Chapter 15 Procedural Sedation

Concern for comfort and alleviating pain and suffering are fundamental to emergency nursing practice and emergency department (ED) care. Sedation is used in the ED setting when the patient’s condition is urgent or emergent, requiring the use of one or more drugs to relieve anxiety and pain.¹ Sedation is also used to induce central nervous system depression (resulting in a decreased level of consciousness) to achieve the intervention or to perform a diagnostic procedure.¹ Procedural sedation consists of the use of sedatives or dissociative agents to allow a patient tolerate an unpleasant procedure. The emergency nurse’s goal is to minimize anxiety and pain during the interventions or diagnostic procedures.² Using moderate sedation, previously known as conscious sedation, prior to procedures is becoming commonplace in the ED; however, it is not without risks. Specialized knowledge of sedation techniques and interventions is critical. This chapter defines and discusses implications for procedural sedation in the ED setting. Safe nursing care and practice before, during, and following the procedure (including medication administration, pharmacology, definitions for levels of anesthesia, regulatory guidelines, and age-specific indications) will be addressed.

The steps of sedation in the ED setting are:

• Presedation assessment and patient and family education

• Ongoing assessments during sedation and the procedure

• Postprocedure recovery and assessments

• Postprocedure discharge instructions and education

The emergency nurse’s primary focus is to ensure patient safety through safe medication administration, anticipation of untoward events, airway management, patient education, and discharge instructions. Table 15-1 explains the different levels of sedation used for procedural sedation.³

TABLE 15-1 SEDATION DEFINITIONS

Minimal Sedation (Anxiolysis)

• Normal response to verbal commands

• Coordination and cognitive function may be impaired

• Airway reflexes intact; no effect on cardiac or ventilations

Moderate Sedation (Conscious Sedation)

• Decreased level of consciousness that is drug-induced

• Purposeful response to verbal and/or light touch

• Airway reflexes intact, spontaneous respirations are normal, and no airway adjuncts needed

• Cardiac function not usually affected

Deep Sedation

• Drug-induced depression of consciousness

• Patient is not easily aroused to verbal or light touch, but will respond following repeated stimulation

• Airway reflexes may not be intact, ventilatory function may not be able to be independently maintained, and airway adjuncts may be needed to maintain ventilations

• Cardiac function not usually affected

General Anesthesia

• Drug induced loss of consciousness

• Patient not arousable

• Unable to maintain independent ventilatory function. Airway adjuncts such as positive pressure ventilation needed to maintain open airway.

• Cardiac function may be affected and impaired

Dissociative Sedation⁹:

• Trance-like catatonic state

• Profound analgesia

• Amnesia

• Airway reflexes intact; no effect on cardiac or ventilations

Data from American Society of Anesthesiologists. (2009, October 21). Continuum of depth of sedation definition of general anesthesia levels of sedation/analgesia. Retrieved from http://www.asahq.org/For-Members/Clinical-Information/~/media/For%20Members/documents/Standards%20Guidelines%20Stmts/Continuum%20of%20Depth%20of%20Sedation.ashx

Following institutional policies and procedures surrounding sedation is necessary. Procedural sedation policies and procedures should include the regulatory, state, and licensing specifics. The use of anesthetic pharmacological or dissociative agents for procedural sedation or analgesia in the ED setting is governed by nationally recognized guidelines as well as institutional policies and procedures that include identification of clinical indications; medical staff and allied health staff credentialing; and emergency nurse education, training, and competencies. State law and nursing scopes of practice dictate nursing administration of anesthetic or dissociative agents.¹

Use of Procedural Sedation in the Emergency Department

A variety of procedures that occur in the ED setting have the potential to increase pain, discomfort, and anxiety in patients. Procedural sedation can alleviate pain and anxiety in the ED setting. The emergency nurse must have special knowledge, skills, and competencies to administer medications for procedural sedation. Nurses who meet the competencies are able to manage procedural sedation within their institutional guidelines. This task is performed under the direct supervision of a physician credentialed by the institution. Compliance with regulatory, legislative, institutional, and professional standards of care is required.²

Therapeutic, diagnostic, or surgical procedures that may require procedural sedation include ⁴:

The goals of procedural sedation include:

• Decreasing the patient’s fear, anxiety, and pain related to the procedure

• Maintaining spontaneous ventilation, airway patency, and reflexes

• Maintaining a level of sedation where patient remains arousable, can cooperate, and can follow verbal commands

• Reducing the patient’s recall of procedures

Registered Nurse Competencies

The emergency nurse managing the care of the patient receiving moderate sedation or assisting with procedural sedation must be able to monitor and respond appropriately to possible adverse reactions to medications administered, changes in vital signs, level of consciousness, airway management, and oxygen saturation. Recommended preparations include:

• Proficiency in airway management

• Advanced cardiac life support (ACLS)

• Pediatric advanced life support (PALS), if caring for pediatric patients

• Knowledge of medications administered, including actions, side effects, half-life, pharmacological dosages and routes of administration, antagonists, and reversal agents for the type of sedation administered

• Ability to identify and manage cardiac dysrhythmias ⁵

• Institutional competency for moderate sedation

It is the position of the Emergency Nurses Association that a registered nurse may administer sedation medications in the presence of a physician, advanced practice registered nurse, or other health care professional credentialed and privileged for procedural sedation.² The state where the nurse is licensed and working defines the scope of nursing practice. As each state has varying scopes of practice, know your state’s scope of practice, as well as institutional guidelines, policies, and procedures on procedural sedation. Each institution has different guidelines to credential medical staff, allied health providers, and advanced practice nurses. Also ensure that the physician or practitioner ordering the moderate sedation is credentialed and has the privileges to manage moderate sedation.

Staffing Requirements

The Joint Commission Standard PC.03.01.01 requires that there be a sufficient amount of staff to ensure patient safety before, during, and following the procedure.⁶ According to The Joint Commission’s minimum requirements, the person performing the sedation procedure must be a nurse who is competent to administer the medications and to monitor and recover the patient.⁶ When the condition of the patient or the complexity of the procedure requires the diversion of the designated individual from monitoring the patient, provisions for additional personnel must be made.⁶