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ASGE/SGNA
ROLE OF GI REGISTERED NURSES IN THE MANAGEMENT OF PATIENTS UNDERGOING SEDATED PROCEDURES
Disclaimer
The ASGE and SGNA assume no responsibility for the practices or recommendations of any member or other practitioner, or for the policies and practices of any practice setting. The Registered Nurse functions within the limits of state licensure, state nurse practice act, and institutional policies.
The safety and efficacy of sedation for GI procedures requires cooperation between the physician endoscopist and the GI registered nurse assistants. This statement is meant to clarify the roles of the physician and registered nurse for the safe administration of sedatives, patient monitoring during sedation, and management of sedation-related complications. In all cases, care must be provided in adherence to locally defined or state-mandated nursing scope of practice. Specific guidelines on the use of moderate[1] and deep sedation[2] have been previously published.
All patients undergoing endoscopic procedures require pre-procedural evaluation to assess their risk and to help manage problems related to pre-existing medical conditions. This assessment includes obtaining a history and performing a focused physical examination, reviewing current medications and drug allergies, assessing cardiopulmonary status, and assessing the airway, particularly if deep sedation will be used.[3] The GI nurse may assist in this assessment, however, it is the responsibility of the physician to determine the suitability of the patient for sedation.
Once the suitability of the patient for sedation has been determined, a sedation plan is formulated. This plan determines the medications to be given and the intended level of sedation. The nurse then prepares and administers the medications under the direct order and supervision of the physician. The physician may also administer medications to the patient.
During the procedure, it is the responsibility of the nurse to monitor the patient’s vital signs, comfort and clinical status. The nurse records these data prior to, at intervals during, and following the procedure. The purpose of patient monitoring is to detect potential intra-procedure complications, especially those due to sedation. During endoscopy under moderate sedation, the nurse may perform interruptible tasks such as assisting with biopsy or polypectomy. For deep sedation, the registered nurse performing the patient monitoring should have no other responsibilities.3,[4] Effective communication is of paramount importance to ensure a safe and comfortable procedure.
Complications due to sedatives, although infrequent, are the most common type of complication seen during endoscopic procedures.[5] Sedatives may cause cardiopulmonary compromise and other complications such as allergic reactions, interactions with other drugs, and idiosyncratic or dose-related adverse events.1 If these complications are recognized the physician must be promptly informed. Management of any complication that may occur is ultimately the responsibility of the physician. This may range from administration of medications to the patient (e.g., oxygen, sedative-reversal agents) to opening the airway and providing assisted ventilation (e.g., bag-mask ventilation, endotracheal intubation). The physician must be immediately available to manage complications, from the beginning of sedation until the patient has adequately recovered from their effects.
Post-procedural care should be delivered according to established protocols or written physician orders regarding the level of monitoring and discharge criteria.
Each endoscopy unit must have policies regarding the use of sedation. These policies specify the responsibilities of each member of the sedation team. Adequate training of physicians and nurses must be undertaken prior to using sedation for GI procedures. This training includes pre-procedural assessment, levels of sedation , pharmacology of sedative and reversal agents , basic life support , establishing and maintaining an adequate airway , recording vital signs and medications used , patient monitoring , and the recognition of complications .[6],[7] For deep sedation, additional training with emphasis on advanced airway management and treatment of cardiovascular complications, particularly hypotension, is required . The endoscopy unit must also provide continuing education with ongoing competencies for administering and monitoring all levels of sedation, and have a functioning quality improvement assurance program.[8]
[1] Waring JP, Baron TH, Goldstein JL, Jacobson BC, Leighton JA, Mallery JS et al. Guidelines for Conscious Sedation and Monitoring during Gastrointestinal Endoscopy. Gastrointest Endosc 2003; in press.
[2] Faigel DO, Baron TH, Goldstein JL, Hirota WK, Jacobson BC, Johanson JF, et al. Guidelines for the use of deep sedation and analgesia for GI endoscopy. Gastrointest Endosc_2002;56(5):613-7.
[3] Gross JB, Bailey PL, Connis RT, Cote CJ, Davis FG, Epstein BS et al. Practice Guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology2002; 96:1004-17.
[4] Statement on Minimal Registered Nurse Staffing for Patient Care in the Endoscopy Unit: May,2002: Society of Gastroenterology Nurses and Associates’ Practice Committee
[5] Eisen GM, Baron TH, Dominitz JA, Faigel DO, Goldstein JL, Johanson JF et al. Complications of upper GI endoscopy. Gastrointest Endosc 2002;55:784-93.
[6] Guidelines for training in patient monitoring and sedation and analgesia. Gastrointest Endosc 1998;48:669-71.
[7] Guidelines For Nursing Care of the Patient Receiving Sedation and Analgesia in the Gastrointestinal Endoscopy Setting : 2000: Society of Gastroenterology Nurses and Associates’ Practice Committee.
[8] Establishment of gastrointestinal endoscopy areas. Gastrointest Endosc 1999;50:910-12.
Copyright American Society of Gastrointestinal Endoscopy 2004
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