see the SedationFacts Special Circumstances section for Pediatrics.

For additional information about SGNA, visit the SGNA web site, or contact SGNA by email or phone 800/245-7462.  

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Q: What should be the nurse to patient ratio for patients who have received moderate sedation (conscious sedation) for GI procedures?

Answer:  There is no specific guideline that addresses the nurse to patient ratio for GI procedures.  Individual State regulations may provide guidelines for Phase I and Phase II recovery.

While the Society of Gastroenterology Nurses and Associates (SGNA) does not recommend specific ratios, their Minimal RN Staffing position statement does address the minimum Registered Nurse staffing for patient care in the Gastrointestinal Endoscopy unit.  As stated, the requirements are at the very least:

The American Society of Perianesthesia Nursing (ASPAN) provides Nurse:Patient ratios for Phase I and Phase II Level of care in their Standards of Perianesthesia Nursing Practice - Patient Classification/Recommended Staffing Guidelines:

Phase I Level of Care

The perianesthesia registered nursing roles during this phase focus on providing postanesthesia nursing care to the patient in the immediate postanesthesia period, and transitioning them to Phase II level of care, the inpatient setting, or to an intensive care setting for continued care.

Two registered nurses, one of whom is a RN competent in Phase I postanesthesia nursing, are in the same unit where the patient is receiving Phase I level of care.

CLASS 1:2 ONE NURSE TO TWO PATIENTS WHO ARE

CLASS 1:1 ONE NURSE TO ONE PATIENT

CLASS 2:1 TWO NURSES TO ONE PATIENT

**Critical elements can be defined as:

• Report has been received from the anesthesia care provider, questions answered, and the transfer of care has taken place.
• Patient has a secure airway.
• Initial assessment is complete.
• Patient is hemodynamically stable.

***Examples of an unstable airway include, but are not limited to, the following:

• Requiring active interventions to maintain patency such as manual jaw lift or chin lift.
• Evidence of obstruction, active or probable, such as gasping, choking, crowing, wheezing, etc.
• Symptoms of respiratory distress including dyspnea, tachypnea, panic, agitation, cyanosis, etc.

Phase II Level of Care

The professional perianesthesia nursing roles during this phase focus on preparing the patient/family/significant other for care in the home, extended observation level of care or the extended care environment.

Two competent personnel, one of whom is a RN competent in Phase II postanesthesia nursing, are in the same unit where the patient is receiving Phase II level of care. A RN must be in the Phase II PACU at all times while a patient is present.

CLASS 1:3 ONE NURSE TO THREE PATIENTS

CLASS 1:2 ONE NURSE TO TWO PATIENTS

CLASS 1:1 ONE NURSE TO ONE PATIENT

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Q: What is MAC?

Answer: MAC refers to Monitored Anesthesia Care. For information about MAC, refer to the Sedation Administration section of SedationFacts.org or see the following references:

Nguyen, A. Monitored Anesthesia Care. The Internet Journal of Health. 2000;1(1)

American Society of Anesthesiologists Standards, Guidelines, and Statements. Distinguishing Monitored Anesthesia Care ("MAC") from Moderate Sedation/Analgesia (Conscious Sedation). 2008

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Q: Is there any literature to support the use of Benadryl to augment the effects of fentanyl and versed in a patient that is difficult to sedate for endoscopy procedures?

Answer: There are no studies that specifically address the use of of diphenhydramine hydrochloride in difficult-to-sedate patient populations . However, diphenhydramine acts synergistically with opioid-benzodiazepine combinations and may help achieve sedation in patients who are resistant to these agents.  It may also allow for the use of lower doses of standard medications.  The American Society for Gastrointestinal Endoscopy (ASGE) guideline Sedation and Anesthesia in GI Endoscopy (2008) endorses the use of the drug in under these circumstances.

In a randomized, double-blind study involving 258 patients undergoing moderate sedation for colonoscopy (Tu et al.) individuals received either 50mg of diphenhydramine or a placebo prior to the IV administration of a standard combination of meperidine and midazolam.  The diphenhydramine group showed better overall sedation scores.  In addition, meperidine usage was reduced by 10.1% and midazolam usage was reduced by 13.7% in the patients receiving diphenhydramine.

Side effects of diphenhydramine include hypotension, dizziness, blurred vision, urinary retention, wheezing, and stomach upset. The drug has a mild stimulatory effect on breathing which may counteract opioid-induced hypoventilation.

Sources:
DeLegge M, The difficult to sedate patient in the endoscopy suite. Gastsrointest Endoscopy Clin NA. 2008; 18:679-693.

American Society for Gastrointestinal Endoscopy Standards of Practice Committee. Guideline: Sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy. 2008;688:816-826.

Tu RH, Grewall P, Leung JW et al. Diphenhydramine as an adjunct to sedation for colonoscopy: a double-blind randomized, placebo-controlled study, Gastrointestinal Endoscopy. 2006; 63(1): 95-6.

Babenco HD, Blouin RT, Conard PF, Gross JB. Diphenylhydramine increases ventilatory drive during alfentanil infusion. Anesthesiology. 1998; 89:642-7. 

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Q: Is CO2 monitoring required for moderate sedation?   

Answer: Currently, there are no guidelines requiring CO2 monitoring during moderate sedation. The 2008 ASGE guideline on Sedation and Anesthesia in GI Endoscopy states that "hypoxemia resulting from depressed respiratory activity is a principal risk factor for adverse respiratory events during sedation, integrating capnography into patient monitoring protocols may improve safety." The document goes on to explain, "Currently, there is insufficient evidence to support its use during routine upper and lower endoscopic sedation. Data are available, however, for support its use during ERCP and EUS."

The ASA Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists recommends that "Monitoring of exhaled carbon dioxide should be considered for all patients receiving deep sedation and for patients whose ventilation cannot be directly observed during moderate sedation." 

For additional information on monitoring during sedation, please see the Patient Monitoring section of SedationFacts.org

In the pediatric population, current guidelines for sedation monitoring specify continuous pulse oximetry and visual assessment. However, a 2006 controlled trial [Lightdale et al.] involving 163 children receiving moderate sedation for elective gastroenterological procedures found that patients monitored with microstream capnography were significantly less likely to experience arterial oxygen desaturation than children in the control group. The authors conclude that incorporating CO2 monitoring into current protocols may ultimately improve safety of moderate sedation in children.

For additional information on sedation in children, please see the Pediatrics section of SedationFacts.org

Sources:

American Society for Gastrointestinal Endoscopy Standards of Practice Committee. Guideline: Sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy. 2008;688:816-826.

American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002; 96(4):1004-17.

Lightdale JR, Goldmann DA, Feldman HA, et al. Microstream capnography improves patient monitoring during moderate sedation: A randomized, controlled trial. Pediatrics 2006; 117:1170-1178.

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Q: Are there national recommendations for discharge instructions in regard to resuming regular activities, including driving, after receiving moderate sedation for endoscopic procedures?

Answer: The question of psychomotor recovery time following endoscopic sedation is a topic clearly in need of additional investigation. The American Society for Gastrointestinal Endoscopy Guidelines for Conscious Sedation and Monitoring During Gastrointestinal Endoscopy states that patients "should be instructed to make plans not to drive, operate heavy or potentially harmful machinery, or make legally binding decisions," but no time limit is specified for this prohibition.  The Guidelines for the Care of the Patient Receiving Conscious Sedation issued by the Canadian Society of Gastroenterology Nurses and Associates stipulates that patients should be advised against driving for 24 hours after receiving IV sedation.

Several studies suggest that the length of time that a patient needs to wait following sedation before driving may largely depend on the type of sedation medication that was used. Most endoscopy units rely on recovery scales such as the Aldrete Scoring System to evaluate a patient's readiness for discharge. However, these tools primarily evaluate cardiovascular and respiratory indicators and do not provide a sensitive assessment of a patient's psychomotor recovery.  For example, in a study by Willey et al. of patients receiving IV meperidine and midazolam for outpatient GI procedures, the average psychomotor recovery was only 60% to 70% of baseline by the time an Aldrete score of 10 was reached. The average psychomotor recovery at the time of discharge was 86.5%.

Due to its rapid onset and recovery profile, propofol-mediated sedation may have advantages for quicker psychomotor recovery.  A 2008 study by Horiuchi et al. evaluated post-procedure driving for patients receiving either low-dose propofol or midazolam for screening EGD.  In the propofol group, driving abilities had recovered to baseline levels within 60 minutes of administration but had not returned to baseline after 120 minutes for the midazolam group.

Similarly, a randomized, controlled study by Riphaus et al. compared psychomotor and driving skills of patients receiving either propofol or midazolam plus pethidine (meperidine) for sedation during routine endoscopic procedures.  The patients who received propofol had significantly faster recovery times and their driving skills were similar to baseline levels when tested two hours post-procedure.  However, the individuals in the midazolam/pethidine group had significantly more lane deviations, missed stoplights, and slower reaction times for unexpected events during simulated driving tests. The authors of this study suggest that the recommendation that patients refrain from driving for 24 hours after sedation can be reconsidered when propofol is used.

Sources:

Willey J, Vargo JJ, Connor JT, et al. Quantitative assessment of psychomotor recovery after sedation and analgesia for outpatient EGD. Gastsrointest Endosc. 2002;56:810-6.

Horiuchi A, Nakayama Y, Katsuyama Y, et al. Safety and driving ability following low-dose propofol sedation. Digestion. 2008;78:190-4.

Riphaus A, Gstettenbauer T, Frenz MB, et al. Quality of psychomotor recovery after propofol sedation for routine endoscopy: a randomized and controlled study. Endoscopy. 2006;38:677-83.

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Q: Where can I find protocols for prevention of nausea/vomiting for GI patients receiving moderate sedation.

Answer: Currently, there are three published guidelines (listed below) on the prevention and/or management of post-operative nausea and vomiting (PONV). Though none specifically addresses PONV in the context of moderate sedation, these documents include information on: risk factor identification and reduction; anti-emetic therapies and prophylaxis; and management approaches if PONV does occur.

PONV Guidelines

Gan TJ, et al. Consensus guidelines for managing postoperative nausea and vomiting. Anesth Analg. 2003 Jul;97(1):62-71.

American Society of PeriAnesthesia Nurses PONV/PDNV Strategic Work Team. ASPAN'S evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. J Perianesth Nurs. 2006 Aug;21(4):230-50.

Gan TJ, et al.  Society for Ambulatory Anesthesia guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2007 Dec;105(6):1615-28.

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Q: Where can I find information about sedation for pregnant women. What is safe to use?

Answer: For information about sedation for pregnant and lactating women, see the Special Circumstances  section of SedationFacts.org.

Q: What is the half life of versed and fentanyl?

Answer: Individually, the clearance time for midazolam and fentanyl is 1.8 - 6.4 hours and 3 - 4 hours, respectively.  Clearance may be prolonged in patients with compromised renal or hepatic function. A double-blind study of 30 patients receiving general anesthesia reported that the systemic clearance of midazolam was decreased by 30% and the elimination half-time was prolonged by 50% when fentanyl was administered simultaneously.  In the control group (which received fentanyl without midazolam) elimination time for fentanyl was similar to times reported in previous studies of i.v. administration of fentanyl without concomitant drugs.

Source: Hase Y, Oda K, Tanaka K, et al. I.V. fentanyl decreases the clearance of midazolam. British Journal of Anesthesia. 1997;79:740-743.

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Q: If a patient is chewing gum before a GI procedure, must there be a wait time before the patient can be sedated for the procedure?

Answer: The act of chewing gum raises gastric acid production and salivary flow therefore has the potential to increase the volume and acidity of gastric fluid. Because of this, patients are generally told to abstain from chewing gum for at least 2 hours prior to undergoing elective procedures to avoid the risk of aspiration of gastric acid.

Several studies have addressed the issue of gum-chewing within the 2-hour fasting interval with contradictory results.  In studies on adults, Dubin et al. found no increase in gastric fluid volume or acidity. Soreide et al. noted greater volume but no change in acidity in gastric fluid. Additionally, a study involving children by Schoenfelder et al. found that subjects who chewed sugared or sugarless gum immediately prior to surgery had both greater gastric fluid volume and higher levels of gastric fluid acidity than children in the control group who had not chewed gum.  However, the clinical significance of gastric fluid volume in patients without other risk factors on risk of pulmonary aspiration remains unclear. At this time more research is needed before a definitive recommendation can be made on whether procedures need to be delayed if a patient is chewing gum immediately prior to receiving anesthesia.

Sources
Dubin S, Jensen H, McCranie J, et al. Sugarless gum chewing before surgery does not increase gastric fluid volume or acidity. C J Anaesth 1994;41:603-6.
Soreide E, Holst-Larsen H, Veel T, et al. The effects of chewing gum on gastric content prior to the induction of general anesthesia. Anesth Analg 1995;80:985-9.
#109 Schoenfleder RC, Ponnamma CM, Freyle D, et al. Residual gastric fluid volume and chewing gum before surgery. Anesth Analg 2006;102:415-7. 

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Q: How long can you safely begin conscious (moderate) sedation for upper endoscopy after drinking milk?

Answer: The American Society of Anesthesiologists Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists (2002) recommends that healthy patients of all ages refrain from drinking non-human milk for 6 hours prior to an elective procedure. (Recommendations summarized below.) The length of the pre-procedure fasting period is influenced by individual patient response, total dose of drug administered, and the risk of the patient entering deep sedation.  Several factors can decrease gastric emptying including: diabetes, esophageal motility disorders; fear; obesity; opioids; pain; and trauma.

• These recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in labor. Following the Guidelines does not guarantee complete gastric emptying.
• The fasting periods noted above apply to all ages.
  
• Examples of clear liquids include: water, fruit juices without pulp, carbonated beverage, clear tea, and black coffee
  
• Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period.
  
• A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining appropriate fasting period.

This table and recommendations can be found in the Preparation for Sedation section of Patient Care and Safety on SedationFacts.org

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Q: Should ASC's be routinely equipped to handle the rare but serious complication of methemoglobinemia given the widespread use of benzocaine as a topical anesthetic for upper GI endoscopy? What is the standard dose of methylene blue and what is the shelf life and cost for stocking this agent for a busy ASC?

Answer: Policies and procedures may be facility-specific and are sometimes established as part of their AAAHC/JC/AAAASF/IMQ certification.  

The usual dose of methylene blue is 1 to 2 mg/kg of 1% solution intravenously over 5 min. The same dose may be repeated within 1 hour if symptoms of hypoxia fail to subside.

For other information on the use of benzocaine, see "Complications related to topical pharyngeal anesthetics" in the Risks and Safety section of SedationFacts.org

Other useful resources on this topic:

Moore TJ et al.  Reported Adverse Event Cases of Methemoglobinemia Associated with Benzocaine Products.  Archives of Internal Medicine  2004;164;1192-6

Curry SC, Carlton MW. Hematologic consequences of poisoning: methemoglobinemia. In:
Haddad LM, Shannon MW, Winchester JF, editors. Clinical management of poisoning and drug overdose. 3rd ed. Philadelphia: WB Saunders; 1998. p. 226–30.

Ellenhorn MJ. Ellenhorn's Medical toxicology: diagnosis and treatment of human poisoning. 2nd ed. Baltimore: Williams & Wilkins; 1997. p. 844–52.

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Q: Do you have literature intended for patients describing conscious sedation? If not, how is conscious sedation best explained so that patient expectations of their sedation experience are met? In our "Open Access Colonoscopy Program" our patient satisfaction scores seem to be most negatively affected by patients reporting they did not receive enough conscious sedation even though they are counseled by a nurse or medical assistant several days prior to the procedure.

Answer: Once referred to as "twilight sleep," the term "conscious sedation" is used to describe a semi-conscious state that allows patients to be comfortable during certain surgical or medical procedures. The appropriate term used today is "moderate sedation." The American Society of Anesthesiologists (ASA) produced a brochure that clarifies some of the information regarding "sedation analgesia" and describes the different levels of sedation as well as the purposes of sedation analgesia. Analgesia refers to the relief of pain that is often included in sedation techniques. 
This patient-friendly brochure is available on the Web at http://www.asahq.org/patientEducation/SedationBrochure.pdf

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Q: What is the SGNA standard for how often vitals have to be documented during a endoscopic procedure with conscious (moderate) sedation?

Answer: The SGNA uses the guidelines set forth by the ASA in Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists, which states the following: "For both moderate and deep sedation, a majority of the consultants indicated that vital signs should be monitored at 5-min intervals once a stable level of sedation is established."

Q: Are there specific Joint Commission Standards that address sedation?

Answer: Yes, the Joint Commission has specific standards that address the hospitals responsibilities related to the administration of moderate, or deep sedation or anesthesia.  These can be found in the Accreditation Manual in the Chapter entitled “Provision of Care, Treatment and Services.”  The standards for 2008 are PC 13.20, PC13.30 and PC 13.40.  The PC numbers will be changing for 2009, they will be PC 03.01.01, PC 03.01.03, PC 03.01.05 and PC 03.01.07.

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Last Updated October 20, 2009