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Sedation Guideline at a Glance (Nursing Practice Guideline)

Sedation Guideline at a Glance (Nursing Practice Guideline) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines


Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 05/2016EArsenaultknudsen@uwhealth.org
1
Guideline Title: Sedation
Effective Date: May, 2016
Approved By: Nursing Practice Guidelines Committee; Nursing Practice Council
I. Guideline Overview
Target Population
Adult and pediatric patients undergoing procedures receiving minimal, moderate and/or deep sedation; including
patients who become sedated beyond (or in excess of) original intent, as a result of sedative agents.
The scope of this guideline includes procedures requiring sedation in the ambulatory setting, on inpatient units, in
procedural areas, and in the emergency department.
Nursing Practice Guideline Objectives
The main objective is to provide an evidence-based guideline for inpatient and outpatient assessment and
monitoring of patients who receive sedation (minimal, moderate, deep).
Clinical Questions Considered
1. How do I prepare a patient and the environment for minimal, moderate and/or deep sedation?
2. What are the risk factors for adverse events such as over-sedation or airway compromise?
3. How should I assess and monitor my patient before, during, and after sedation?
For more information, please see the complete guideline.
DEFINITIONS
The following definitions are extracted from the America’s Society of Anesthesiologists’ Continuum of Depth of
Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia (click here for more details).
Minimal Sedation (anxiolysis): A drug induced state during which patients are quiet, drowsy and respond normally
to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular
functions are unaffected. Level of awareness for minimal sedation correlates with a Ramsey sedation score of 1, 2 or 3
on the adult sedation scale or Pediatric sedation score of 1, 2, 3.
Moderate Sedation/analgesia ("conscious sedation"): A drug-induced depressed level of consciousness during
which patients respond appropriately to verbal commands, either alone or accompanied by light tactile stimulation. The
ability to independently maintain ventilatory and cardiovascular function is retained. No interventions are required to
maintain an adequate airway and pulmonary ventilation. Level of awareness for moderate sedation correlates with a
Ramsey sedation score of 4 on the adult sedation scale or score on Pediatric sedation score of 4.
Deep sedation/analgesia: A drug-induced depressed level of consciousness during which patients cannot be easily
aroused but respond appropriately to painful stimulation. The ability to independently maintain ventilatory and
cardiovascular function may be impaired. Patients may require assistance in maintaining an adequate airway, but
ventilatory drive is usually sufficient to avoid the need for positive pressure ventilation. Level of awareness for deep
sedation correlates with a Ramsey sedation score of 5 on the adult sedation scale or score on Pediatric sedation score of
5.
General Anesthesia: 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 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. This correlates with pediatric sedation score of 6 and Ramsey sedation score of 6.
Inadequate-sedation-analgesia: Increased arousal/change in level of consciousness as a response to stress and
may result in undue patient discomfort.
University of Wisconsin Hospitals and Clinics
Nursing Practice Guideline At-a-Glance

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 05/2016EArsenaultknudsen@uwhealth.org
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Over-sedation: A level of sedation that is deeper or lasts longer than intended. It occurs as a result of accumulation
of sedative and analgesic medications and is associated with prolonged ventilatory monitoring and/or assistance.
II. Practice Recommendations
Use this active table of contents to directly link to individual sections of the practice recommendations.
I. General Recommendations for Procedure-Related Moderate and Deep Sedation
A. Nursing Considerations
B. Considerations for Specific Patient Populations
II. Assessment and Monitoring
A. Preparation
B. Pre-Sedation
C. Intra-Procedure
D. Post-Procedure Monitoring
III. Deep Sedation
A. General Considerations
B. Assessment and Monitoring
For more information about rating scheme used to describe strength of recommendations, see below.
I. General Recommendations for Procedure-Related Moderate and Deep Sedation (C IIa)
A. Nursing Considerations
1. Moderate and deep sedation procedures may cause cardiovascular and respiratory depression and
therefore require more frequent assessments.
2. Nurses should be able to recognize changes in the continuum of sedation and rescue the patient from
the various sedation levels.
3. Level of sedation goal should be based on clinical circumstances such as anticipated pain of
procedure, need for immobility, and patient anxiety.
4. Nurses administering moderate sedation should be trained to administer medications and monitor the
patient during intra-procedure, phase 1 and 2.
5. Nurses prepping the patient and recovering the patient should be knowledgeable regarding
medication side effects and potential complications of moderate sedation.
6. Nurses involved in moderate sedation need to have access to emergency equipment and personnel
with advanced airway skills.
7. Nurses should be knowledgeable about the risk factors for over-sedation such as:
a. patient is unable to handle secretions without aspiration
b. patient is unable to maintain a patent airway independently or independent ventilation
(excludes mechanically ventilated patients)
c. patient has severe systemic disturbance or disease which limits activity
d. patient has received opioids, benzodiazepines, or initiated therapy with any central nervous
system (CNS) depressant within the past 6 hours
e. patient has begun extended release opioids, received methadone, or intraspinal/epidural
opioids within the past 24 hours
f. patient has begun receiving opioids via an implantable pump within the past 72 hours
g. sedative drug is administered intravenously (regardless of drug or dose used)
h. two or more sedative drugs are administered concomitantly or sequentially such that there
is an overlap in the duration of action, which places the patient at increased risk for airway
compromise
8. Any complications or sudden change in condition should be reported immediately to the provider.
a. Conduct a rapid assessment of patient and equipment to determine possible cause(s)
b. Consider the use of reversal agents, if needed
c. Nurses should be knowledgeable about the special considerations when using reversal
agents:
i. Patients who receive reversal agents need to be recovered for minimum of 2 hours
after reversal agents are given to assure the patient doesn't become re-sedated
once the reversal agents wear off
ii. Initially, reversal medication should be intended to reverse the last dose of sedative
iii. Careful consideration should be given to reversal agents in patients with seizure
disorders, chronic opioid or benzodiazepine use, or complex medical history. The
reversal agent may have an impact on their condition and usually last shorter than
the benzodiazepine or opioid
iv. When reversal agents are administered to patients with respiratory depression,
abrupt reversal can cause pain, hypertension, tachycardia or pulmonary edema
v. Whenever a reversal agent is administered, organizational requirements specific to
safety reporting should be followed

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9. The nurse should be aware of and abide by organizational policies regarding provider credentialing to
perform sedation and to direct airway management and cardiopulmonary resuscitation.
B. Considerations for Specific Patient Populations
1. Additional considerations for patients receiving sedation: Some patient populations such as pediatrics,
pregnant and lactating women, patients with sleep diagnosis that require the use of CPAP, BiPAP, or
other forms of ventilation, elderly and/or those with previous problems with anesthesia or sedation,
as well as patients scored to be “at risk” for sleep apnea, with co-morbidities and anatomic variants,
may need special consideration related to their sedation plan.
2. Anesthesia should be consulted for severely compromised or medically unstable patients (difficult
airway, severe COPD, severe heart disease) or in situations where the patient will need to be sedated
past the point of responsiveness. Note that this list is not all inclusive for situations when anesthesia
might be needed.
II. Assessment and Monitoring (C IIb)
A. Preparation
1. Nurses should follow organizational policy requirements related to verification of provider credentials.
Refer to I.A.9 above.
2. Nurses should prepare the environment and ensure that appropriate equipment is in procedure room
with patient prior to the sedation initiation.
a. The following equipment will be available in the procedure setting: oxygen delivery
devices, suction apparatus (setup and ready to use), noninvasive blood pressure cuff, EKG
(if required), pulse oximetry, opioid and sedative reversal agents, and an Intravenous line.
b. Oxygen equipment should be immediately available.
3. The nurse should review patient’s pertinent history, laboratory values, NPO status and allergies.
Additional assessments include:
a. Pre-sedation assessment of patient’s current level of sedation
b. A baseline assessment of patient's ability to communicate with the nurse and develop a
plan during the procedure
c. Review all medications (including over-the-counter and herbal remedies) taken and the
time of the last dose
d. Review health history and systems assessment with special focus on abnormalities that
may alter expected responses to sedation and analgesic medications
i. Such concerns may include respiratory abnormalities, such as the use of CPAP or
BiPAP, sleep apnea, or screened “at risk” for sleep apnea
ii. Other concerns may include, facial deformities, increased intracranial pressure or
cardiac abnormalities
4. An approved tool for assessing level of sedation should be utilized for intra-procedure monitoring of
patient’s sedation level.
5. Pre-procedure fasting is necessary because of the risk of respiratory depression and possible
aspiration. If fasting was not done prior to procedure, may need to re-evaluate the urgency of the
procedure and possibly delay the procedure.
6. Ensure that patient meets NPO requirements; except in extenuating circumstances that should be
approved by the credentialed sedation provider (e.g. emergency department) and dependent on the
urgency of procedure.
a. For adults patients, use the following guidance:
i. Solids (including tube feeding) and non-clear liquids: 6-8 hours prior to procedure
schedule time
ii. Clear liquids minimum of 2 hours prior to procedure schedule time
b. For pediatric patients
i. Solids/milk/formula: NPO for 6 hours
ii. Breast milk all ages: 4 hours
B. Pre-Sedation (C I)
The nurse who is administering the sedation medications (the sedation nurse) and monitoring the patient
intra-procedure through Phase I should complete the assessments below.
Pre-sedation assessment increases the likelihood of satisfactory sedation and decreases the likelihood of
adverse outcomes for sedation.
1. The sedation nurse should verify procedural and emergency equipment availability.
2. Assess the patient’s history of receiving sedation for a procedure and the dose and medications
received. Assess patient’s tolerance of sedation and any adverse events.
3. Prior to beginning sedation, establish a system of responding to questions during the procedure for
the patient and/or family.

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a. Monitoring of patient's verbal response during sedation is important during the sedation,
except in procedures where movement could be detrimental or when patients are unable
to respond.
b. During procedures where verbal responses are not possible, an alternative method for
patient acknowledgment of verbal/tactile stimulation should be developed.
4. A “time out” will be done by all personnel in the room prior to sedation initiation and procedure. Final
verification to confirm the correct patient, correct procedure, correct site, correct position and correct
implants or equipment using a "time out” is carried out.
5. An organizationally approved sedation assessment tool will be used to assess any changes from pre-
sedation/procedure through Phase I.
C. Intra-Procedure (CII)
1. The frequency of assessment and documentation for the vital signs is determined by patient’s age,
level of sedation (deep vs. moderate) and any changes in the patient’s condition.
2. The sedation nurse should assess the patient’s respiratory effort including depth of respiration, use of
accessory muscles, signs of hypoxemia and any sign indicating that the patient is having difficulty
breathing.
a. Oxygen does not need to be placed on the patient at the time of the sedation procedure.
If signs of hypoxemia occur, oxygen may be administered according to physician orders.
3. The sedation nurse should assess the patient's ability to respond purposefully to verbal and/or tactile
stimulation.
4. The sedation nurse will monitor the patient’s tolerance to the procedure and sedation. Patient’s level
of sedation/analgesia is continuously monitored to maintain the desired level of sedation.
5. The sedation nurse should take into consideration the medication pharmacokinetics and the
individual’s response (or anticipated response) to the medication to prevent respiratory depression.
a. Each medication should be administered individually to allow each medication to achieve
desired effect. If medications are given in combination or in multiple doses, caution should
be taken to ensure doses are not given too close together (e.g. need to avoid “stacking”).
D. Post-Procedure Monitoring (CI)
1. Phase I post-procedure monitoring:
a. Only nurses who are considered competent in performing moderate sedation will monitor
the patient during this phase.
b. Patient’s blood pressure, heart rate, ventilatory function should be closely monitored;
oxygen can be administered as needed.
c. Phase I monitoring requires continuous monitoring by a moderate sedation competent
nurse and documentation at least every 15 minutes.
2. To discharge from Phase 1 criteria Aldrete Score should be greater than 8 and commensurate with
baseline Aldrete score.
3. Phase II monitoring should be a minimum of 30 minutes with assessment and documentation
occurring at least every 15 minutes by a nurse. This can be performed on any general care, IMC or
ICU area.
4. Patients should meet all Phase I and II criteria to discontinue sedation monitoring or be discharged
from sedation monitoring.
5. Discharge instructions should be provided to the patient and support person(s) both in writing and
verbally.
6. Ensure patient safety as patients receiving sedation are at higher risk for falls due to the procedure,
medications and potential co-morbidities.
7. Outpatients should be able to eat and drink prior to discharge. NPO status for hospitalized patients
will be evaluated by the primary team and revised when appropriate.
8. Patients should be discharged with a responsible adult who will provide transportation home.
III. Deep Sedation (C IIa)
A. General Considerations
1. Sedative drugs may result in deep sedation. When these drugs are used as intended or result in deep
sedation, additional requirements and precautions are necessary related to assessments, equipment,
monitoring, documentation, outcome evaluation, and staff competencies that are beyond those
required for moderate sedation.
2. Nurses require successful completion of ACLS and PALS courses (as applicable to their patient
populations) to care for patients under deep sedation.
3. The nurse should be aware of and abide by organizational policies regarding provider credentialing to
perform deep sedation and to direct airway management and cardiopulmonary resuscitation.
B. Assessment and Monitoring

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 05/2016EArsenaultknudsen@uwhealth.org
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1. Deep sedation for adult patients requires etCO2 monitoring, pulse oximetry, and EKG monitoring in
addition to blood pressure, heart rate, respiratory rate, level of consciousness, level of pain and any
signs of complications (respiratory depression, hypotension, aspiration and procedure specific).
2. Deep sedation for pediatric patients may use etCO2 monitoring or pre-tracheal stethoscope
monitoring, pulse oximetry, blood pressure, respiratory rate, pulse rate, level of consciousness, level
of pain and any signs of complications (respiratory depression, hypotension, aspiration and procedure
specific). Pediatric patients may have EKG monitoring.
3. Oxygen should be administered unless contraindicated.
4. The frequency of assessment and documentation for the vital signs is determined by patient’s age,
level of sedation (deep vs. moderate) and any changes in the patient’s condition.
5. Testing the patient's response to more profound stimuli is necessary, unless contraindicated, in order
to assure the patient has not become oversedated and is under general anesthesia.
6. The nurse monitoring the patient should not perform any tasks other than administering medications
and monitoring the patient's response.
III. Pertinent Resources
A. UWHC Policies
• UWHC Administrative Policy 8.38, UWHC Adult Sedation Policy
• ED Policy Manual 33.3, Deep Sedation for patients 13 years and older in the ED
• UWHC Clinical Policy 8.56, Pediatric Sedation Policy
• UWHC Administrative Policy 8.34, Performance of Procedures and Sedation in Clinics and Ambulatory
Settings
• UW Health Clinical Policy 2.3.2, Outpatient Discharge After Receiving Sedation
B. Patient Education Resources
• Health Facts for You 5821, Moderate Sedation for Adult and Pediatric Patients
C. Clinical Tools
• UW Health Clinical Practice Guideline: Assessment and Treatment of Pain, Agitation, and Delirium in the
Mechanically Ventilated Intensive Care Unit Patient
• UW Health Clinical Practice Guidelines: Neonatal Analgesia
• To search for Providers’ Sedation Privileges: Privilege List Search
• Educational Opportunities: search Learning and Development System Catalog for “Moderate Sedation” –
multiple computer-based training and in-class didactic course offerings.
IV. References
See full guideline document for list of references.
V. Rating Scheme For The Strength Of The Recommendations
Category Description
Class I Conditions for which there is evidence and/or general agreement that a given
procedure or treatment is beneficial, useful, and effective.
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion
about the usefulness/efficacy of a procedure or treatment
Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb Usefulness/efficacy is less well established by evidence/opinion.
Class III Conditions for which there is evidence and/or general agreement that a
procedure/treatment is not useful/ effective and in some cases may be harmful.