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Practice Guidelines | Procedural Sedation: An Education Review
Practice Guidelines | Procedural Sedation: An Education Review
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Pre-procedure Assessment | Procedural Sedation: An Education Review
Pre-procedure Assessment | Procedural Sedation: An Education Review
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Airway Assessment | Procedural Sedation: An Education Review
Airway Assessment | Procedural Sedation: An Education Review
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Pharmacology- Benzodiazepines | Procedural Sedation: An Education Review
Pharmacology- Benzodiazepines | Procedural Sedation: An Education Review
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Pharmacology- Versed | Procedural Sedation: An Education Review
Pharmacology- Versed | Procedural Sedation: An Education Review
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Pharmacology- Opiods | Procedural Sedation: An Education Review
Pharmacology- Opiods | Procedural Sedation: An Education Review
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Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
Pharmacology- Antagonists & Additional Medications | Procedural Sedation: An Education Review
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Administration | Procedural Sedation: An Education Review
Administration | Procedural Sedation: An Education Review
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Intraprocedure | Procedural Sedation: An Education Review
Intraprocedure | Procedural Sedation: An Education Review
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Q&A- Procedural Sedation | Procedural Sedation: An Education Review
Q&A- Procedural Sedation | Procedural Sedation: An Education Review
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Transcript

so my name's Heather I'm a nurse in interventional radiology at NYU Langone health in New York and I am the clinical resources for our department so what that means is I'm responsible for individualizing our education to meet the needs of our department and one of

the first things I wanted to look at when I took on the role was our procedural sedation practices and how we can improve by enhancing our knowledge this presentation includes many of the lessons and concepts that I learned

along the way that I think are really important to understanding how to effectively administer procedural sedation so our learning objectives are going to be a review of the guidelines pre-procedure assessment components

including airway assessment pharmacology of the medications that we give and intra procedure assessment so this is the 2018 AAS a practice guidelines for a procedural sedation by non anesthesiologist has everyone seen this

good great as so this is especially important because as you'll see the American College of Radiology and Society of interventional radiology were involved in its development so this is our guideline and I think it's really

important to look at this look at the practice recommendations and see how they align with your own practice and if there may be some changes you need to make first thing you always want to look at when you're reviewing any sort of

literature whether it's evidence-based guidelines or maybe just a review article is you want to look at the methodology that the author used to create the guideline so anybody know why that's important you just shout it out

so if I want to write a guideline for procedural sedation I could find a bunch of studies or review articles that fit my point of view and use them throw them at the bottom and that would be that but even if I use for an demise control

trials which are considered the gold standard of experimental research those randomized controlled trials could be poorly constructed randomized controlled trials so they may have introduced bias at some point into the study

that's skewed the outcome and the findings so you really want to make sure that the authors of the guideline that you're looking at appraise the research that they're using to support their recommendations and that's what the

aasa' task force did so they used randomized control trials and observational studies and then they categorize the strength and the quality of the study findings so as you're going through you'll see that statistically

significant was deemed a p-value of less than 0.01 and outcomes were designated as either beneficial harmful or equivocal equivocal meaning this findings were not significant one way or the other and then they also used

opinion based evidence from experts so they surveyed members of their task force and they did take into account some informal opinion from message boards and letters to the editor so I think a good example here is one of

their recommendations about capnography so they did a meta-analysis of randomized control trials that indicated that the use of continuous and title carbon dioxide monitoring was associated with a reduced frequency of hypoxemic

events when compared to monitoring without capnography and then you'll see at the end of the recommendations this category so for this particular recommendation they labeled it as category a1 - B evidence and what that's

telling you as category a means it was a randomized control trial which is great it was a level one meaning it's a high level of strength and quality and B is telling you that there was statistically significant findings that demonstrated

benefit to the patient now another recommendation that you may see as you're reading through would be the NPO guidelines so if you look at any of the literature about NPO recommendations it's really all expert

opinion because all of the evidence has shown equivocal findings so for example one of the studies they looked at compared the outcomes of patients who had clear liquids one hour prior to the procedure versus two hours and they

found no change in the outcome I think it's important when you're a provider and you're looking at that because you're gonna base your judgment calls on the evidence so you may have a patient come in who had tea up until one hour

prior to their procedure and you have to make a decision whether or not you want to cancel or proceed and you could look at the findings of the literature that shows that there really hasn't been a proven difference in outcomes so you may

decide to just do the procedure versus capnography there's very strong evidence showing it's beneficial to the patient always so I think this is a real big take-home point of why we do everything we do about procedural sedation all of

our assessments and enhancing our practice as a sedation is a continuum and practitioners intending to produce a given level of sedation should be able to rescue the patients whose level of sedation becomes deeper than initially

intended pre-procedure our assessment

includes an interview of the patient abnormalities of major organ systems like cardiac status do they have a reduced ejection fraction do they have coronary artery disease I want to know

if they have an EF of 10% because if they become hemodynamically unstable and I want to give them fluids I'm not going to bolus a patient with a very low ejection fraction with two liters of fluid you're gonna cause

pulmonary edema and you're going to worsen the situation renal status is huge a lot of our patients are renal e impaired and that can affect the way that they clear the sedation medications that we're giving pulmonary status do

they have COPD asthma or sleep apnea sleep apnea is major in procedural sedation neurologic status do they have a history of seizures endocrine status hyper or hypo metabolism of medications can occur if they have a thyroid

disorder we want to know about adverse experiences with sedation in the past do they have a history of a difficult airway for us at NYU if they have been already been identified as a difficult airway that automatically means we're

doing the procedure with anesthesia current medications potential drug interactions is very important we'll go over that a few slides drug allergies and herbal supplements that they're taking tobacco alcohol or

substance use and frequent or repeated exposure to sedation agents is just going to increase their tolerance of the medications physical exam vital signs auscultation of heart and lungs and then their airway assessment sorry excuse me

do they have any Strider snoring or sleep apnea advanced RA they're gonna have a hard time tilting their neck back if they have cervical spine disease or they have rheumatoid arthritis chromosomal abnormalities like

trisomy 21 patients with Down syndrome can have an enlarged tongue that can impair your ability to manually ventilate them if respiratory depression wants to occur body habitus if they have significant obesity especially of the

head and neck areas and head and neck limited neck extension short neck decreased ornamental distance which is basically just looking at how far back they can tilt their head any neck mass and then again cervical spine disease or

trauma do they have a c-spine collar are they on c-spine precautions that's not a patient we're going to be able to manipulate their airway and then mouth opening we do use Mallampati and I'll review

that in a couple of slides so the AFC classification is a categorization of the patient's physiologic status that can be helpful in predicting operative risk it is recommended by the AFA that if a patient is an Asaf or that that

should prompt an evaluation by an anesthesiologist I will tell you at NYU we will still get procedural sedation to some patients who are in Asaf or but we like to identify it ahead of time because if they have significant

comorbidities that will potentially increase their likely hurt likelihood of having an adverse outcome we then have a lower threshold for activating a rapid response or a code if something was to happen if we got concerned about

something so the airway assessment is

all about effective bag-valve-mask it's the mainstay of airway management and procedural sedation but also in the o.r so you're gonna see if you're ever working with an anesthesiologist that

the first thing they want to see is how easily they can ventilate the patient with a mask and if they have trouble they know that's potentially going to be a patient that may give them difficulty later on when they're attempting to

intubate because when they go to intubate the patient if they're not successful they immediately stop and go back to bagging the patient they want to know that that's gonna be there their failsafe and that they have an

effective way of delivering breaths the difficult airway is going to be defined in terms of whether effective gas exchange can take place with an Ambu bag so at NYU we use the sorry we use the Mallampati so this classification system

attempts to grade the degree of airway difficulty the foundation of the assessment is that the tongue is the largest anatomical structure that can inhibit mask ventilation now again if you look at the research surrounding

this Mallampati used in isolation it's not useful you really want to look at all of the other airway assessment criteria that I just previously discussed because it's on our required documentation you know it can be

something that maybe providers get focused on just open your mouth cool and move on but it really is important to look at all the other components not to call out my attending sitting over there so this is a great mnemonic that I like

moans it's just a quick easy way to identify a patient that may give you a little bit of trouble when it comes to manual ventilation so M is for mask o for OB 3a for age and for no teeth and s for stiff lungs so you can see with this

patient here with the beard he has a lot of facial hair so that's a patient that you're gonna have a difficulty getting a good seal with and if you can see they actually covered his beard with Tegaderm in order to get an effective seal right

painful later but great for his airway um last thing yes at this point oh great this points you guys can still hear me okay so for this patient for for obese patients in general my biggest pain point I guess you could say is when I

see patients inappropriately position during procedural sedation and a nurse will call and say the patient's not really well sedated but his his capnography waveform looks all off he's occasionally having periods of apnea can

you come and help and the patient looks like this so a patient who's sedated is not going to be able to comfortably spontaneously mentally win their position like that you can see his airway is a little bit compressed here

he has to overcome extra body habitus in order to effectively take a breath so what you want to do is just ramp your patient and this is obviously extreme like if you're doing an angiogram you're not the providers gonna say what on

earth are you doing but what you can do is take that pillow out and put a little roll underneath the shoulders and you're gonna see the airway open up and if I get patients who come in and they can't be flat maybe they have congestive heart

failure so they have that pillow orthopnea you can position them like this give them the sedation and then take everything out that's what I always do you you want to make sure that you have

good positioning and that's going to set you up for success patients who are elderly or have no teeth are going to be what we call a dentist and they essentially just have loss of musculature in the face which is going

to correlate with surface area which means you're not gonna be able to get a good seal so what they did in this particular patient is they actually put gauze in to just increase that surface area and then patients with stiff lungs

are going to be patients who have a history of COPD or any other restrictive lung disease and they just may be difficult to ventilate Pharmacology and

we know try to make this painless but I think it's kind of interesting

so metabolism is just talking about converting a medication into a less or more active form and that gets converted into what we call metabolites within metabolism you have your cytochrome p450 system which is responsible for

metabolism of a lot of the drugs that we give and essentially that's just a family of enzymes that are responsible for metabolism properties are going of the drug are going to influence the duration of action and the half-life of

your medication so for instance of a pee if a drug is highly protein bound what it does when you administer it is it binds to the protein molecules and slowly dissociates so you have a longer duration of action

because when it's bound to the protein it's in active half-life again any properties that increase the duration of action are going to be something we want to pay attention to and how is the drug excreted you can have excretion through

the bile feces renal system a big thing I think for us and IR is drugs that are really excreted benzodiazepines are the mainstay in providing the sedative component a procedural sedation it's going to enhance the inhibitory effect

of the gaba neurotransmitter in the central nervous system why do we care about that does anyone know have something to do with our reversal so our gaba neurotransmitter is responsible for inhibiting the activity

in the brain so if we didn't have a gaba neurotransmitter we would have seizures all day patients who have seizure history of seizure disorder are sometimes on benzodiazepine therapy at home if you sedate them and they require

reversal and you give them flemeth know you can potentially precipitate a seizure so it's just something you want to keep in the back of your mind it doesn't mean you're not going to reverse them you just want to be prepared to

handle a seizure if that occurs versed is our number one drug that we use onset of action and peak effect or seen in 3 to 5 minutes the antagonist as I mentioned is flumazenil and the half-life is three

hours typically in our department we give one milligram depending on the patient's physical condition and what they require and how anxious they are we may give 0.5 or up to two in one dose now you're gonna see and an Aaron says

this to in their procedural sedation guideline that you shouldn't exceed five milligrams I don't complete and that means overall in one case I don't completely agree with that I'll explain more why later but I think patients are

really complex and there can be a lot of drug interactions that are occurring that may cause them to require more sedation than a typical patient so it's not so cut and dry you could look at five milligrams and go that's kind of

more than the norm and maybe I need to look at is the sedation not working but you may have a patient that could take 10 11 12 milligrams of versed and be

fine versed is extensively metabolized by the liver so I mentioned the Cy p450

systems so the specific enzyme that metabolizes versed cyp3a4 now that sounds like way too much information but what's important about that is there are some drugs that are also metabolized by the same enzyme that are inhibitors of

this enzyme and one of them is verapamil so at my institution when you order verapamil and versed together a warning comes up that's telling you that the verapamil may potentiate the effect of the versed and that's because the

verapamil is inhibiting the metabolism of the versed which means it's sticking around longer it's a consideration because we give wrap a mill for our radial access cases for a Vizsla spasm prophylaxis and neural patients yes yeah

a lot of neural patients for a cerebral vasospasm properties it's 97 percent protein bound so that means if you have a patient who has low serum albumin you may see a more potent effect right away because they don't have as an

a lot of protein circulating so that drug won't have protein to bind to half life in patients with renal failure reduced elimination of an act of the active metabolite can cause drug accumulation and prolonged sedation and

I'll tell you why that's especially important in the next couple of slides and then considerations prolonged tap life and the elderly obese and reduce hepatic and kidney function I think most of us know this but I think it kind of

helps to drive at home if you know why why is it prolonged half life in reduced kidney function well it's because it's 97% protein bound and it needs to be excreted by the kidney and you have an active metabolite circulating around not

getting cleared opioids are the mainstay

in providing the analgesic component of procedural sedation they activate opioid receptors in the brain and spinal cord to inhibit transmission of painful impulses fentanyl is the main drug that

we use the onset of action is seen in one to three minutes and the peak effect is seen in five to fifteen the half-life is two to four hours and we typically give a dose of 50 mics to start again it's metabolized by that cyp3a4 what's

especially I think important to note is that it gets metabolized to inactive metabolites so I had a situation when I was a newer nurse I was working in the ICU I had an elderly patient it was my third night with her and she was

admitted for acute kidney injury related to her urosepsis so she really wasn't making a lot of urine and she lives in an incredible amount of pain she has been screaming for two nights and I finally said enough I went to the

resident so we have to give her something so she said let's give her some morphine you want to give her one milligram she's elderly can we at least start with 0.5 and see how she does with that she said that's fine I gave her the

point for five of morphine and she went to sleep maybe thirty minutes later and she looked really comfortable now we didn't we don't or at that time we didn't use capnography for non intubated patience in my ICU I was in but she did

have a pulse oximeter on and all the other monitoring I didn't really disturb her throughout the night I knew she hadn't slept in two days so I would go in and check on her and turn her and see how she was doing and she seemed really

asleep but comfortable I go and do my bedside handover with the day nurse in the morning we go to wake her up and she's not waking up and we do a really good sternal rub and all your nail bed pressure and all those tricks

and nothing's working and she's she's out so we called in the attending in the resident and pees and they ended up doing an arterial blood bath and her paco2 was 75 yes so they did give her narcan and thankfully it worked and she

didn't require intubation the nurse practitioner pulled me over afterwards when things had settled down she said you know I want to talk to you about what happened why did you decide to give her morphine and start a fentanyl and I

said well you know morphine of aura fentanyl rather is a hundred times more potent than morphine and I thought I was doing the right thing because she's an elderly patient I was worried about her cuz she's frail but then she explained

to me that morphine gets metabolized to several different metabolites and one of them is actually 2 to 3 times more potent than the original morphine that you're giving in the IV and because she was in acute renal failure she wasn't

excreting the drug so she had this two to three times more potent drug just circulating around her system all night which led to her respiratory depression and her hypercarbia with fentanyl you have metabolism to inactive metabolites

so it's considered to be more safe for patients who are in renal failure that was a real big aha moment for me because there's a lot that you have to know when you're a nurse especially if you're working in a critical care area and you

hope that you're the providers you're working with are thinking of these things but they're also very stressed so it's all of our responsibilities to know the way that these drugs work and I think it's great in IR because we we

don't give it a lot of medications we give a fair amount but they're pretty much the same medications over and over so we do have an opportunity to really take a better deep dive and really the mechanism of action and their

pharmacokinetic properties considerations you do want to consider renal e impaired patients because it can alter the kinetics meaning that there's decrease protein binding as I said for versed but there is they are slightly

less protein bound than versed and there is a black box warning for cyp3a4 inhibitors specifically for fentanyl just something to keep in mind when you're giving it though I think this is really more I'm talking about patients

that are going home with a fentanyl patch you want to make sure they're not taking inhibitors at home kind of

interesting to grapefruit if a few YP three a-four inhibitor so I always remembered from nursing school they said

don't give grapefruit but I never really knew why but that's why it's just inhibiting the enzyme that's required for metabolism flumazenil is the reversal agent for benzodiazepines your initial dose is going to be 0.2

milligrams over 15 seconds what's important to note about flumazenil other than the seizures that I mentioned before is that the half-life is shorter for flumazenil than it is for versed so you can see a recitation effect which is

why you really need to monitor them for a good period of time after you're giving it and monitor to make sure they don't become reefa dated we're all familiar with narcan it's the reversal agents for opioid medications the

initial dose is 0.4 milligrams given over 30 seconds and you can repeat every one to three minutes to a maximum of ten milligrams other medications I think are useful to mention because you do see them and I are usually given by an

anesthesiologist propofol is a great drug onset of action is less than one minute but it's a potent drug so you can see significant hypotension and respiratory depression for us in New York it's not permitted for use by non

anesthesiologists Dex Mehta Tommy Dean is another interesting drug that's sort of getting into the kind of talk in the IR world so in the 2018 guidelines that I mentioned before they address sex medicine

and they said that it could be an alternative for versed in particular cases it's a highly selective centrally acting alpha-2 agonist with eggsy oolitic sedative and some analgesic effects

you usually administer it as a bolus over 10 minutes and then you start a continuous infusion however some of the very potent bradycardia that you can see can be mitigated by eliminating the bolus infusion or the bolus

administration rather and significant considerations with this are hypotension and bradycardia does anyone use pres iudex in their ir suite oh you do okay you guys give it cool we'll talk our our anesthesiologists are

a little territorial with it however the research does show that it does have a better safety profile in certain patients so it you know yeah so that's my experience with it but our particular anesthesiologist that oversees our

sedation committee and all of our sedation practices is concerned about us using in an ir because not all the practitioners have experience administering it there's not a reversal so if the patient became bradycardic you

would have to treat their bradycardia with fluids or atropine or other medications for your particular institution yeah right it yes yes always look at your state guidelines yes so the a what the a sa says about the

timing of a minute administration is that you need to know the drugs time of onset peak response and duration of action and titration of drug to effect is an important concept so you need to know whether the drug you just gave hit

its peak effect before you start Rideau seing them that concept is called Li and C to peak drug effect and all that's saying is that you just want to make sure that you're hitting the peak effect before you redose if you don't you can

have dose stacking which can put the patient at risk for toxicity and latency to peak drug effects can be changed by the physical physical chemical properties like we just discussed so how much it provides to protein is it lipid

soluble it's basically talking about how quickly it can get to the site of action and do what it needs to do pharmacokinetic and pharmacodynamic variability is basically just telling you that I could give one person a

milligram of versed and then give the next patient a mil a milligram of versed and they can have completely different responses and some things we can predict ahead of time and other things are we're just not going to know I mentioned the

cytochrome p450 system there are patients that have genetic variances of those enzymes that can change the way they metabolize the drug there's no way that we're going to know that beforehand the way that you deal with this or

tackle this problem is you start small assess and adjust we all know this you learn this in nursing school it's easy to add more it's always going to be worse to try to take it back you won't be able to take it back

I like this chart just because it kind of talks about the different variables that you may encounter so we already talked about the pharmacokinetic variabilities but some of the pharmacodynamic variabilities are going

to be your drug receptor status genetic factors drug interactions and tolerance when I look at drug receptor status I'm thinking methadone buprenorphine if you have a patient on buprenorphine and that receptor is occupied by the

buprenorphine it's going to cause competition for the next opioid you try to give like fentanyl we've had some problems patience in our department with this drug as far as titration is concerned

you want to administer each component individually to achieve the desired effect now this was a change for us when I first started talking about this because we used to give versed and fentanyl together every single time but

with the AFA recommends is that you give the drugs individually monitor the response and then assess accordingly this is an algorithm I found on up-to-date it's just a suggestion obviously it's not going to fit every

patient but it's just describing how you would start out with midazolam first give that time to hit the peak effect which again remember is gonna be 3 to 5 minutes and that can feel like a long time NIR so it's a little painful to do

this but it is going to I think lead to a better outcome for you and for the patient as far as their experience then if necessary give fentanyl I usually give that for the access because really I think for the most part most of the

things we do aren't overtly painful there may be painful parts of the procedure but it's not just two hours of pain or it shouldn't be and then you want to observe the patient if you gave fentanyl you really want to wait five

minutes and then redose from there so usually I just give the one dose of fentanyl and then I stick with my versed by eliminating that that double dose every time you're going to be able to go higher on your versed or your fentanyl

depending on what you need to give so that makes sense to everybody we were we were giving we call it one round versed in fentanyl one round and then by the fourth round nurses were understandably going oh good I the

patient needs more but I feel really uncomfortable and a CRNA said to me one day why are you guys giving fentanyl and versed every time it's great for the synergistic effect but you're going to hit that feeling a lot faster than if

you just give small incremental doses of versed to get them through the procedure and leading into synergistic interactions so giving a benzodiazepine and opioid together elicits a synergistic interaction you can think of

it as 1/2 plus 1/2 equals 4 in the city and that's a lot of what we were seeing we were seeing this you know give the fence alone verse said okay they're really sedated and then they're not anymore and then they're really

sedated and then they're not anymore versus this really nice steady maintenance of sedation during the procedure intra procedure you want to be

checking on the patient periodically at least every five minutes and monitor the

response to verbal commands if a verbal response isn't possible come up with some technique with the patient ahead of time if they're gonna give you a thumbs up or thumbs down if they're gonna close one eye raise an eyebrow whatever they

want to do come up with that come up with that with them in advance and use that to guide their to their ability to maintain their airway because sedation is going to be the main indicator of eventual respiratory depression if

that's going to occur it's not going to be your respiratory rate or your other dimo dynamics it's going to be the level of sedation we we have this problem a lot one of the nurses came up to me the other day and said the doctor told me

not to talk to the patient during the procedure I said no that's just pull this up I always say pull up the guide line this is Society event you can say this is your Society they told me I need to assess the patient every five minutes

and assess their response to me there has to be some sort of verbal response the patient doesn't have to move their arms around or give you a hug it's it's really just saying I'm okay Richmond agitation sedation scale

this is what we use at NYU this is a scale essentially to measure the level of sedation our goal is to try to get patients into this negative three sometimes it's not always possible but we want to use this to determine whether

or not the patient is slipping into a deeper level of sedation and again that's important because this is going to tell us that the patient is then at risk for respiratory depression or apnea if they transition into a negative 4 or

negative 5 ventilatory depression and airway obstruction are two different problems I just think it's important to know this because it's gonna require two different rescue mechanisms although you will usually see both of these happening

at the same time I only saw one time where it was true ventilatory depression it was in the neuro suite does anybody do wadda tests yeah okay so I had only I've only seen this once but we gave the amytal and the patient had complete

depression of their respiratory center so she did not breathe at all we had to do really deep stimulation in order to get her to take a breath so we could have done all the airway maneuvers in the world it wasn't going to help her we

had to wake her brain up and tell her to take a breath if she didn't we would have had to have intubated her that would have been the only way to rescue her because as far as I know there's no reversal for the amytal that we give bag

mask ventilation this is the cornerstone of basic airway management it's not a skill easily mastered I think a lot of people will sometimes fly through this because you do this in ACLs if you worked in an ICU you did this a hundred

times but what's different between this and a sedation setting and in a code situation is the patient and the code is already dead the thing that's not going to save them is is you're good you know Ambu bag skills it's gonna be the CPR

what's going to save your patient who is respiratory depressed in a procedural sedation setting is effective airway skills because according to the H a ventilation via an Ambu bag may be just as effective as ventilation via an

endotracheal tube that's huge so you can buy your patients some time while you're getting the reverse or you're calling for an anesthesiologist to come and intubate them if you're not able to effectively

ventilate them and they progress to a CPA as I'm sure you're all aware that just is a major indicator for eventual poor outcomes the patient could experience some airway techniques that are helpful you can do the head tilt

chin lift or a jaw thrust in patients what you do want to be mindful of obviously if they're in c-spine precautions if you are doing the procedure with procedural sedation which I would caution against then you would

just go right to a jaw thrust you're obviously not going to manipulate their cervical spine and capnography I know everyone knows capnography I'm a huge huge fan of capnography I can't stress it enough I think does everyone use it

does anyone not use it you don't use it okay okay just know if you are having trouble getting your institution to provide the finances if that's their concern as I just showed you in the beginning of the presentation there is

very strong evidence showing that there it's a positive outcome for the patient if something was to happen one day with a patient and and maybe it was to go to litigation although guidelines aren't meant to be a

hard and fast rule likely it would be brought up in the litigation they would say why do all of these organizations recommend capnography but it wasn't used in your institution and then they may say well we haven't seen any cost

benefit and then they would say well but there is cost benefit it's level a one evidence so it's really really useful and most importantly pulse-ox is going to report an average saturation overtime so you are going to see some lag so it

could be one to two minutes before you actually see a change in the pulse ox and your patient may not have been breathing for those one to two minutes so once the pulse ox does go down it's going to go down real quick and also if

you want to look at some additional resources I think the air and capnography toolkit they did not ask me to say that but I do think it is actually really really great and it was put out

steer another thing I just want to say to make the capnography work for you I think in our institution we've been using it for a long time but it doesn't always work we use this nasal cannula that's supposed to have this nice little

reservoir but it's really not great because it's cold in the room so the plastic will stiffen and it flips up use some tape or I just put a simple mask over the nasal cannula and then you'll get your waveform you'll have the the

carbon dioxide captured I think there's some fancy masks out there I think Medtronic is may be releasing a mask that does a capnography which will be great but in the meantime just make it work for you and make it work in the

beginning of the procedure sooo as you're giving more and more sedation potentially you're not then worrying about futzing around with making the capnograph you work nonpharmacologic methods I think are really important so

we get this a lot Twilight are you giving me propofol it's the same as a colonoscopy right or you're gonna knock me out right right so these are really important conversations to have in the prep area when you're getting your

patient ready make them aware they're not going to have these things and be honest with them if they're adamant they want to be asleep they want the Twilight you reschedule there it's I have found it's not worth trying to convince them

to do something that they don't want to do because they're just gonna write a really nasty letter later and and I don't and I don't blame them because I think sometimes we're not honest and we think we're doing the right thing and

you know don't worry we'll get you through it were you gonna be really comfortable and sometimes patients aren't going to be comfortable and that's okay and if they're not okay with that then we have to do what we need to

do to make sure that we're meeting what their needs and that leads into setting realistic expectations I always tell patients you might not see me the whole time I'm gonna check on you at least every five minutes if you don't see me

it's because I'm right behind you tell me what you need every five minutes I'm going to say are you okay if you need to be a little bit more asleep if you're in pain you're having anxiety tell me and I'll give you more medication this is a

collaboration and I find that that really eases a lot of the anxiety especially them knowing you're right behind them the whole time if they can't see you like their tented you know without a halo I think yeah the covered

halo we were talking about before if they can't see you it gives them a lot of anxiety if they think no one's in the room and there's just a provider they can't see doing a procedure on them sedation scripts my attending left but

we had a little bit of a healthy argument about this so I talked to him about scripting the way that we talked to patients about sedation so we're all saying the same thing all the time and he said you know I'm an attending and I

I didn't do a residency and a fellowship to be a robot and all these things and you know it was and I he loves giving me a hard time about this stuff so it was kind of funny because he's doing he's currently engaged in a grant project

that's looking at our work flow throughout the institution and he has research assistants that are working on it with him and one of the things that they did was they went on the floor with some of our residents who are consenting

the patients for procedures and she the very next day in a meeting it was totally unrelated it said to him you know they're saying the wackiest things to the patients some of them are saying don't worry about it you'll be asleep

yeah yeah it's like whatever you had last time and they're really not setting them up with realistic expectations so when we get them at least our impatience when we get them down stairs for their procedure they're totally confused about

what they're gonna have done and then I think they feel very anxious because they're about to go right into the room and now we're telling them you're not going to be asleep you'll you'll be able to talk to me during the keys so you're

not saying everyone has to be a robot and say exactly the same thing but I you may want to talk to your staff about hitting the same take-home messages so that they're not hearing all different descriptions of sedation throughout

their stay all right thank you everyone

are there any questions yeah yes that's a really good sure so the question was do you have any rules or guidelines in my institution about how long the procedure can be before you start

talking about anesthesia versus sedation is that right and positioning prone supine we did come up with a guideline with within our department we looked at a little bit of research but honestly was more expert opinion just best

practice and experience I in in general I would say if the procedure is 3 plus hours the patient should know they're going to be on the table not asleep for three plus hours and talk to them about what that means and if they're ok with

that I just think again that comes into setting realistic expectations that's one of the reasons actually that we're very interested in using Dex med otama Dean because that's going to be a better

drug for those longer procedures first was giving functional and versed for four hours it's just not it's not appropriate but you know and some people would say we'll just get an anesthesiologist them but a lot of these

patients are really thick so in our institution anesthesia is just really super regulated and they require all of these clearances for their involvement no matter what they're giving sometimes they'll require all these clearances and

they give exactly what we were going to give so you know it's it's really a juggling act I would say in our department we really just make sure the patient knows what the expectation is and then we'll usually say to the

provider to if if something goes like if anything looks a little concerning during the case we're stopping and they have to be ok with that and they are they really are but that took a lot of work to get everybody on board with that

type of communication yeah we don't know so they I know I think Sloane is anyone here from Sloane no I think Sloane has with dedicated anesthesiologists they work really closely with them and it's easier for

them to get cases scheduled they will give us they will assign us an anesthesiologist for the day but if we don't have any anesthesia cases they get reassigned somewhere in the o.r and it's a different analysis every time it tends

to be the same group some are stricter than others some will have a patient say I really want anesthesia and we can call up the provider and there they say no problem let me do a quick chart review whereas the next day the provider goes

no absolutely not send them for clearances that's a little tricky yeah right so what I showed you is from the american society of anesthesiology i am not affiliated with them at all i just think they bide non anesthesiologist

sedation so i rely heavily on what they say and they recommend waiting till peak effects so i would look at the pharmacokinetics so for versed it's 3 to 5 minutes so i would wait at least 3 minutes before your readmit a stirring I

think a good example with that is when diazepam with the sedative of choice the on the peak effect for diazepam is 1 minute so when midazolam came onto the market there were a lot of adverse outcomes

with patients because providers administering it weren't familiar with the pharmacokinetics and assumed that the peak effect for versed was the same for diazepam so in theory you could give a patient in 5 minutes 5 milligrams of

versed so by the time that fully hits them they could be in a negative 5 on your raft scale so you know just look at those pharmacokinetics look at that peak effect and I would use that to drive your dosing scheme Atlee that's what I

do and I think since we've done that we've seen better meet info cities and better safety outcomes yes okay yeah we don't do that we do one thing with uterine fibroid embolization swear they'll do a superior mesenteric block

but otherwise we don't do any other type of regional blocks but I have read about that I think that's really are the IR providers giving the block okay right I've seen two with uterine fibroid embolization we'll do an epidural in

advance some I think some institutions or some literature exists about that it's interesting it would be interesting if the IR providers could actually give it though I'm not sure if that's kosher in the anesthesia world but they're

certainly qualified to do it they they do already kind of do it really but so I mean that's certainly something interesting and if you have a provider that is comfortable taking that on and their institution I think it's worth

looking at because anything that's sort of I think mixes things up and and provides a different Avenue especially for high-risk patients is worth looking into definitely yes I believe it yeah

mm-hm right so I'll just repeat what she said so just jumping on the talk about blocks so in her institution they the providers to administer blocks and I think you said

coleus estas Tamizh and PTC's and biliary dream placements they'll use that and it will decrease the amount of sedation that's required sedation being versed and fentanyl that's required during the case which like yes like you

said is really great for patients who are already on opioids previously and habit aller ins yes [Music] something right so we again he left same provider though had a patient on Groupon

or Fein and it was our first experience within about a year ago and it was terrible and she did not have realistic expectations going in of how sedated she would be and she was very very unhappy

afterwards so we talked a lot about that and in that guideline I had mentioned that we made about when we involve anesthesia and when we don't there's a caveat about that that says that if a patient is on

methadone or buprenorphine that a discussion needs to take place making them aware that they will probably not feel very sedated but we will try our best and if they're not comfortable with that we reschedule the procedure with

anesthesia but they have to know going into it that they they may not feel completely sedated and we just keep that open and honest communication but we haven't really come up with a scheme of what's best we did actually try with her

we had her come in one day having taken her buprenorphine the day of the procedure and she seemed okay with that and then we tried having her go off of it so that the receptors wouldn't be blocked she was not happy with that

experience so that's really when a person like that probably would do great with propofol but we can't give propofol so you know if the and if the patient tells us no then we just reschedule with the anesthesia

right - hmm right right right you could at least if they're if they're on an opioid uh if they're on people nor Fein then in theory they should respond to the verse said you could go heavier hand it on the

versed just to get them sedated but they will probably still feel pain but it they hopefully won't remember it that's true I you know with the Richmond agitation sedation scale that's not going to fit every patient that's a

really good point I gave a patient seven of versed during an adrenal vein sampling and she was just talking my ear off I got I fed are you okay you know do you need me to give you anything else no no I'm good I'm good and then I wheeled

her out we got her in the recovery area and she goes sit over I said yeah she said wow I don't I don't remember anything the power of her said that that was like a true and music effect I hadn't seen that so strongly in a

patient before but if you if I had done you know I was documenting that she was a zero it looked like I wasn't doing much for her but then I was putting comments you know patient comfortable denying needing any more sedation so

won't fit every patient so it is good to look at that but yeah as far as the buprenorphine I mean it's it's it's tough yeah if they have an addiction specialist I would say talk to them and they might be

able to come up with a scheme that works for them and if there's a lot of pain expected afterwards those patients are gonna have to be on parenteral opioid therapy they'll probably have to stay you know if you're in a hospital they

would have to stay overnight so those are all things you have to consider yeah yes hmm yeah I'm like it so Adam and Alexa are nurse practitioners that we work with and I'm looking at Adam because

this is actually was a very hot topic for us in the last six months so we actually cheat we met with our sedation committee that's run by that in a physiologist who's blocking us from using pres of X and discuss with him

that in the protocol that guides our practice it's said that you did the timeout and then gave sedation but Ari anesthesiologists don't do that right so they intubate the patient and everything and then and they and then the provider

comes in and does the timeout right before the puncture or incision so we talked about to him about how well if we're gonna do the latency to peak effect it's not enough time right so we do now bring the patient in and start

sedation right away our orders are put in in advance I know some by the attending or the Li P so we have a PRN dose and with an a certain number of occurrences and a titrate to a certain Ross scale

yes yeah so and that our anesthesiologist mentions that our providers are present but it's it's a certain use of the language I think it might be like direct observation or immediately available and our providers

are immediately available it's up to your hospital so our profit our providers aren't like down the street on their way in to work with coffee and street clothes and we're sedating they're they're just down the hall maybe

or the way our department looks is we have a control area and it's like the you know the Central Station and you can see all of the rooms so they might be in the Central Station but just haven't gone in to do the time out yet that

being said I always talk to them before I bring the patient in and say what's the goal Rath and I address any concerns that I have and I think people think I'm a little kooky when I do that for every case but it I think it works really well

and I think the providers really like it so we just already start from the Gecko our line of communication I tell them the patient seems really anxious this is my plan what do you think agree disagree yes the procedural if does the procedure

list or the Lak but I've sedated the patient so the patient if you look at what Jayco describes in the universal protocol it's ideal if they can participate in the timeout however not required because then when they do the

timeout they're right there stabbing them with lidocaine so I like to you know I mean I would argue that by starting I would argue about that by starting at the sedation earlier and getting the patient into a comfortable

state you're more safe because you're doing the dosing appropriately according to the a sa yeah correct right right right

okay I think it's important to say though it's not about getting around Joint Commission this is what Joint Commission says you may feel uncomfortable with it and that's okay

but it is what our accrediting body says is okay we're also not intimating the patient and paralyzing them like an Asst the anesthesiologist is now having said that it's not like we walk the patient in and we go oh I think you're mr. Jones

we throw you on the table there is an initial timeout that's done with the nurse and the technologist and the other people in the room shaking his head yes as so the acceptable amount of time after reversal

yes so if it happens if it happens mid procedure you need to it's I believe the language the a sa uses that you have to have a discussion amongst the care team about whether or not you're going to proceed if it happens after the

procedure in the recovery area or it happens mid procedure and you abort then it has to be at least two hours before you discharge that patient or move them back to their unit where they came from because of that recitation effect and

because you can have really adverse effects from sedation like flumazenil can cause serious delirium I had a patient like that one time it was it was awful and it can cause serious cardiac arrhythmia so at least two hours if you

continue with the procedure I would just make sure everyone knows that you have to be really careful with recitation effects and and all of the adverse effects that you'd be looking at yes I think one more question I'm sorry

with hyperkalemia I have come across I want to say it was in perioperative guidelines when I was looking at the labs that we do cuz we do a lot of unnecessary labs in our department you guys might - I feel like we just really

overdo it I believe the perioperative recommendations are to check a serum potassium if the patient has a reason to have hyperkalemia however right if their hyperkalemic and

they develop a cardiac arrhythmia you know could hypoxia also precipitate that cardiac arrhythmia the results from the hyperkalemia maybe I just went in I wouldn't take an ounce

I would I would consider hyperkalemia severe hyperkalemia and unstable patient because that patient could go into a fatal arrhythmia so I would correct that before you bring them into an elective Percy what's often an elective procedure

so if you're doing a fistula gram you know right five point yeah why are we will go up to five point eight we personally will go up to five point eight because a lot of times they're hyperkalemic

because they're fish too less clothes now and we need to open it right so just again it I don't think there's ever going to be any hard and fast data that you see it's all about making sure everyone knows this patient has a serum

potassium of five point eight we're going to be really closely watching the ECG monitoring yeah thank you everyone thank you so much [Applause]

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