Procedural Sedation

1.0 Policy: Establish Safe Anaesthesia Practice guidelines of International

standards for care of the patient under procedural sedation, including pre
anaesthetic assessment and post operative care. All patients who receive
procedural sedation will be provided a safe and comparable level of care
consistent with, or in excess of the minimum recognized standards for such
procedures.

2.0 Purpose

1) to establish the highly recommended standard policy and procedure for the
safe management of patients requiring procedural sedation.

2) to enhance patient comfort whilst facilitating completion of the planned

procedure

3) to ensure that the highly recommended standards are applicable throughout

any elective procedures, from patient evaluation to recovery

4) life saving measures take priority in case of emergencies

5) regular updating of highly recommended standards to provide the best care

possible for safe practice of anaesthesia

3.0 Definition

A technique of administering sedatives or dissociative agents with or without

analgesics to induce a state that allows the patient to tolerate unpleasant
procedures while maintaining cardio respiratory function. Procedural sedation
and analgesia is intended to result in a depressed level of consciousness that
allows the patient to maintain oxygenation and airway control independently.

Procedures requiring procedural sedation

Operation theatre- minor procedures which does not require the patient to be
given general anaesthesia like incision and drainage, debridement, suturing,
lipoma excision,,fasciotomy etc.
Endoscopy suite- Endoscopic retrograde pancreaticocholangiography(ERCP), stent
removal,endoscopic dilatation, colonoscopy, endo sonography, double balloon
enteroscopy, endoscopic foreign body retrieval, endoscopic polypectomy etc.

Radiology suite- Patients who cannot lie down still for CT or MRI, radiofrequency
ablation etc.

Cath lab procedures- embolisation procedures

4.0 Abbreviations

ECG-electrocardiogram, PACU-post anaesthesia care unit,ETCO2-end tidal carbon

dioxide, ASA-american society of anaesthesiologists

5.0 Scope

Minor surgeries, various minimally invasive diagnostic and therapeutic procedures

in the cath lab, endoscopy and radiology suites

6.0 Responsibility; Anaesthesiologist, surgeon, proceduralists, anaesthesia

technician, nurse in charge

7.0 Distribution

Operation theatre, endoscopy suite, radiology suite, cath lab.

8.0 Process details

8.1 Description of the process

8.1.1staff competency/ qualifications

1. Procedural sedation is provided by qualified individuals

2. Anaesthesia specialists are trained and accredited with clinical and

administrative autonomy to

a) administer pharmacological agents in order to predictably achieve the

desired plane of sedation
 b) to monitor patients vitals such that the pre procedural physiology is
maintained through the procedure and post procedure.

3) Individuals administering procedural sedation should have the appropriate

credentials to manage patients at all levels of sedation

4) Included in the qualifications of individuals administering procedural sedation

are competency based education, training and experience in

a) evaluating patients prior to administering procedural sedation and

formulating an appropriate plan

b) induction, maintainence and recovery of patients from procedural

sedation

c) manage a compromised airway patient during procedural sedation taking

care of oxygenation and ventilation

d) maintain an unstable cardiovascular system

e) methods and techniques required to manage those who unavoidably,

unintentionally slip into deeper than desired levels of sedation

8.1.2 staffing

Sufficient numbers of qualified personnel in 1:1 ratio along with additional

qualified consultants to provide anaesthesia services outside the operating
room(in addition to the licensed independent practitioner performing the
procedure) are present during procedures using sedation to:

1)appropriately evaluate the patient prior to beginning of the sedation

2)provide deep sedation

3) maintain that desired level of sedation

4)monitor the required parameters

5) monitor recovery parameters at the end of the procedure and in the recovery
area prior to shifting the patient either to the ward or discharge from the hospital.

6)care in the post preocedure period

8.1.3 Equipment and monitoring

The procedure is performed in a location which is of adequate size and is staffed

and equipped to deal with a cardiopulmonary emergency. These facilities and
equipment must be sufficient and appropriate for the age and condition of the
patient, so that if required, basic life support may be maintained until more
specialized help,equipment and drugs become available.

a)adequate room to perform basic life support should this prove necessary

b)appropriate lighting

c)an operating table, trolley or chair which can be tilted head down readily is
preferable but not mandatory

d)an adequate suction source,catheters and hand piece

e)a supply of oxygen and suitable devices for the administration of oxygento a
spontaneously breathing patient

f)a means of inflating the lungswith oxygen together with ready access to a range
of equipment for advanced airway management(laryngoscopes,
masks,airways,laryngeal mask airways,endotracheal tubes etc)

g)appropriate drugs for cardiopulmonary resuscitations and a range of

intravenous access and fluids including drugs for reversal of opiates and
benzodiazepenes.

h)pulse oximeter

i) ETCO2

j)a sphygmomanometer
k)an ECG and defibrillator

l)a means of summoning emergency assistance

m)adequate access throughout the facility to allow the patient to be transported

easily and safely

n)a clinical emergency response plan to manage potential clinical deteriorations

o)monitoring of the depth of sedation, typically by assessing the patient’s

response to verbal commands or stimulation, response to painful stimulus,
presence of airway reflexes is of utmost importance. Modified Aldrete scoring is
the scoring system to assess the depth of anaesthesia during the procedure and in
the PACU

8.1.4 Patient assessment

Pre procedural assessment is done 24-48 hrs prior to any of the above mentioned
elective procedures and if required, any conditions can be optimized. ASA risk
classification is done. Re assessment just before the procedure to check for
optimal pre procedural conditions is vital.

a) details of the current problem, co-existing ,past medical and surgical history

b)history of previous sedation and anaesthesia, current medications, allergies

c)history or any predictors of potential difficult airway problems including lose or

artificial dentures

d) patients exercise tolerance and functional status

e)examination of the airway, respiratory and cardiovascular status, any other

system as indicated by the history

f)results of relevant investigations is noted

g) as preanaesthetic advice –appropriate drugs if needed to be taken/continued

are suggested and fasting guidelines are adviced.
h)informed written consent is obtained from the patient or a person entitled to
give consent on behalf of the patient. The information provided should include
nature and risk of the procedure, preparation instructions, fasting guidelines,
what to expect during the immediate and long term recovery period, including
after discharge.

8.1.5 Procedure

Prior to administration of drugs, relevant monitors are attached and vitals noted.

The same monitors are continued through the procedure and post procedure till
the patient is completely awake and devoid of any sedation effects. Appropriate
sized intravenous canula is secured and fluid infusion initiated. The anaesthetic
drugs are loaded as required depending on the weight of the patient.

Inj glycopyrrolate 0.2mg ,inj fentanyl 1 micrograms/kg was given iv. inj
Dexmedetomedine is given as a bolus dose of 1 microgram/kg body weight over a
period of 15 minutes just prior to the procedure. During the start of the
procedure, inj Propofol 1 mg/kg is given as a bolus dose and continued as an
infusion at the dose of 0.5mg/kg/min through the procedure. The depth of
sedation is assessed using the modified Aldrete scoring system. In between the
procedure if the patient is very restless and too uncomfortable, additional bolus
dose of 10 mg is given in increments. An anaesthetic record shall be maintained
indicating the dosages of all drugs administered, haemodynamic and respiratory
variations.

At the end of the procedure, the patient is taken to an appropriate recovery area
for monitoring. The depth of sedation is reassessed and the care plan is
transferred to appropriately trained personnel. Patients shall be discharged from
the recovery area when they meet the criterion based on Aldrete scoring system
(score of 8-10). Outcomes from patients undergoing procedural sedation shall be
collected and analyzed in order to identify opportunities to improve care.

8.2 activity and responsibility