Another patient is a 6-year- old child whose parents have left to eat. Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicating the findings). The propensity for combinations of sedative and analgesic agents to cause respiratory depression and airway obstruction emphasizes the need to appropriately reduce the dose of each component, as well as the need to continually monitor respiratory function. Intravenous ketamine is as effective as midazolam/fentanyl for procedural sedation and analgesia in the emergency department. A discharge criterion may be valid for one population of patients but not for another (e.g., discharge criterion of Sa, 1. hbbd```b``f +@$4dL`!XMmG^`vL[$cc"V"MAfa`bd`(?CO = For studies that report statistical findings, the threshold for significance is P < 0.01. Literature citations are obtained from healthcare databases, direct internet searches, task force members, liaisons with other organizations, and manual searches of references located in reviewed articles. Evaluation of complications during and after conscious sedation for endoscopy using pulse oximetry. They do not address mild or deep sedation and do not address the educational, training, or certification requirements for providers of moderate procedural sedation. Discharge criteria must be applied consistently. Sedatives and analgesics not intended for general anesthesia (e.g., benzodiazepines and dexmedetomidine). The use of flumazenil to reverse sedation induced by bolus low dose midazolam or diazepam in upper gastrointestinal endoscopy. Meet American Society of PeriAnesthesia Nurses (ASPAN) Standards of Perianesthesia Nursing Practice 2008-2010. Like phase I PACU, this level of care requires a flexible staffing pattern to allow for the influx of patients with a variety of care needs. For these guidelines, a systematic search and review of peer-reviewed published literature was conducted, with scientific findings summarized and reported below and in the document. The evidence model below guided the search, providing inclusion and exclusion information regarding patients, procedures, practice settings, providers, clinical interventions, and outcomes. Immediately available in the procedure room refers to easily accessible shelving, cabinetry, and other measures to assure that there is no delay in accessing medications and equipment during the procedure. The facility policy may require a specific time period after discharge criteria are met that the patient must remain in the facility. Comparison of sedation, amnesia, and patient comfort produced by intravenous and rectal diazepam. Preprocedure patient evaluation consists of the following strategies for reducing sedation-related adverse outcomes: (1) reviewing previous medical records for underlying medical problems (e.g., abnormalities of major organ systems, obesity, obstructive sleep apnea, anatomical airway problems, congenital syndromes with associated medical/surgical issues, respiratory disease, allergies, intestinal inflammation); sedation, anesthesia, and surgery history; history of or current problems pertaining to cooperation, pain tolerance, or sensitivity to anesthesia or sedation; current medications; extremes of age; psychotropic drug use; use of nonpharmaceuticals (e.g., nutraceuticals); and family history; (2) a focused physical examination; and (3) preprocedure laboratory testing (where indicated). Aspects of care include assessment . The elements to consider for assessments as well as discharge from Phase I, Phase II, or Ex tended Care levels of care are found in the ASPAN 2019-2020 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements , "Practice Recommendation 2-Components of c. Discharge score attained within acceptable range set by institutional policy. The standards are, at times, vague (e.g., standard #1 below) and can certainly be. Etomidate and midazolam for reduction of anterior shoulder dislocation: A randomized, controlled trial. Reported by author as oxygen desaturation to less than 94%. These standards apply to postanesthesia care in all locations. We are a 14 bed inpatient PACU. Phase I and Phase II nursing care. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. The guidelines do not apply to patients receiving deep sedation, general anesthesia, or major conduction (i.e., neuraxial) anesthesia. Remifentanil and propofol sedation for retrobulbar nerve block. Because fast-tracking in the ambulatory setting implies taking a patient from the OR directly to the Propofol sedation for upper gastrointestinal endoscopy in patients with liver cirrhosis as an alternative to midazolam to avoid acute deterioration of minimal encephalopathy: A randomized, controlled study. Therefore, ASPAN recommends that the ability to void be assessed . Fifth, the task force held open forums at major national meetings to solicit input on its draft recommendations. National organizations representing specialties whose members typically provide moderate sedation were invited to participate in the open forums. If the patient response results in deeper sedation than intended, these sedation practices can be associated with cardiac or respiratory depression that must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest, or death. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. The literature is insufficient to determine the benefits of contemporaneous recording of patients level of consciousness, respiratory function, or hemodynamics. ASPAN'S evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. "tN[(gk40=s\,.nv/+|A@06 dP3;=8d$sHpp The purposes of these guidelines are to allow clinicians to optimize the benefits of moderate procedural sedation regardless of site of service; to guide practitioners in appropriate patient selection; to decrease the risk of adverse patient outcomes (e.g., apnea, airway obstruction, respiratory arrest, cardiac arrest, death); to encourage sedation education, training, and research; and to offer evidence-based data to promote cross-specialty consistency for moderate sedation practice. A nonrandomized comparative study reported equivocal outcomes (e.g., emesis, apnea, oxygen levels) when preprocedure fasting (i.e., liquids or solids) is compared to no fasting (category B1-E evidence).27 Another nonrandomized comparison of fasting for less than 2h versus fasting for greater than 2h reported equivocal findings for emesis, oxygen saturation levels, and arrhythmia for infants (category B1-E evidence).28 Finally, a third nonrandomized comparison reported equivocal findings for gastric volume and pH when fasting of liquids for 0.5 to 3h is compared with fasting times of greater than 3h (category B1-E evidence).29. Choosing a specialty can be a daunting task and we made it easier. : Midazolam/fentanyl, propofol/alfentanil, or alfentanil only for colonoscopy: A randomized trial. In total, 4,349 new citations were identified, with 1,428 articles assessed for eligibility. St. Louis, MO: Saunders; 2016. Body mass index (BMI) predicts the need for airway intervention and sedation related complications in anesthesiologist-directed propofol sedation for routine EGD and colonoscopy. Dec 30, 2006. 3. * This is not intended for application during the recovery of the obstetrical patient in whom regional anesthesia was used for labor and vaginal delivery. A complete bibliography used to develop these guidelines, arranged alphabetically by author, is available as Supplemental Digital Content 1, http://links.lww.com/ALN/B594. Finally, the literature is insufficient to determine the benefits of rescue support availability during moderate procedural sedation/analgesia. The member of the Anesthesia Care Team shall remain in the PACU until the PACU nurse accepts responsibility for the nursing care of the patient. Browse openings for all members of the care team, everywhere in the U.S. Lead the direction of our specialty by engaging in academic, research, and scientific discovery. What factors are associated with the difficult-to-sedate endoscopy patient? %%EOF An accurate written report of the PACU period shall be maintained. (Separate Practice Guidelines are under development that will address deep procedural sedation.). Survey findings from task forceappointed expert consultants, a random sample of the ASA membership, and membership samples from the American Association of Oral and Maxillofacial Surgeons (AAOMS) and the American Society of Dentist Anesthesiologists (ASDA) are fully reported in this document. The literature is insufficient to assess whether the presence of an individual capable of establishing a patent airway, positive pressure ventilation, and resuscitation will improve outcomes. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. Sedation for upper endoscopy: Comparison of midazolam. endstream endobj startxref Accepted studies from the previous guidelines were also rereviewed, covering the period of August 1, 1976, through December 31, 2002.1 Only studies containing original findings from peer-reviewed journals were acceptable. Changes in oxygen saturation using two different sedation techniques. For instance, it is known that most perioperative myocardial infarctions occur 24 to 48 hours postoperatively and likely arise from supply-demand mismatch rather than plaque rupture events. Job specializations: Nursing. The consultants agree and the ASA members, AAOMS members, and ASDA members strongly agree that in patients who have received sedation/analgesia by nonintravenous routes or whose intravenous line has become dislodged or blocked, determine the advisability of reestablishing intravenous access on a case-by-case basis. Nursing use between 2 methods of procedural sedation: Midazolam, Intravenous sedation for implant surgery: Midazolam, butorphanol, and dexmedetomidine. LD2* 8dBd \L J9c04'jFJeI5'DF95F! For hospitalized inpatients, phases 2 and 3 both occur on an inpatient ward. %PDF-1.5 % Preparation of these updated guidelines followed a rigorous methodological process. phase 2 education Impact of flumazenil on recovery after outpatient endoscopy: A placebo-controlled trial. Risk factors associated with vasovagal reactions during colonoscopy. In addition, the literature is insufficient to determine the benefits of keeping an individual present to establish intravenous access during procedures with moderate sedation/analgesia. Creation and implementation of quality improvement processes. A double-blind, randomised, placebo-controlled trial of oral midazolam plus oral ketamine for sedation of children during laceration repair. 48 0 obj <>stream We need help! Specializes in PACU. 562 0 obj <>/Filter/FlateDecode/ID[<0D3FE10DC311684CA65BE70439B1C1B9><61B9B247E3C1CF4089E4F3E1D43639DD>]/Index[541 44]/Info 540 0 R/Length 106/Prev 374132/Root 542 0 R/Size 585/Type/XRef/W[1 3 1]>>stream The Guidelines do not apply to Patient is awake, alert, responds to commands appropriate to age, or returned to pre-procedure status. Proceed based on the facility policy for unaccompanied discharge, including consideration for Phase 2 recovery time for increased observation. As early as 1801, some British hospitals had areas dedicated to the care of patients recovering from operations and also those who were severely ill. Use of a novel electronic pre-sedation checklist improves safety documentation in emergency department sedations. After sedation/analgesia, observe and monitor patients in an appropriately staffed and equipped area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression, Monitor oxygenation continuously until patients are no longer at risk for hypoxemia, Monitor ventilation and circulation at regular intervals (e.g., every 5 to 15min) until patients are suitable for discharge, Design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel####. 3. Buy Membership for Anesthesiology Category to continue reading. The consultants and ASA members agree with the recommendation to, if possible, perform the preprocedure evaluation well enough in advance (e.g., several days to weeks) to allow for optimal patient preparation; the AAOMS members and ASDA members strongly agree with this recommendation. Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. Create well-written care plans that meets your patient's health goals. However, the distribution of complications differed a bit. They are intended to encourage quality patient care, but cannot guarantee any specific patient outcome. A. Describe the function of discharge criteria. Consultants were drawn from the following specialties where moderate procedural sedation/analgesia are commonly administered: anesthesiology, cardiology, dentistry, emergency medicine, gastroenterology, oral and maxillofacial surgery, pediatrics, radiology, and surgery. A comparative evaluation of intranasal dexmedetomidine, midazolam and ketamine for their sedative and analgesic properties: A triple blind randomized study. Moderate and deep sedation or general anesthesia may be achieved via any route of administration. nursing unit. Nursing roles during this phase focus on providing post anesthesia care to the patient in the immediate post anesthesia period . She served on the ASPAN Board of Directors for 2 terms as the Director for Education and has been a long time member of the Education Provider committee. For output's they go from phase 1, ready for DC from pacu, Phase II, ready for DC from phase II, to DC from phaseII. Accepted for publication November 22, 2017. These guidelines apply to moderate sedation and analgesia before, during, and after procedures. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) continually monitor ventilatory function by observation of qualitative clinical signs; (2) continually monitor ventilatory function with capnography unless precluded or invalidated by the nature of the patient, procedure, or equipment; (3) monitor all patients by pulse oximetry with appropriate alarms; (4) determine blood pressure before sedation/analgesia is initiated unless precluded by lack of patient cooperation; (5) once moderate sedation/analgesia is established, continually monitor blood pressure and heart rate during the procedure unless such monitoring interferes with the procedure; (6) use electrocardiographic monitoring during moderate sedation in patients with clinically significant cardiovascular disease or those who are undergoing procedures where dysrhythmias are anticipated; (7) record patients level of consciousness, ventilatory and oxygenation status, and hemodynamic variables at a frequency that depends on the type and amount of medication administered, the length of the procedure, and the general condition of the patient; (8) set device alarms to alert the care team to critical changes in patient; (9) assure that a designated individual other than the practitioner performing the procedure is present to monitor the patient throughout the procedure; and (10) the individual responsible for monitoring the patient should be trained in the recognition of apnea and airway obstruction and be authorized to seek additional help. 2. These guidelines are intended for use by all providers who perform moderate procedural sedation and analgesia in any inpatient or outpatient setting including but not limited to hospitals, ambulatory procedural centers, hospital-connected or freestanding office practices (e.g., dental, urology, or ophthalmology offices), endoscopy suites, plastic surgery suites, radiology suites (magnetic resonance imaging, computed tomography), oral and maxillofacial surgery suites, cardiac catheterization laboratories, oncology clinics, electrophysiology laboratories, interventional radiology laboratories, neurointerventional laboratories, echocardiography laboratories, and evoked auditory testing laboratories. For rare uncooperative patients (e.g., children with autism spectrum disorder or attention deficit disorder) recording oxygenation status or blood pressure may not be possible until after sedation. Duration of antagonistic effects of nalmefene and naloxone in opiate-induced sedation for emergency department procedures. A randomized controlled trial of capnography during sedation in a pediatric emergency setting. Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), Allergy and Anaphylaxis During the Postoperative Period, Postoperative Care of the Thoracic Surgery Patient, Postoperative Care Handbook of the Massachusetts General Hospital. Accessed on August 21, 2017). Reevaluate the patient immediately before the procedure. Meta-analyses from other sources are reviewed but not included as evidence in this document. Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse oximetry. Surgery Phase, PACU Phase I, Phase II and Extended Care PR 4 Recommended Competencies for the Perianesthesia Nurse PR 5 Competencies of Perianesthesia . HV0z? Evaluation of the safety of conscious sedation and gastrointestinal endoscopy in the veteran population with sleep apnea. HU@/ A\.Hq'H/cEF%pMh}nZm/Ow4]O;On[)X. Use of discharge criteria shown to reduce PACU time by 24%. 2. Second, original published research studies relevant to the guidelines were reviewed and analyzed; only articles relevant to the administration of moderate sedation were evaluated. Phase 2 is when the patient no longer requires phase 1 level of nursing care. Any patient in phase II PACU requiring 1:1 . Perioperative Services Registered Nurse. Interobserver agreement among task force members and two methodologists was obtained by interrater reliability testing of 36 randomly selected studies. Nurse Practice Act: determining discharge readiness is a delegated act (refer to specific practice act of each state). b. Knowledge of each drugs time of onset, peak response, and duration of action is important. 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