Monitoring During Procedural Sedation
Sharon Ramagnano
Introduction
All patients undergoing procedural sedation in the emergency department (ED) should have continuous monitoring until ready for discharge.
Continuous monitoring of vital signs and clinical presentation of patient constitute a minimum requirement for patient safety monitoring.
Vital signs should include:
Heart rate
Respiratory rate
Blood pressure
Oxygen saturation
Capnography is more sensitive for detecting inadequate ventilation/apnea and should now be a standard practice.
Pre-procedural Preparation
Staff should ensure that the following equipment is set up in working condition prior to proceeding with the procedure:
Oxygen
Suction
Resuscitation equipment, that is, airway/intubation tray
Hemodynamic monitoring—includes BP, pulse, cardiac monitor, oximetry, and capnography
Sedative reversal agents on hand
Intravenous (IV) access established and maintained
The equipment listed in Table 5.1 should be readily available during sedation, while ensuring adequate monitoring of the patient.
Monitoring During the Procedure
Appropriate monitoring during procedural sedation is crucial (see Figure 5.1).
Monitoring should be targeted to detect early signs of hypotension, bradycardia, apnea, airway obstruction, or hypoventilation.
Table 5.1: Equipment necessary during the procedural sedation
Intubation tray
Nasal airway
Various ETT tube sizes
Laryngeal masks
Laryngoscope
Lidocaine spray
Stylette
Emergency crichotomy kit
Tape
Defibrillator
Syringes
Cardiac monitoring
Masks
Continual blood pressure, pulse and oxygen saturation
Ambu bag
Capnography
Suction
Intravenous maintenance
Oxygen
Intravenous fluids
Oral airway
Blood gas syringes
Regular review and documentation of vital signs is necessary for safe practice.
Consensus guidelines recommend recording every 5 minutes once sedation is established.
May decrease frequency once patient is awake and alert to the point of discharge.
Clinical Assessment
No monitoring device replaces clinical assessment of the sedated patient.
The level of awareness should be used as a guide to depth of sedation.
Check response to verbal or painful stimuli, eyelash response, etc. (see Chapter 1).
Continuous visual inspection of chest-wall motion and air movement is especially important to confirm adequate ventilation.
Signs of inadequate ventilation should be sought, including:
Inadequate or infrequent respirations.
Apnea.
Cyanosis.
Stridor.
Snoring.
Other signs of upper airway obstruction.
Monitoring of respiratory status has two components: ventilation and oxygenation.
Ventilation status can be monitored by clinical observation and auscultation or by capnography, while oxygenation is followed by pulse oximetry.
See Chapter 6 on complications related to inadequate oxygenation versus ventilation.Related posts:
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