MONTEFIORE MEDICAL CENTER
The University Hospital for The Albert
Einstein College Of Medicine
CLINICAL PEARLS FOR MODERATE CONSCIOUS
SEDATION (M/CS)
1. JCAHO requires documentation
of TWO patient examinations: One exam must be documented
at the point during which the patient is evaluated before
the procedure. This could be days before the procedure
when prescreening is done by the clinical department,
or it may be just minutes before the procedure begins.
The second examination must occur immediately prior
to starting the procedure. The first set of vital signs
may suffice if there is a notion to the effect that
it is the second patient evaluation being done for the
procedure.
2. New regulations require that
every patient have an airway assessment prior to M/CS.
Airway assessment means assessing the patient’s ability
to hyperextend his/ her neck, identification of loose
teeth and visible obstructions.
3. Airway, airway, airway."
Acute airway obstruction is the leading cause of all
problems with M/CS.
4. "If it sounds like snoring
its probably early airway obstruction." Chin lifts,
and jaw thrusts will help stimulate the patient and
re-establish the airway. Always have oral airways ready
if these maneuvers fail.
5. "When in doubt, check
it out." If medication dosages are unfamiliar or
seem unusual, recheck guidelines, package inserts, and
ask supervisors.
6. "Less is more."
Start with small doses of sedating medications and give
more as needed. Patients who require reversal of narcotics
and benzodiazepines become harder to sedate as the procedure
continues. Remember that narcotics and benzodiazepines
have a synergistic effect, in other words expect much
more respiratory depression with a combination of narcotics
and benzodiazepines than with either drug alone.
7. "Extremes of age require change."
Very young and very elderly patients tend to be more
sensitive to sedating medications. A good rule of thumb
with elderly and medically frail patients is to reduce,
by half, the initially planned sedating medication dose
and proceed slower with these patients.
8. "Oxygen is a cheap drug: prescribe
it first and prescribe it liberally." It is only the
rare patient where high FI02 concentration may be contraindicated.
Everybody should get 02 for conscious sedation.
9. Emergency and rescue drugs should
be clearly labeled and immediately nearby during all
sedation procedures.
10. "Suction, suction, suction."
Always confirm the presence of a functioning suction
device during the set up phase and recheck it just prior
to starting sedation.
11. "The monitors are always correct!"
If the pulse oximeter signal goes away or the blood
pressure cuff doesn't record blood pressure on one cycle
assume your patient is hypoxic and hypotensive until
proven otherwise. Fiddle with the patient before you
fiddle with the monitors. Remember your ABC"s. Check
respiration and pulses, stimulate the patient, call
for help if necessary.
12. " Know your patient's limitations
and know your own." A good understanding of your patient's
general history is important including allergies, NPO
status and, in particular the cardiac and respiratory
systems. After you know your patient, proceed with caution.
If you're not comfortable proceeding, then get help.
Nobody has ever died from excessive vigilance or caution.