Statement of the Use of Sedation and Analgesia in the Gastrointestinal Endoscopy Setting

Disclaimer

The Society of Gastroenterology Nurses and Associates, Inc. assumes no responsibility for the practices or recommendations of any member or other practitioner, or for the policies and procedures of any practice setting.  Nurses and associates function within the limitations of licensure, state nurse practice act, and/or institutional policy.

Definitions

For the purpose of this document, SGNA has adopted the following definitions:

Nurse refers to the registered nurse, licensed practical nurse, or licensed vocational nurse.

Associate refers to assistive personnel such as technicians, technologists, and assistants (SGNA, 2001).

Patient Care in the Gastrointestinal Endoscopy Unit refers to the pre-procedure, intra-procedure and post-procedure care of the patient undergoing gastrointestinal endoscopy regardless of the setting.

Sedation and analgesia comprise a continuum of states ranging from minimal sedation (anxiolysis) through general anesthesia (ASA, 2001).

Minimal Sedation (Anxiolysis) is a drug-induced state during which patients respond normally to verbal commands.  Although cognitive function and coordination may be impaired, ventilatory and cardiovascular function is usually maintained (ASA 2001).

Moderate Sedation/Analgesia (“Conscious Sedation”) is a drug-induced depression of consciousness during which patients respond purposefully* to verbal commands, either alone or accompanied by light tactile stimulation.  No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.  Cardiovascular function is usually maintained (ASA, 2001).

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully* following repeated or painful stimulation.  The ability to independently maintain ventilatory function may be impaired.  Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.  Cardiovascular function is usually maintained (ASA, 2001). 

General Anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.  The ability to independently maintain ventilatory function is often impaired.  Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of the neuromuscular function.  Cardiovascular function may be impaired (ASA, 2001)

*Reflex withdrawal from a painful stimulus is NOT considered a purposeful response (ASA, 2001)

Background

The role of the registered nurse in the use of sedation and analgesia is expanding.  Moderate sedation is  standard for gastrointestinal endoscopy (Heuss, et al, 2003). Multiple studies now exist supporting the use of deep sedation for select groups of patients undergoing diagnostic or therapeutic procedures in the field of gastroenterology (Rex, 2003; Heuss, et al, 2003;  Walker, 2003; Sipe, 2002).   Currently, the literature suggests there is a growing body of evidence supporting the safe use of nurse administered deep sedation under the direct supervision of the physician (Rex, 2003; Heuss, et al, 2003;  Walker, 2003; Sipe, 2002).   

Most endoscopic procedures are performed under moderate sedation and analgesia, known as conscious sedation.  The purpose of sedation and analgesia is to relieve anxiety, discomfort or pain, and diminish memory for the event (ASGE, 2000; ASGE, 2002). The level of sedation should be titrated to achieve a safe, comfortable and technically successful procedure.

The American Society of Anesthesiologists (ASA, 2001), the American Society of Gastrointestinal Endoscopists (ASGE, 2003) and the Society of Gastroenterology Nurses and Associates, Inc.(SGNA, 2000) have all published practice guidelines.

Position

Moderate Sedation (Conscious Sedation)

The Society of Gastroenterology Nurses and Associates, Inc. supports the position that registered nurses trained and experienced in gastroenterology nursing and endoscopy can administer and maintain moderate sedation and analgesia (conscious sedation) by the order of a physician.  In addition, the gastroenterology registered nurse can be given responsibility for the administration of reversal agents prescribed by the physician.  The gastroenterology registered nurse has education and experience in endoscopy, knowledge of medications used and the skills to assess, diagnose, and intervene in the event of complications. 

The registered nurse is responsible for monitoring and assessing the patient receiving moderate sedation and analgesia throughout diagnostic and therapeutic endoscopic procedures.  Automatic monitoring devices may enhance the ability of the registered nurse to accurately assess the patient, but are no substitute for the watchful, educated assessment by the registered nurse.

During moderate sedation, the registered nurse monitoring the patient may assist with minor, interruptible tasks once the patient’s level of sedation/analgesia and vital signs have stabilized.  Adequate monitoring of the patient’s level of sedation must be maintained (ASA, 2001; ASGE, 2002; SGNA, 2000).  Because of the importance assigned to managing the patient who is receiving sedation and analgesia, a second nurse or associate is required to assist the physician with those procedures that are complicated either by the severity of the patient’s illness and/or the complex technical requirements associated with advanced diagnostic and therapeutic procedures (ASGE, 2000; SGNA, 2000).

Deep Sedation

The Society of Gastroenterology Nurses and Associates, Inc. recommends that registered nurses and physicians involved in the administration of deep sedation have additional training with emphasis on advanced airway management and treatment of cardiorespiratory complications.  This may include, but is not limited to, Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support (PALS), additional advanced airway management training and advanced training on medications that can be used to achieve deep sedation or can lead to or easily induce a state of general anesthesia.  The regulations governing administration of these medications by registered nurses vary from state-to-state. Registered nurses and physicians must be aware of the limitations of state licensure, state nurse practice act, and current individual institutional policies.

The Society of Gastroenterology Nurses and Associates, Inc. recommends that the registered nurse be present to monitor the patient throughout procedures performed with sedation /analgesia. Automatic monitoring devices may enhance the ability of the registered nurse to accurately assess the patient, but are no substitute for the watchful, educated assessment by the registered nurse.  During deep sedation, the registered nurse should have no other responsibilities (Gross, et al, 2002). Because of the importance assigned to managing the patient who is receiving deep sedation and analgesia, a second nurse or assistant is required to assist the physician.   

The Society of Gastroenterology Nurses and Associates, Inc. supports the position of the ASGE that the assistance of anesthesiologists should be considered in patients undergoing prolonged procedures requiring deep sedation (ASGE, 2002).

References

American Society of Anesthesiologists (ASA).  (2001). Updated practice guidelines for sedation and analgesia by non-anesthesiologists. [Practice Guideline]. Park Ridge , IL : Author.

American Society for Gastrointestinal Endoscopy (ASGE).  (2000). Modifications in endoscopic practice for pediatric patients.  ASGE Publication 1047.  Oak Brook , IL :  Author.

American Society for Gastrointestinal Endoscopy (ASGE).  (Rev. 2003).  Standards of Practice Committee.  Sedation and monitoring of patients undergoing gastrointestinal endoscopic procedures. [Practice Guideline].  Oak Brook , IL :  Author.

American Society for  Gastrointestinal Endoscopy (ASGE), (2002).  Standards of Practice Committee.  Guidelines for the use of deep sedation and anesthesia for GI endoscopy.[Practice Guideline], Gastrointestinal Endoscopy56(5):613-617.

Centers for Medicare and Medicaid Services (CMS), (Rev. 2002), Monitored Anesthesia Care (MAC).  Medicare Carriers Manual (MCM) 4830, 8310.E, 15018.

Gross, J.B., Bailey,P.L., Connis, R.T., Davis , F.G., Epstein, B.S.,  Gilbertson, L., Nickinovich, D.G., Zerwas, J.M. Zuccaro, G. (2002) Practice guidelines for sedation and analgesia by non-analgesia by non-anesthesiologists.  Anesthesiology. 96, 1004-1017

Heuss, L.T., Schnieper, P., Drewe, J., Pflimlin, E., and Beglinger, C.  (2003).  Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist:  a prospective observational study of more than 2000 cases.  Gastrointestinal Endoscopy 57(6), 664-671.

Sipe, BW, Douglas , KR, Latinovich, D, et al, (2002).  Propofol versus midazolam/meperidine for outpatient colonoscopy:  administration by nurses supervised by endoscopists.  Gastrointestinal Endoscopy 55(7):815-825.

Society of Gastroenterology Nurses and Associates, Inc. (2001). Role delineation of the advanced practice nurse in gastroenterology/hepatology and endoscopy. [Position Statement]. Chicago : Author.

Society of Gastroenterology Nurses and Associates, Inc. (2001). Role delineation assistive personnel. [Position Statement]. Chicago : Author.

Society of Gastroenterology Nurses and Associates, Inc. (2001). Role delineation of the licensed practical/vocational nurse in gastroenterology and/or endoscopy. [Position Statement]. Chicago : Author.

Society of Gastroenterology Nurses and Associates, Inc. (2001). Role delineation of the registered nurse in a staff position in gastroenterology and/or endoscopy. [Position Statement]. Chicago : Author.

Society of Gastroenterology Nurses and Associates, Inc.  (2000).  Guidelines for nursing care of the patient receiving sedation and analgesia in the gastrointestinal endoscopy setting. [Guideline].  Chicago :  Author.

Walker ,J.A., McIntyre, R.D., Schleinitz, P.F., Jacobson, K.N., Haulk, A.A., Adesman, P., Tolleson, S., Parent, R., Donnelly, R., and Rex, D.K.  (2003).  Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center.  American Journal of Gastroenterology. 98(8), 1744-50.

Practice committee members 2003-2004

Susan L. Bohlander,BSN,RN,CGRN- Committee Chair

Anne F. Grand, RN, MSN,FNPC,CGRN

Loralee Kelsey,RN,CGRN

Lisa D. Miller,LPN,CGN

Sharon C.Reid,ADN,RN,CGRN

Cindy A.Taylor,MSA,BSN,RN,CGRN

Sandra A. Cialfi, RN,BSN,MBA,CGRN

Cynthia M. Friis,RN,BSN,MEd

Adopted by the SGNA Board of Directors January 1991
Revised September 1992; Reviewed 1995; Revised 1998; Revised 2000; Revised 2004