SUBJECT: SEDATION REFERENCE

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DEPARTMENT: HOSPITALWIDE OF: 8
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APPROVED BY: REVISED:

PURPOSE:
To provide guidelines for patient management of all procedures requiring the use of sedation.
DEFINITION:

• Sedation is produced by the administration of pharmacologic agents. The patient

under sedation has a depressed level of consciousness, but retains the ability to
maintain a patent airway independently and continuously, and respond purposefully
to physical stimulation and/or command. The following are definitions for the four
levels of sedation and anesthesia:
• Minimal sedation (anxiolysis):
A drug-induced state during which patients respond
normally to verbal commands. Although cognitive
function and coordination may be impaired, ventilatory
and cardiovascular functions are unaffected.
• Moderate sedation/analgesia (conscious sedation):
A drug-induced depression of consciousness during
which patients respond purposefully to verbal commands,
either alone or accompanied by light tactile stimulation.
No interventions are required to maintain a patent airway,
and spontaneous ventilation is adequate. Cardiovascular
function is usually maintained.
• Deep sedation/analgesia:
A drug-induced depression of consciousness during
which patients cannot be easily aroused but respond
purposefully following repeated or painful stimulation.
The ability to independently maintain ventilatory function
may be impaired. Patients may require assistance in
maintaining a patent airway and spontaneous ventilation
may be inadequate. Cardiovascular function is usually
maintained.
• Anesthesia:
Consists of general anesthesia and spinal or major
regional anesthesia. It does not include local anesthesia.
General anesthesia is a drug-induced loss of
consciousness during which patients are not arousable,
even by painful stimulation. The ability to independently
maintain ventilatory function is often impaired. Patients
 SUBJECT: SEDATION REFERENCE
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DEPARTMENT: HOSPITALWIDE OF: 8
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often require assistance in maintaining a patent airway,

and positive pressure ventilation may be required
because of depressed spontaneous ventilation or drug-
induced depression of neuromuscular function.
Cardiovascular function may be impaired.

• The parameters of this policy relate to moderate and deep sedation definitions.
POLICY:

• It is the policy at __________________ Hospital that these guidelines apply to all

locations in the hospital where moderate and deep sedation is administered (specific
departments described at end of this policy).

• Only licensed independent practitioners (physician or CRNA) that are trained in

professional standards and techniques to administer pharmacologic agents to
predictably achieve desired levels of sedation and to monitor patients carefully in
order to maintain them at the desired level of sedation, will provide sedation.

• A pre-sedation assessment is performed and documented in the medical record for

each patient before administering moderate or deep sedation.

• The patient will be reevaluated immediately before moderate or deep sedation is

administered.

• The ordering licensed independent practitioner (LIP) will review the risks, options
and benefits of the selected agents with the patient, parent or guardian and
document the patient, parent or guardian’s informed consent in the chart. The nurse
must verify the presence of this documentation before administration of the sedative.
Documentation may consist of a written note in the chart by the LIP.

• A pre-sedation plan of care will be documented by the LIP in the patient’s medical
record prior to administration of sedation.

• The LIP administering moderate and deep sedation must have privileges for clinical
administration of this category of drugs:
• The LIP administering moderate sedation must have the appropriate
privileges and be qualified to rescue patients from deep sedation, and
must be competent to manage a compromised airway and to provide
adequate oxygenation and ventilation.
• The LIP administering deep sedation must have the appropriate
privileges and be qualified to rescue patients from general anesthesia,
and must be competent to manage an unstable cardiovascular system
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DEPARTMENT: HOSPITALWIDE OF: 8
EFFECTIVE:
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as well as a compromised airway and inadequate oxygenation and

ventilation, including ACLS certification.

• Patients requiring moderate and deep sedation and who meet the criteria for patient
selection will be monitored by an RN trained in basic EKG/arrhythmia, current BCLS
certification, and has satisfactorily completed the moderate and deep sedation
medication education program, in addition to a technician or nurse assisting the LIP.
Monitoring will include:
• Physical assessment
• Blood pressure
• Heart rate
• Respirations
• Oxygen saturation
• Cardiac monitoring
• Level of consciousness (sedation scale)
• Skin color

• The patient will be continuously monitored and reassessment will be documented

every 5 minutes until the procedure is completed. Emergency resuscitation
equipment will be readily available.

• Patient Selection:
• Candidates for moderate and deep sedation are those patients who
must undergo painful or difficult procedures where cooperation and/or
comfort will be difficult or impossible without pharmacologic support.
Patients must be screened for potential risk factors for any
pharmacologic agents selected. This decision on which agent to use
must be based on the goals of sedation, type of procedure and
condition and age of the patient. Patients will be screened by the
ordering LIP for risk factors utilizing the ASA Physical Status
Classification. Patients considered appropriate for moderate and deep
sedation are ASA Class I and Class II. Patients who fall into ASA
Class III or Class IV present special problems which may necessitate a
consultation by a member of the Anesthesia department. If the nurse
disagrees with classification, Anesthesia personnel will be consulted
and agreement among the RN, Anesthesia personnel and LIP on
appropriate monitoring and who should be responsible will be
determined and agreed upon by those involved.
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DEPARTMENT: HOSPITALWIDE OF: 8
EFFECTIVE:
APPROVED BY: REVISED:

• ASA (American Society of Anesthesiology) PHYSICAL STATUS CLASSIFICATION:

• Class I No organic, physiologic, biochemical or psychiatric
disturbance. Normal, healthy patient.
• Class II Mid-moderate systemic disturbance; may or may not be
related to reason for surgery. (Examples: hypertension, diabetes
mellitus)
• Class III Severe systemic disturbance. (Examples: heart disease,
poorly controlled hypertension)
• Class IV Life threatening systemic disturbance. (Examples:
congestive heart failure, persistent angina pectoris)
• Class V Moribund patient. Little chance for survival. Surgery is
last resort. (Example: uncontrolled bleeding, ruptured abdominal
aortic aneurysm)
• Class E Patient requires emergency procedure. (Example:
appendectomy, D&C for uncontrolled bleeding)

• Sedation Scale:
• 1 - Alert
• 2 - Occasionally drowsy; easy to arouse
• 3 - Frequently drowsy; easy to arouse
• 4 - Asleep; easy to arouse
• 5 - Somnolent; difficult to arouse.

• Equipment Needed:
• Oxygen and nasal cannula
• Suction
• Emergency crash care with defibrillator
• Cardiac monitor
• Pulse oximeter
• Blood pressure monitor

• Preprocedure Monitoring:
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DEPARTMENT: HOSPITALWIDE OF: 8
EFFECTIVE:
APPROVED BY: REVISED:

• Physical and baseline assessment parameters include, but are not

limited to:
Level of consciousness
Anxiety level
Vital signs, including temperature
Skin color and condition
Sensory defects
Current medications and drug allergies
Relevant medical/surgical history including history of substance abuse
Patient perceptions regarding procedure and moderate and deep
sedation
• IV access is established. Fluid type and rate per LIP order.
• Supplemental oxygen is administered as necessary.

• Intraprocedural Monitoring:
• Patient is continually reassessed throughout the procedure.
• Vital signs (EKG, oxygen saturation, heart rate and blood pressure) are
recorded every 5 minutes. Level of consciousness (sedation scale) is
recorded every 15 minutes.
• Verbal reassurance to patient frequently throughout the procedure.
• Untoward reactions or sudden/significant changes in monitoring parameters
should be immediately reported to the LIP.

• Postprocedure Monitoring and Discharge Criteria:

Documentation of the Aldrete score will be completed prior to patient discharge. The score
must return to the baseline assessment before the patient may be released from the
procedure area. The range is 10 for complete recovery to 0 in comatose patients.
Evidence that patient has met discharge criteria must be clearly documented in the medical
record. Aldrete scoring is as follows:
• Activity:
Muscle activity is assessed by observing the ability of the patient to move
his/her extremities spontaneously or on command.
Score:
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DEPARTMENT: HOSPITALWIDE OF: 8
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2 - Able to move 4 extremities

1 - Able to move 2 extremities
0 - Not able to control any extremity
• Respiration:
Respiratory efficiency evaluated in a form that permits accurate and objective
assessment without complicated physical tests.
Score:
2 - Able to breathe deeply and cough
1 - Limited respiratory effort (dyspnea or splinting)
0 - No spontaneous respiratory effort
• Circulation:
Use changes of arterial blood pressure from preanesthetic level.
Score:
2 - Systolic arterial pressure between plus or minus 20% of
preanesthetic level (Riva-Rocci method)
1 - Systolic arterial pressure between plus or minus 20% to 50% of
preanesthetic level
0 - Systolic arterial pressure between plus or minus 51% or more of
pre-anesthetic level
• Consciousness:
Determination of the patient's level of consciousness.
Score:
2 - Full alertness seen in patient's ability to answer questions and
acknowledge his/her location
1 - Aroused when called by name
0 - Failure to elicit a response upon auditory stimulation
Physical stimulation should not be considered reliable as even a
decerebrated patient might react to it.
• Color:
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DEPARTMENT: HOSPITALWIDE OF: 8
EFFECTIVE:
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This is an objective sign that is sometimes difficult to recognize, confusion,

decreased 02 saturation noted on pulse oximeter.
Score:
2 - Normal skin color and appearance
1 - Any alteration in skin color; pale, dusky, blotch, jaundiced, etc.
0 - Frank cyanosis
All outpatients who receive sedation for any procedure must be
observed and monitored for a minimum of 1 hour prior to being
discharged home. Vital signs (heart rate, respiratory rate and blood
pressure) are recorded at 15 - 30 minute intervals.

• Discharge Home:
• Medical staff approved discharge criteria includes:
Completion of Aldrete score.
Ability to ambulate consistent with baseline assessment.
Ability to demonstrate a gag reflex.
Ability to retain oral fluid, as appropriate to LIP orders
Pain minimal.
Ability of patient and home care provider to understand
all home care instructions.
Written discharge instructions given to patient/family.
Concurrence with prearrangements for safe transportation including
discharge to the care of a responsible adult. The patient may not drive
self home.

• Return to Nursing Unit:

• All inpatients who receive sedation for any procedure will have vital
signs (heart rate, respiratory rate and blood pressure) monitored every
15 - 30 minutes until criteria is met in the recovery area. The patient
may then be returned to their specific unit, where monitoring is
continued as per that unit’s nursing standard.

• Specified Departments:
• Surgery
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DEPARTMENT: HOSPITALWIDE OF: 8
EFFECTIVE:
APPROVED BY: REVISED:

• Anesthesia
• Outpatient Surgery/GI Laboratory
• Radiology
• Emergency Department
• Intensive Care
• Cardiopulmonary

• Outcomes from patients undergoing moderate or deep sedation will be collected for
measurement and analysis, and reported as a component of the organizationwide
performance improvement program. Evaluation of patient outcomes will be utilized
in an effort to identify opportunities to improve the use of moderate and deep
sedation throughout the institution.