Preprocedure steps

Essential to successful endoscopic sedation is proper pre-procedure preparation. The American Society for Gastrointestinal Endoscopy, the AGA Institute, and American Society for Anesthesiologists guidelines recommend that the following steps be completed before sedation can be performed.

• A standardized form to record all facets of events before, during, and following a procedure should be established.
• A pre-sedation assessment must be completed within 30 days of the procedure and documented in the patient's medical record. The assessment should include:
  • Physical status assessment (review of systems, vital signs, airway, cardiopulmonary reserve)
  • Past and present drug history including drug allergies (also see Patient Safety Issues with Herbal Supplements)
  • Previous adverse experience with sedation and analgesia as well as with regional and general anesthesia
  • Results of relevant diagnostic studies
  • History of tobacco, alcohol, and substance use/abuse
  • Verification of patient NPO status
  • Plan and choice of sedation
  • Transport arrangements upon discharge
• The pre-sedation assessment must be reviewed immediately prior to administration of sedation and analgesia and signed by the individual supervising the sedation.
• Patient factors that may affect response to sedation and analgesia or present difficulties in airway management must be assessed and consultations with the anesthesiologist or medical specialist should be sought where appropriate. See Patient Factors Affecting Response to Sedation.
  
• Verification of NPO status should occur before the start of sedation and analgesia. See Summary of American Society of Anethesiologists Preprocedure Fasting Guidelines
• The patient must be informed of the risks and benefits of sedation and must consent to the sedation plan. Documentation of informed consent is to be included in the patient’s medical record. It is recommended that informed consent for sedation be covered in a separate document than informed consent for the endoscopic procedure.
• The expectations for discharge management should be reviewed with the patient prior to the procedure to ensure that an individual who is responsible for transporting the patient from the endoscopy unit to home and implementing other instructions such as diet and activity level is available.  Under certain circumstances, this person may be also designated by the patient to review the endoscopic findings with the physician.
• Vascular access should be established before the procedure for patients receiving intravenous sedation/analgesia. Access should be maintained throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression.
• Baseline vital signs and oxygenation should be documented before the start of the procedure.

• 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.

Source: 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.

Additional Information on Fasting

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Personnel and Equipment

Before sedating a patient the appropriate personnel should be present including:

• A registered nurse with appropriate training in endoscopic sedation should be dedicated to administering sedative drugs and monitoring the patient throughout the procedure. During moderate sedation, this individual may assist with minor interruptible tasks. When deep sedation is planned, this person should be dedicated exclusively to observation and monitoring. This individual should possess:
  • An understanding of the levels of sedation
  • The ability to monitor and interpret the patient’s physiologic parameters
  • Current certification in basic or advanced life support
  • Skills to initiate the proper intervention in the case of a complication related to sedation

See ASA Statement on Granting Privileges to Nonanesthesiologist Practitioners for personally administering deep sedation

• At least one individual with training in advanced cardiac life support (tracheal intubation, defibrillation, use of resuscitation mediation, ACLS) that is capable of establishing an airway and providing positive-pressure ventilation.

Emergency equipment must be immediately available whenever sedation and analgesia are being performed.

• The equipment should be appropriate for the practice environment (i.e. size-appropriate equipment where pediatric endoscopy is being performed) and for the training of the sedation team.
• It is strongly recommended that a cardiac defibrillator be available onsite.
• Equipment for providing positive airway pressure must be immediately available. (See below)

Source: Cohen LB et al. AGA Institute Review of Endoscopic Sedation, Gastroenterology. 2007 Aug;133(2):675-701

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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.
http://www.asahq.org/publicationsAndServices/sedation1017.pdf Accessed April 22, 2008.

American Society for Gastrointestinal Endoscopy. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointestinal Endoscopy. 2003;58(3):317-322.
http://www.asge.org/uploadedFiles/Publications_and_Products/Practice_Guidelines/2003_sedation.pdf Accessed August 24, 2009.

Cohen, LB et al. AGA Institute Review of Endoscopic Sedation, Gastronenterology 2007;133:675-701.

Kost M. Moderate Sedation/Analgesia: Core Competencies for Practice, 2nd Ed. St. Louis, MO: Saunders, St. Louis; 2004:3.

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Last Updated April 1, 2009