What are the risks in IV sedation?

[coffeeluver]

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What are the risks involved in light IV sedation and how do I minimize these risks? Can I undergo a light IV sedation without an anesthesiologist present? Is a CRNA sufficient?

 

[UTSouthwestern]

Don't eat for at least 8 hours before your procedure.
Make sure that the facility has qualified anesthesia personnel and emergency equipment available.
Ask that supplemental oxygen be provided during the case.
Don't be afraid to ask questions (What drug are you using? What are it's potential side effects? Will I remember anything? How will you monitor my progress? etc.).

 

[gaslady]

You can undergo light IV sedation safely without an anesthesiologist. There just needs to be someone there who isn't doing the procedure who will be monitoring you (in addition to what is also listed above).

 

[Gator05]

UT, is supplemental O2 really necessary? We were taught the theory of using the pulse-ox as a rough estimator of ventilation, ie a decrease in ventilation will be evident on Pulse-ox earlier if only RA is used versus supplemental O2.

Now, if the patient has confounding medical conditions, all bets are off and O2 will probably help more than hurt.

Anything I'm missing, or is this merely a difference in styles?

 

[jwk]

UT, is supplemental O2 really necessary? We were taught the theory of using the pulse-ox as a rough estimator of ventilation, ie a decrease in ventilation will be evident on Pulse-ox earlier if only RA is used versus supplemental O2.

Now, if the patient has confounding medical conditions, all bets are off and O2 will probably help more than hurt.

Anything I'm missing, or is this merely a difference in styles?

Supplemental O2 gives you a wider margin of safety - it's cheap, it's easy. Why would you NOT want it, ESPECIALLY where you don't have any anesthesia providers handy?

This is one of many reasons anesthesia providers are extremely leery of GI nurses administering propofol for sedation. A weekend class at the local convention hotel is not going to provide them with the knowledge and experience needed for this task.

 

[Gator05]

The patient is starting to move a bit, GI gives 10 more of propofol. GI proceeds on, stimulus disappears. Patient is on supplemental O2, sats are sitting at 98%. Frequency response wasn't turned up on the pulse ox. Meanwhile, patient stops ventilating with cessation of stimulus. Nobody notices the patient has stopped breathing, because the sats are still at 97%. As the FRC deoxygenates, relatively rapid decline in saturations; worse still, you've got to catch up on the ventilation let alone deal with the falling oxygenation.

If the patient wasn't on supplemental oxygen, you'd have a better chance at noticing cessation of ventilation. Thanks to the alveolar gas equation, an increase in alveolar CO2 means a decrease in alveolar O2, with resulting decrease in blood oxygenation and fall in SaO2. Thus your pulse oximeter tells you up front the patient has changed their ventilatory status, and you can intervene earlier, more safely and with less alarm(s).

Obviously, there are many patient populations who require supplemental O2 for sedation; this becomes a medical decision based on clinical experience, and represents an important exception to the above practice.

And yes, I believe any type of sedation should be accompanied by an anesthesiologist/anesthetist. Knowledge of sedation is only one component of a skilled provider of sedation; the other, arguably more important is the ability to recognize compromise AND secure an airway. Anesthesia happens, and not always in the most likely/friendly of places.

 

[coffeeluver]

what are GI nurses?

 

[jwk]

what are GI nurses?

The nurses who work in the GI Lab, or whatever your facility calls the place where they do colonoscopies, esophagoscopies, etc.

 

[deleted9493]

Nurses working in Endoscopy.

 

[jwk]

If the patient wasn't on supplemental oxygen, you'd have a better chance at noticing cessation of ventilation.

Tell me you're not an MDA or CRNA or AA making this amazingly stupid observation. That is one of the single most absurd comments I have heard in 25 years of anesthesia practice.

 

[InGasWeTrust]

I would agree with Gator05,

I heard a tremendous lecture that stated that supplemental O2 is overused precisely for the reasons gator05 stated.

That your warning for decreased ventilation is prolonged.

I will attempt to dig out the appropriate references and post links for them

 

[Gator05]

Whoa there; tone of the last message was a bit harsh, and that's NOT the spirit of this thread.

First, not an MDA/CRNA; I'm an MS3 interested in anesthesiology, formely an anesthesiology tech, and am going off a couple of sources I've found. And I did ask in my initial post if "I was missing anything, or is this merely a difference in styles?" I'm not aiming to be pedantic, just asking some questions while presenting what I've been taught.

From the Gasnet discussions, to our own didactic sessions, to handouts I've read in other sources, the rationale I've presented seems to be well-founded. I understand there are alternative schools of thought, but I'm unsure of the basis of these methods.

I don't understand what the supplemental O2 contributes in an otherwise healthy patient undergoing sedation. If you're breathing well, your hemoglobin is saturated. Unless you are anemic, the dissolved O2 is contributing next to nothing in terms of tissue oxygenation. If not breathing well, isn't it better to be cognizant of this in order to intervene? WHY give supplemental oxygen; what is your goal, and your rationale?

Another of our professors pointed out we should question everything until we're getting annoying. Hope he'd approve. 🙂

 

[jwk]

Sorry - not trying to be harsh. Just a little shocked at the suggestion.

I've flown this statement by a half dozen experienced anesthetists and anesthesiologists in the half hour since I first saw your post, and it was universally panned.

I fully understand the physiology involved. If you're just giving maybe 1 or 2 mg of Versed, it wouldn't be a problem. We do that all the time in our pre-op area. But if you're talking sedation for a procedure, and PARTICULARLY if using propofol, you are taking a huge risk not using supplemental O2, and it would be easy to find any number of expert witnesses for a plaintiff to agree with that statement. There is a HUGE difference in giving a little Versed to "take the edge off" and actually sedating a patient to enable you to perform a procedure. If you are giving sedation for a procedure, using drugs where the potential exists to overly sedate your patient (propofol again is just such an agent), you would simply be foolish not to be using supplemental O2.

Again, there is a big debate raging about propofol use by non-anesthesia providers. The GI doctors and nurses associations are in favor of giving it themselves, the ASA and AANA are not. Also, remember that the manufacturer currently and HAS ALWAYS included in their prescribing information that propofol should be given ONLY by ANESTHESIA providers. Yet another thing for a plaintiff's lawyer to hang their hat on.

Again, I apologize if I was harsh. We could volley Gasnet and theoretical classroom discussions around for days, and that wouldn't change anything. In the real world, O2 and pulse oximetry are both there to keep you out of trouble. Use them both!

 

[EMRaiden]

I understand gator05's point regarding the problem with supplemental O2 and concerns about missing something. One solution is the use of ETCO2 monitoring which will pick up changes in ventilation much more quickly.

 

[jwk]

I understand gator05's point regarding the problem with supplemental O2 and concerns about missing something. One solution is the use of ETCO2 monitoring which will pick up changes in ventilation much more quickly.

Are you talking about monitoring ETCO2 with a nasal cannula?

It works - kinda - but it is not accurate for one thing (the value is worthless because of entrained air), and all the different types I've used are easily messed up by changes in position, patient scratching their nose, mouth-breathing, etc. You get a respiratory waveform on the monitor - sometimes.

I'm still waiting for someone to explain the "problem" with supplemental O2, outside of the argument that if you go without, you'll know more quickly if your patient is hypo-ventilating when using a pulse oximeter (and of course I still maintain that that is a total BS argument, no harshness intended)

 

[coffeeluver]

So most Anesthesiologists will provide supplemental O2 with IV sedation? What about CRNAs? I'm still not sure if supplemental O2 should be used, I'll wait until you guys come up with a conclusion. So if a patient is young and in relatively good health, then IV sedation should be pretty safe?

Why is epinephrine mixed in with local anesthesia? I've read that some people have had a bad reaction to the epinephrine which resulted in tachycardia and increased blood pressure. Is there a test beforehand to know if the patient will have a bad reaction to epinephrine? Thanks.

 

[jwk]

So most Anesthesiologists will provide supplemental O2 with IV sedation? What about CRNAs? I'm still not sure if supplemental O2 should be used, I'll wait until you guys come up with a conclusion. So if a patient is young and in relatively good health, then IV sedation should be pretty safe?

Why is epinephrine mixed in with local anesthesia? I've read that some people have had a bad reaction to the epinephrine which resulted in tachycardia and increased blood pressure. Is there a test beforehand to know if the patient will have a bad reaction to epinephrine? Thanks.

I think if you require sedation in order to have a procedure done on you (colonoscopy, biopsy, whatever) you should have supplemental O2. MD, CRNA, or AA, it doesn't make any difference. Again, my point is it's cheap, it's easy, it has no ill effects, so why not use it? IV sedation should be very safe for you.

Epinephrine is mixed with local anesthetics in order to delay it's absorbtion by the body and prolong the effect of the local. If someone gets an immediate tachycardia and increase in blood pressure, it's usually because it has been injected directly into a blood vessel instead of into the tissues. The practitioner should be aspirating the syringe once the needle is in position. That way if they're in a blood vessel, they'll get blood back in the syringe and can reposition the needle before injecting. This becomes VERY important when doing major regional anesthetics (epidurals, axillary blocks, etc.).

 

[Tenesma]

supplemental O2 - it is NOT a good idea to use desaturation as a monitor for lack of ventilation!!!!

The whole point of conscious sedation is to monitor the patient sufficiently so as to know whether the patient has ceased to breathe or maybe is obstructing.... Supplemental O2 is a MUST as it provides you a lot more reserve should the patient lose their airway.

Things that can assist with monitoring ventilation: EtCO2 (yes, even with a nasal cannula - while the number will be highly inaccurate, the presence of a regular tracing will be reassuring of air movement), watching the chest move, interacting with the patient (ie: if they are unresponsive not a good thing), placing a mirror in front of their nose/mouth for condensation... etc... the list goes on.

This all goes to show that conscious sedation should be administered by somebody whose only focus is to monitor the patient and the patient's airway.

 

[jwk]

supplemental O2 - it is NOT a good idea to use desaturation as a monitor for lack of ventilation!!!!

The whole point of conscious sedation is to monitor the patient sufficiently so as to know whether the patient has ceased to breathe or maybe is obstructing.... Supplemental O2 is a MUST as it provides you a lot more reserve should the patient lose their airway.

Things that can assist with monitoring ventilation: EtCO2 (yes, even with a nasal cannula - while the number will be highly inaccurate, the presence of a regular tracing will be reassuring of air movement), watching the chest move, interacting with the patient (ie: if they are unresponsive not a good thing), placing a mirror in front of their nose/mouth for condensation... etc... the list goes on.

This all goes to show that conscious sedation should be administered by somebody whose only focus is to monitor the patient and the patient's airway.

Thank God - I'm not the only one who thinks this way! Thanks T.

 

[InGasWeTrust]

JWK, Tenesma, et al.


Here is the reference regarding supplemental oxygen and the fallacies surroounding it.

Respiratory Care 2003;48(6):611-620

Check it out...please opine!

 

[Tenesma]

ingaswetrust:

I know John Downs - he is a wonderful man (and has also made some good money along the way inventing ventilators) 😀

his article is an excellent review of our common misconceptions about oxygenation, and I agree with everything he says.

However, you cannot use his reasoning to support your idea of using hypoxia as an indication of hypoventilation. for two reasons: 1) his 3rd point regarding "HAS OXYGEN ADMINISTRATION DELAYED APPROPRIATE RESPIRATORY CARE?" revolves around supplemental oxygenation covering up worsening intra-pulmonary shunts --- by the time somebody is hypoxic due to apnea, giving them more oxygen isn't the issue: what needs to be corrected is re-institution of ventilation 2) confusing oxygenation with ventilation: I can have a patient apneic and provide continuous intra-tracheal oxygen, and they won't desaturate for hours!!!! However, you can imagine what happens to their CO2....

The caveat of IV sedation is avoiding loss of airway - and that is usually lost due to obstruction and hypoventilation, not due to worsening intra-pulmonary shunt. The supplemental oxygen provides you a window of opportunity to intervene due to the prolonged reserve you have, because the whole point of IV sedation is paying attention to the patients respiratory effort.

 

[LongSnow]

I don't liketo use supplemental O2 unless I have to. Agree with gator05, in addition, supplemental O2 is a fire risk. If the patient's face is all draped( like for an ear SCCA or other small face case), I hook the nasal cannula (with the CO2 monitor - agree with JWK - limited in value at best) to air just to get some circulation under there.

As I was told, using the Spo2 monitor as a measure of ventilation/oxygenation is like flying an airplane using the landing gear as your altimeter. There is no substitute for good old fashion clinical monitoring and watching the patient.

 

[coffeeluver]

Is it safe if a regular RN administer Versed under the supervision of a physician?

 

[jwk]

Is it safe if a regular RN administer Versed under the supervision of a physician?

Depends. I think a lot of areas use a little Versed for mild sedation - a couple mg or so.

Where the trouble can start is when more than that is given in a short period of time, and/or combining it with other drugs, such as Fentanyl or Demerol.

Make sure if there is an RN doing sedation that they have been trained appropriately, and that they are ONLY doing the sedation and monitorin, not participating in the procedure itself. Under NO CIRCUMSTANCES should an RN be giving propofol (Diprivan) for sedation for a procedure, regardless of what the GI docs and nurses associations may say.

 

[bestiller]

Depends. I think a lot of areas use a little Versed for mild sedation - a couple mg or so.

Where the trouble can start is when more than that is given in a short period of time, and/or combining it with other drugs, such as Fentanyl or Demerol.

Make sure if there is an RN doing sedation that they have been trained appropriately, and that they are ONLY doing the sedation and monitorin, not participating in the procedure itself. Under NO CIRCUMSTANCES should an RN be giving propofol (Diprivan) for sedation for a procedure, regardless of what the GI docs and nurses associations may say.

First of all, whoever is saying that an RN cannot administer Versed is misinformed and I suspect, has never been a nurse or physician. Everyone knows(medical personnel) that ICU nurses use Versed daily as well as other benzodiazepines such as Valium, Ativan.....Whoever is posting.....have you ever taken care of an ICU patient? What are your qualifications and medical background? Are you a student? If so, get yourself in an extern program so that you can have patient care experience for when you graduate. Taking care of ICU patients and or ER patients is invaluable and a great advantage for medical school or nurse anesthesia school. Propofol is in a different class and should only be independently administered by anesthesiologists or nurse anesthetists.
Make sure also, that if an AA is doing the sedation that there is an MD anesthesiologist also present/immediately available. Under no circumstances should an RN being administering propofol and under no circumstances should an AA be administering propofol w/o an MDA present, as they are not legally permitted or trained/qualified to do so.

 

[jwk]

First of all, whoever is saying that an RN cannot administer Versed is misinformed and I suspect, has never been a nurse or physician. Everyone knows(medical personnel) that ICU nurses use Versed daily as well as other benzodiazepines such as Valium, Ativan.....Whoever is posting.....have you ever taken care of an ICU patient? What are your qualifications and medical background? Are you a student? If so, get yourself in an extern program so that you can have patient care experience for when you graduate. Taking care of ICU patients and or ER patients is invaluable and a great advantage for medical school or nurse anesthesia school. Propofol is in a different class and should only be independently administered by anesthesiologists or nurse anesthetists.
Make sure also, that if an AA is doing the sedation that there is an MD anesthesiologist also present/immediately available. Under no circumstances should an RN being administering propofol and under no circumstances should an AA be administering propofol w/o an MDA present, as they are not legally permitted or trained/qualified to do so.

No one said anything about RN's not giving Versed. My comment was that if the RN is giving sedation for the procedure (much different than giving a couple mg of Versed as a pre-med for surgery) that they should be trained appropriately and their sole responsbility during the procedure should be administering the sedation and monitoring the patient, not assisting with the procedure itself.

Your comments about AA's are incorrect and intended to flame AA's as you have in other threads. Why don't we leave that topic elsewhere and stick to the topic at hand?

 

[DrQuinn]

No one said anything about RN's not giving Versed. My comment was that if the RN is giving sedation for the procedure (much different than giving a couple mg of Versed as a pre-med for surgery) that they should be trained appropriately and their sole responsbility during the procedure should be administering the sedation and monitoring the patient, not assisting with the procedure itself.

Your comments about AA's are incorrect and intended to flame AA's as you have in other threads. Why don't we leave that topic elsewhere and stick to the topic at hand?

jwk-
Why do you feel that other specialties shouldnt' use Diprivan? I use it in the ED all the time for procedures (shoulder/hip reductions, fracture reductions, etc). I am trying all different techniques and find Diprivan or Etomidate to be my favorite forms of conscious sedation (I do use Versed/Fentanyl at times). I know some hospitals will not allow non anesthesiologists to use Diprivan or Etomidate for procdures, but ours does (tertiary care hospital). Of course there are inherent risks in all conscious sedation procedures, but what is it about Diprivan that you are afraid of non anesthesia/CRNA care providers using it for?

Thanks
Q, DO

 

[Tenesma]

DIPRIVAN Injectable Emulsion should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Patients should be continuously monitored, and facilities for maintenance of a patent airway, artificial ventilation, and oxygen enrichment and circulatory resuscitation must be immediately available

this is quoted from the drug insert of Propofol... and also can found in the PDR... Some hospitals allow non-anesthesia providers to give propofol, but if it is done, it should be done in a well monitored environment with one person dedicated to monitoring the airway and hemodynamics and able to take control of the airway (which in the ED could be another EM resident, but definitely not a nurse).

 

[jwk]

jwk-
Why do you feel that other specialties shouldnt' use Diprivan? I use it in the ED all the time for procedures (shoulder/hip reductions, fracture reductions, etc). I am trying all different techniques and find Diprivan or Etomidate to be my favorite forms of conscious sedation (I do use Versed/Fentanyl at times). I know some hospitals will not allow non anesthesiologists to use Diprivan or Etomidate for procdures, but ours does (tertiary care hospital). Of course there are inherent risks in all conscious sedation procedures, but what is it about Diprivan that you are afraid of non anesthesia/CRNA care providers using it for?

Thanks
Q, DO

It's really a different animal. It's very easy to give too much and move from conscious sedation to deep sedation with a loss of airway reflexes. The cavalier attitudes about propofol make it that much more of a problem. Propofol, by itself, is not a good conscious sedation drug for a procedure since it offers no analgesic properties. If you give enough to render your patient unconscious, then you've created a much larger potential problem. If you combine it with Versed and/or Fentanyl, as many anesthesia providers do, then you have a problem as well. You've moved past "conscious sedation" into general anesthesia. Hence the warning from propofol manufacturers since it was introduced in the 80's - it's intended for anesthesia providers.

There was a similar problem when Versed was reduced. I can't tell you how many codes I went to in endoscopy labs and ER for respiratory arrests caused by Versed. Everyone wanted to slam in 10mg, just like Valium, then were surprised when the patient quit breathing.

 

[DrQuinn]

It's really a different animal. It's very easy to give too much and move from conscious sedation to deep sedation with a loss of airway reflexes. The cavalier attitudes about propofol make it that much more of a problem. Propofol, by itself, is not a good conscious sedation drug for a procedure since it offers no analgesic properties. If you give enough to render your patient unconscious, then you've created a much larger potential problem. If you combine it with Versed and/or Fentanyl, as many anesthesia providers do, then you have a problem as well. You've moved past "conscious sedation" into general anesthesia. Hence the warning from propofol manufacturers since it was introduced in the 80's - it's intended for anesthesia providers.

There was a similar problem when Versed was reduced. I can't tell you how many codes I went to in endoscopy labs and ER for respiratory arrests caused by Versed. Everyone wanted to slam in 10mg, just like Valium, then were surprised when the patient quit breathing.

I definately can understand your point. Believe you me, I'm a pretty conservative conscious sedator. Usually my attendings will manage airway for me but while I'm doing hte procedure i'm always just trying to see what's going on ABC-wise.

I DO like diprivan for procedures but find Etomidate (.15/kg) to be better to my taste, although on one patient who needed a hip reduction, she had mm spasms which kind of defeated the purpose. Went to Versed/Fent and it worked great.

Q, DO

 

[jwk]

I definately can understand your point. Believe you me, I'm a pretty conservative conscious sedator. Usually my attendings will manage airway for me but while I'm doing hte procedure i'm always just trying to see what's going on ABC-wise.

I DO like diprivan for procedures but find Etomidate (.15/kg) to be better to my taste, although on one patient who needed a hip reduction, she had mm spasms which kind of defeated the purpose. Went to Versed/Fent and it worked great.

Q, DO

So you're giving sedation and your attending is managing the airway. Are you doing the procedure as well? I'm just curious who is monitoring the patient.

Hadn't thought much about etomidate as a sedation agent. I only use it for induction, and it's not really my favorite drug.

 

[chillindrdude]

propofol/fentanyl
versed/fentanyl
etomidate...


you know...any one have used Ketamine and Versed?
i used it with great success in peds patients while having their fractures reduced in the ER.

i feel that ketamine is an underused medication. supports cardiovascular parameters, great for hypovolemic patients. provides analgesia, anesthesia, and amnesia. minimal loss of airway reflexes. i think the bad rap of ketamine comes from the its association with PCP...but i've never observed anyone spazzing out emerging from ketamine administration. i figure, as long as the patient is relatively healthy, just keep environmental stimulus to a minimum during emergence and perhap 1 or 2 of versed to smooth things out.

what do you all think?

 

[jwk]

propofol/fentanyl
versed/fentanyl
etomidate...


you know...any one have used Ketamine and Versed?
i used it with great success in peds patients while having their fractures reduced in the ER.

i feel that ketamine is an underused medication. supports cardiovascular parameters, great for hypovolemic patients. provides analgesia, anesthesia, and amnesia. minimal loss of airway reflexes. i think the bad rap of ketamine comes from the its association with PCP...but i've never observed anyone spazzing out emerging from ketamine administration. i figure, as long as the patient is relatively healthy, just keep environmental stimulus to a minimum during emergence and perhap 1 or 2 of versed to smooth things out.

what do you all think?

Ketamine is God's gift to (inadequate) regional anesthesia. It also is the primary treatment for polylordy syndrome (oh lordy, lordy, lordy, lordy).
Give 10mg boluses about 1 min apart and usually by the time you hit 30-40mg things just magically mellow out.

 

[DrQuinn]

So you're giving sedation and your attending is managing the airway. Are you doing the procedure as well? I'm just curious who is monitoring the patient.

Hadn't thought much about etomidate as a sedation agent. I only use it for induction, and it's not really my favorite drug.

Uh, I'm doing the procedure. Oft times my attending will ask which drug I'd like to use, I pick the dose, and once adequate sedation is achieved, I'll do the procedure. But honestly it doesn't take that much brain power to pull on a shoulder while using a couple neurons to also see what the meds are doing to the patient, as long as my attending or another resident is there as well.

Q, DO

 

[blotto geltaco]

Kids eyes party like crazy when you give them ketamine

blotto
almost pgy1