Then inpatients go to the floor and outpatients go to phase 2 to eat/drink, go to the bathroom and get up and ambulate before discharge to home. Allow nurses to act on behalf of anesthesia personnel. Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. When I covered nights I did call in a backup RN and never heard boo from management. Use of conscious sedation for lower and upper gastrointestinal endoscopic examinations in children, adolescents, and young adults: A twelve-year review. Used to monitor intraoperative and postanesthesia interventions for effectiveness during quality assurance activities, 5. Moderate and deep sedation or general anesthesia may be achieved via any route of administration. Patient Discharge Education in the Phase II Setting, 4. Review previous medical records and interview the patient or family to identify: Abnormalities of the major organ systems (e.g., cardiac, renal, pulmonary, neurologic, sleep apnea, metabolic, endocrine), Adverse experience with sedation/analgesia, as well as regional and general anesthesia, Current medications, potential drug interactions, drug allergies, and nutraceuticals, History of tobacco, alcohol or substance use or abuse, Frequent or repeated exposure to sedation/analgesic agents, Conduct a focused physical examination of the patient (e.g., vital signs, auscultation of the heart and lungs, evaluation of the airway, and, when appropriate to sedation, other organ systems where major abnormalities have been identified), Order additional laboratory tests guided by a patients medical condition, physical examination, and the likelihood that the results will affect the management of moderate sedation/analgesia, Evaluate results of these tests before sedation is initiated, If possible, perform the preprocedure evaluation well enough in advance (e.g., several days to weeks) to allow for optimal patient preparation.**. Specializes in NICU, PICU, Transport, L&D, Hospice. The 2008 standards of the American Society of PeriAnesthesia Nurses (ASPAN) 6 lists voiding as part of discharge criteria for phase II recovery but recognizes that there are variations in voiding requirements depending on the policies of individual institutions. Phase 2 (Intermediate): starts when the patient meets PACU discharge criteria. the family or responsible care giver is allowed into this unit. The literature is insufficient regarding the benefits of consultation with a medical specialist or providing the patient (or legal guardian, in the case of a child or impaired adult) with preprocedure information about sedation and analgesia. Patients given sedatives or analgesics in unmonitored settings may be at increased risk of these complications. Patient is awake, alert, responds to commands appropriate to age, or returned to pre-procedure status. This study guide will help you focus your time on what's most important. 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. These guidelines specifically apply to the level of sedation corresponding to moderate sedation/analgesia (previously called conscious sedation), which is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Mental status and neuromuscular function, a. Normothermia, pain control, shivering control, and nausea/vomiting prevention/treatment. Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. 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. Reported by author as oxygen desaturation to less than 94%. 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. Findings from these RCTs are reported separately as evidence. A randomized, clinical trial of oral midazolam plus placebo. Sedation for day-case urology: An assessment of patient recovery profiles after midazolam and flumazenil. The use of practice guidelines cannot guarantee any specific outcome. 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 lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. Phase 2 is when the patient no longer requires phase 1 level of nursing care. Fast cardiologist-administered midazolam for electrical cardioversion of atrial fibrillation. In this study, we measured actual and appropriate PACU LOSs and evaluated clinical factors that may influence PACU LOS. Using a standardized tool provides consistency of care, reduces errors, promotes efficient use of resources, meets Joint Commission requirements, and meets ASPAN recommended standards. We also have am ambulatory surgical center for minor cases which operates completely separate from the main OR. %PDF-1.6 % The literature relating to six evidence linkages contained enough studies with well defined experimental designs and statistical information to conduct formal meta-analyses. 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 STANDARD III Not surprisingly, respiratory incidents comprised the majority of the cases (49 of the 84), whereas cardiovascular incidents represented a minority (9 of 84). These guidelines focus specifically on the administration of moderate sedation and analgesia for adults and children. There shall be a policy to assure the availability in the facility of a physician capable of managing complications and providing cardiopulmonary resuscitation for patients in the PACU. 541 0 obj <> endobj Level 1: The literature contains a sufficient number of RCTs to conduct meta-analysis, and meta-analytic findings from these aggregated studies are reported as evidence. 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. Supplemental oxygen during moderate sedation and the occurrence of clinically significant desaturation during endoscopic procedures. Discharge criteria approved by the medical staff. % Has 16 years experience. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to use supplemental oxygen during moderate procedural sedation/analgesia unless specifically contraindicated for a particular patient or procedure. Tolerance to intravenous midazolam as a result of oral benzodiazepine therapy: A potential problem for the provision of conscious sedation in dentistry. This may not be feasible for urgent or emergency procedures, interventional radiology, or other radiology settings. Assessment of conceptual issues, practicality and feasibility of the guideline recommendations was also evaluated, with opinion data collected from surveys and other sources. a. An assessment by the attending anesthesia personnel, b. Apply to all registered nurses in clinical practice C. Standards of care: describe a competent level of nursing care 1. Standards of PeriAnesthesia Nursing Practice. Cherry Hill, N.J.: American . Our facility has a phase 1 which is immediately from the O.R. Of the over 8,000 total cases, 5% occurred in the recovery room. Microstream capnography improves patient monitoring during moderate sedation: A randomized, controlled trial. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. We are a 14 bed inpatient PACU. : Midazolam/fentanyl, propofol/alfentanil, or alfentanil only for colonoscopy: A randomized trial. When discharge criteria are used, they must be approved by the Department of Anesthesiology and the medical staff. Endoscopist administered sedation during ERCP: Impact of chronic narcotic/benzodiazepine use and predictive risk of reversal agent utilization. Conversely, inadequate sedation or analgesia can result in undue patient discomfort or patient injury, lack of cooperation, or adverse physiological or psychological responses to stress. These guidelines specifically apply to the level of sedation corresponding to moderate sedation/analgesia (previously called conscious sedation), which is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Another patient is a 6-year- old child whose parents have left to eat. Two conscious patients, stable, and free of complications but not yet meeting discharge criteria. Intravenous midazolam: A study of the degree of oxygen desaturation occurring during upper gastrointestinal endoscopy. (The preoperative level of consciousness or awareness is documented on the Adult assessment record on admission in EPIC under . Sedation, topical pharyngeal anesthesia and cardiorespiratory safety during gastroscopy. Mar 2, 2016. phase 1 = 2 patients max (or 1 if critical). The guidelines exclude patients who are not undergoing a diagnostic or therapeutic procedure (e.g., postoperative analgesia). Responses to intravenous sedation by elderly patients at the Hokkaido University Dental Hospital. hb``e`` Evidence-Based Practice and Nursing Research, PeriAnesthesia Nursing Core Curriculum Preprocedure. Conscious sedation for gastroscopy: Patient tolerance and cardiorespiratory parameters. endstream endobj 11 0 obj <> endobj 12 0 obj <> endobj 13 0 obj <>stream 8. The use of midazolam and flumazenil for invasive radiographic procedures. 3. Recovery from sedation with remifentanil and propofol, compared with morphine and midazolam, for reduction in anterior shoulder dislocation. The Perianesthesia RN#s scope includes, but is not limited to, the preadmission assessment/process, Post Anesthesia Care Unit (Phase 1), Phase 2 recovery/discharge. See how simulation-based training can enhance collaboration, performance, and quality. Risk factors of hypoxia during conscious sedation for colonoscopy: A prospective time-to-event analysis. A comparison of the effects of midazolam/fentanyl and midazolam/tramadol for conscious intravenous sedation during third molar extraction. 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). Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. A PHYSICIAN IS RESPONSIBLE FOR THE DISCHARGE OF THE PATIENT FROM THE POSTANESTHESIA CARE UNIT. Fourteen years later, another study of over a thousand patients found a similar 23% overall rate of post-op complications. When midazolam combined with opioids are compared with opioids alone, RCTs report equivocal findings for patient recall, pain during the procedure, frequency of hypoxemia,### hypercarbia and respiratory depression (category A2-E evidence).75,78,8385, One RCT comparing dexmedetomidine with midazolam reports equivocal outcomes for recovery time, oxygen saturation levels, apnea, and bradycardia (category A3-E evidence).86 Another RCT reports a longer recovery time for dexmedetomidine compared with midazolam (category A3-H evidence), with equivocal findings for analgesia scores, oxygen saturation levels, respiratory rate, blood pressure, and pulse rate (category A3-E evidence).87 One RCT reports a lower frequency of hypoxemia when dexmedetomidine is combined with an opioid analgesic compared with midazolam combined with an opioid analgesic (category A3-B evidence).88 One RCT reports deeper sedation (i.e., higher sedation scores) and a lower frequency of hypoxemia when dexmedetomidine combined with midazolam and meperidine is compared with midazolam combined with meperidine (category A3-B evidence).89, One RCT comparing intravenous midazolam with intramuscular midazolam reports equivocal findings for oxygen saturation levels, respiratory rate, and heart rate (category A3-E evidence).90 One RCT comparing intravenous midazolam with intranasal midazolam reports equivocal findings for sedation efficacy (category A3-E evidence), but discomfort from the nasal administration was reported for all intranasal patients with no nasal discomfort from the intravenous patients (category A3-B evidence).91 One RCT comparing intravenous diazepam with rectal diazepam reports lower recall for the intravenous method (category A3-B evidence); findings were equivocal for sedative effect, anxiety, and crying (category A3-E evidence).92 One RCT comparing intravenous with intranasal dexmedetomidine reported equivocal findings for sedation time, duration of the procedure, and the frequency of rescue doses of midazolam administered (category A3-E evidence).93, One RCT comparing titration (i.e., administration of small, incremental doses of intravenous midazolam combined with meperidine until the desired level of sedation and/or analgesia is achieved) of midazolam combined with an opioid compared with a single, rapid bolus reports higher total physician times, medication dosages, frequencies of hypoxemia, and somnolence scores for titration (category A3-H evidence).94. 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