Procedural sedation: Safely navigating the twilight-zone

Nursing, Apr 2003 by O'Donnell, John M, Bragg, Krista, Sell, Sandra

Hovering somewhere between alertness and deep sedation, your patient relies on you for a smooth return to full consciousness. Here's how to make sure he has a safe, comfortable journey.

IN RECENT YEARS, procedural sedation, previously known as conscious sedation, has moved outside of the controlled operating room (OR) setting into many other clinical areas. Now commonplace for an array of tests and treatments, it provides anxiolysis, amnesia, and analgesia while avoiding a depth of sedation that would require interventions to maintain airway patency. Less stressful for the patient, it can speed recovery times and reduce postoperative risks.

Like any form of sedation, however, procedural sedation has drawbacks and potentially serious risks. Because you're likely to care for patients undergoing procedural sedation, we'll discuss what you need to know to steer them clear of complications.

Depressed level of consciousness

Procedural sedation is a drug-induced, minimally depressed level of consciousness in which the patient can still maintain his airway and respond purposefully to verbal commands, with or without light tactile stimulation. Three organizations-the Joint Commission on Accreditation of Healthcare Organizations, American Association of Nurse Anesthetists, and American Society of Anesthesiologists (ASA)-have established guidelines for administering procedural sedation. (For more on levels of sedation, see How the JCAHO Defines Sedation Levels.)

Physician supervision is always required for procedural sedation, and you must be prepared to rescue patients who slip from procedural sedation into a deeper sedation level. Your facility should have a multidisciplinary protocol for treating sedated patients who lose their protective reflexes.

Because of the risk of airway compromise, facilities require practitioners who administer procedural sedation and deep sedation to be certified in basic life support; some require advanced cardiac life support certification as well. Pediatric practitioners typically must be educated in both basic and pediatric advanced life support.

In general, nurses who administer procedural sedation must have the appropriate institutional credentials and privileges. In addition, states, professional associations hospitals committees and reulatory bodies (such as state boards of nursing) may issue their own definitions and regulations regarding procedural sedation. If you're involved in administering or caring for patients undergoing procedural sedation, make sure you meet legal, professional, and institutional criteria relevant to your practice and be prepared to provide airway management interventions, such as a jaw lift, nasal or oral artificial airway insertion, and bag-valve-mask ventilation.

Many hospitals require health care providers who administer procedural sedation or who monitor patients during the procedure to complete institutionbased education and training in the pharmacology of drugs commonly used in sedation and analgesia, including reversal agents. Health care providers may also need to pass a procedural sedation competency exam. Some facilities require nurses who administer procedural sedation to gain experience in rescue techniques by partnering with an anesthesia care provider in the OR.

Who benefits from procedural sedation?

Indications for procedural sedation range from such procedures as repair of minor lacerations or bone fracture reductions in the emergency department to more extensive planned events, including central line placement, lumbar puncture, vasectomy, breast biopsy, endoscopy, and colonoscopy Some patients, such as children, confused adults, and mentally challenged patients, may benefit from procedural sedation to relieve anxiety associated with noninvasive physical exams and diagnostic testing.

The ASA has developed a simple classification system based on physical status that can help you and the physician you're working with decide if your patient is a candidate for procedural sedation. The ASA specifies these six physical status classes:

* P1-a normal, healthy patient

* P2-a patient with mild systemic disease that doesn't limit activities, such as controlled hypertension or controlled diabetes without target organ damage

* P3-a patient with severe systemic disease that does limit activities, such as stable angina or diabetes with target organ damage

* P4-a patient with severe systemic disease that's a constant threat to life, such as severe heart failure or end-stage renal disease

* P5-a moribund patient who's not expected to survive without the operation or other intervention

* P6-a patient declared braindead whose organs are being removed for donation.

If the procedure is an emergency, the physical status classification is followed by an E (for example, ASA Class P2E).

If your patient is an ASA Class P3 or higher, consult the anesthesia department. A patient with a complex multisystem problem requires care from someone specially educated and prepared to manage the effects of anesthesia on compromised patients.