Pre-procedure Moderate Sedation Assessment (Pediatric, Adult and Geriatric)
A comprehensive pre-procedure preparation is essential to safe endoscopic moderate sedation. Standardized nursing assessment and interventions before, during and following a procedure should be included:
- Physical status (review of systems, vital signs, airway and cardiopulmonary reserve – i.e. Obstructive Sleep Apnea; did patient bring CPAP equipment to procedure?)
- Medication history/allergies – e.g.. cardiac, hypertensive, diabetic, anticoagulants and narcotics; Did patient take and hold AM medications as instructed? (See also Patient Safety Issues with Herbal Supplements)
- dverse reactions with sedation and analgesia – i.e. conscious, monitored anesthesia care, regional and/or general anesthesia. Is there a family history of anesthesia complications, i.e. malignant hypertension, and does today’s sedation seem appropriate given patient’s medical, ASA 3 and 4: Consider anesthesia and medical clearance
- Relevant diagnostic studies – e.g. H & H, platelet count, INR
- History of tobacco, alcohol and substance abuse – is patient actively using illicit drugs?
- Verification of NPO status and bowel preparation adherence
- Discharge instructions – responsible person and transportation need to be been verified
- Immediately prior to sedation/informed consent and time out should be verified
Summary of American Society of Anesthesiologists Pre-procedure Fasting Guidelines
Ingested Material: Clear Liquids
Minimum Fasting Period: 2 hours
Minimum Fasting Period:
Ingested Material: Instant Formula
Minimum Fasting Period: 6 hours
Ingested Material: Nonhuman Milk
Minimum Fasting Period: 6 hours
Minimum Fasting Period:
- These recommendations apply to healthy patients who are undergoing elective procedures. They are not intended for women in labor. Following the guidelines does not guarantee complete gastric emptying
- The fasting periods noted above apply to all ages
- Examples of clear liquids include: water, fruit juices without pulp, carbonated beverage, clear tea and black coffee
- Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be considered when determining an appropriate fasting period
- light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or meat may prolong gastric emptying time. Both the amount and type of foods ingested must be considered when determining appropriate fasting period
For more information, please view the following position statements:
Before sedating a patient, the appropriate personnel should be present:
- A registered nurse with appropriate training in endoscopic sedation should be dedicated to administering sedative drugs and monitoring the patient throughout the procedure. During moderate sedation, this individual may assist with minor interruptible tasks. When deep sedation is planned, this person should be dedicated exclusively to observation and monitoring. This individual should possess:
- An understanding of the levels of sedation
- The ability to monitor and interpret the patient’s physiologic parameters
- Current certification in basic or advanced life support
- Skills to initiate the proper intervention in the case of a complication related to sedation
- At least one individual with training in advanced cardiac life support (tracheal intubation, defibrillation, use of resuscitation mediation, ACLS) that is capable of establishing an airway and providing positive-pressure ventilation
- See also the American Society of Anesthesiologists document, Granting Privileges for Administration of Moderate Sedation to Practitioners Who Are Not Anesthesia Professionals, Statement on (2011).
Emergency equipment must be immediately available whenever sedation and analgesia are being performed
- The equipment should be appropriate for the practice environment (i.e. size-appropriate equipment where pediatric endoscopy is being performed) and for the training of the sedation team
- It is strongly recommended that a cardiac defibrillator be available onsite
- Equipment for providing positive airway pressure must be immediately available (see below)
Emergency Resuscitative Equipment
- Assorted syringes, tourniquets, adhesive tape
- Intravenous access equipment including fluids
- Basic airway management equipment
- Oxygen supply
- Suction machine and catheter
- Nasal cannulae and face masks*
- Bag-mask ventilation device
- Oral and nasal airways (all sizes)
- Advanced airway management equipment
- Laryngoscope handles and blades*
- Endotracheal tubes and stylets*
- Laryngeal mask airway (LMA)*
- Cardiac Equipment
- Pulse oximeter
- Cardiac defibrillator
- Emergency medications
- Glucose, 50%
- Sodium bicarbonate
*All appropriate sizes should be available
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Herbals are just one type of dietary supplements as defined by the Food and Drug Administration (FDA). According to the FDA, a dietary supplement is defined as a product that contains one or more dietary ingredient such as:
- a vitamin or a mineral
- an herb or other botanical
- an amino acid
- a dietary substance intended to increase the total dietary intake
- a concentrate, metabolite, constituent, extract
- a combination of the above ingredients
Risks of Herbal Supplements
There is no systematic scientific methodology to evaluate possible interactions between herbal supplements and medications that might be prescribed by a physician. As a result, information and recommendations are largely based on the aggregate of animal studies, case reports, historical contraindications, extrapolation from basic pharmacology data and the occasional clinical trial. Much of the information on adverse effects related to herbal supplements has focused around the following problems:
- Liver toxicity from pyrrolizidine alkaloid compounds found in some plants
- Nephrotoxity induced by some Chinese herbs, in particular aristolochia, which may also be associated with urothelial cancers
- Cardiac events have been associated with ephedra alkaloids. Ephedra has been banned by the FDA and is no longer legally available in the USA. Nevertheless, all clinicians should be aware of its risks, as patients may acquire ephedra when abroad
Warfarin is the most common physician prescribed pharmaceutical cited to have negative interactions with herbals. St. John's Wort is the most frequent herbal product reported as being associated with adverse interaction effect with drugs.
In addition, herbal supplements that are not known to cause adverse effects when taken at the recommended doses may have toxic effects if extremely high doses are used. Licorice and ginseng in particular have been associated with toxicities from overuse.
(FDA) has classified the following supplements as high risk and therefore need be avoided by all patients:
- Ephedra or ephedrine
- Gamma butyrolactone
Preprocedure assessment of herbals should commence in the primary care setting before the patient is actually referred to gastroenterology for a procedure. By the time the patient arrives to his/her procedure, it may already be too late to stop potential drug-to-drug interactions with herbals.
The assessment of the patient scheduled to undergo sedation for a procedure includes a history and physical exam. Many patients do not tell their doctor about dietary supplements they may be taking, in part because physicians may not be as knowledgeable about supplements, and patients may fear the physician will be unhappy about the patient using nonconventional therapy. However, doctors and nurses need to know if the patient is taking any supplements because the risk of complications from herbal supplements may be elevated in the perioperative period. This is because of potential interactions between herbals the patient is taking and the anesthesia drugs and other medications that may be administered during the procedure. Also, herbs may contain contaminants and/or other unknown ingredients.
Rare complications that might in part be due to supplements include myocardial infarction and stroke (i.e. ephedra) liver injury (i.e., echinacea,kava), ineffective anticoagulation and bleeding (i.e. garlic and gingko), prolonged or inadequate anesthesia (i.e. kava) and rejection of organ transplant (i.e. St. John’s wort). As a result it is generally recommended to avoid herbal supplements for 2 weeks prior to a surgical procedure and anesthesia.
The following is a list of common supplements that are of particular concern with regard to the perioperative period.
- Most commonly used by US adults in 2002 National Health Interview Survey (NHIS) and known to affect surgical outcomes:
- St. John’s Wort
- Other supplements of concern:
- Fish oil
- Ginkgo biloba
- Milk thistle
- Saw Palmetto
- Vitamin E
(Sudafed, Actifed, etc.)
||alcohol, benzodiazepines, barbituates
St. John's wort
||warfarin, aspirin, clopidogrel,
gingko, feverfew, ginseng
|Potentiate anticoagulant effect
||SSRI drugs, phenelzine sulfate, sertraline, citalopram, bupropion, tranylcypromine sulfate
||St. John's wort
||Serotonin syndrome, Monoamine oxidase inhibitors (MAOI) interaction potentially leading to mental effects such as confusion, as well as shivering, sweating, fever, muscle twitching
||insulin, all antidiabetics
bitter melon, dandelion, garlic
|Potentiates lowering of glucose levels
||anabolic steroids, amiodarone, HIV drugs
||Decrease action of corticosteroids; may interfere with immunosuppression
- The drugs used for sedation and analgesia can interfere with a patient's ventilation both by relaxing the airway muscles and suppressing the urge to breathe
- The primary risk related to sedation is respiratory complications
- Ability to maintain a patent airway is an essential prerequisite for administration of sedation
- Airway obstruction can be either total or partial
Symptoms of Partial Airway Obstruction
- Rocking motion of the chest not in sync with respiratory effort
- Harsh, high-pitched sound upon inspiration (stridor)
Symptoms of Complete Airway Obstruction
- Lack of any air movement perceived by feeling with the hand over the mouth or placing the ear over the mouth
- Lack of breath sounds while listening with stethoscope to lung fields
- Retraction of the sternum and rib cage
- Rocking motion of the chest not in sync with respiratory effort
Normal respiration relies on a series of structures that conduct air into and out of the lungs. An understanding of the functional anatomy of this region is critical to airway management.
The upper airway consists of the structures above the vocal cords. It is divided into the following regions:
- Nose and oral cavity
- Pharynx – The pharynx is divided into three sections:
- Bronchial tree
Basic Airway Management
Immediate action must be taken at the first signs of compromised respiratory function.
If initial attempts to relieve airway obstruction through verbal and tactile stimulation are unsuccessful, the following techniques can be employed to restore effective ventilation:
Artificial airway devices
- When the muscles of the tongue and mouth floor relax, the tongue lies close to or on the back wall of the oropharynx
- The epiglottis may obstruct the glottic opening or seal against the back wall of the pharynx, as well
The following positioning maneuvers can be performed to relieve the soft tissue obstruction and improve airflow.
- Jaw thrust
- This maneuver moves the tongue forward with the mandible which reduces the tongue's ability to obstruct the airway
- Stand at the head of the bed
- The middle finger of the right hand is placed at the angle of the patient's jaw on the right
- The middle finger of the left hand is similarly placed at the angle of the jaw on the left
- An upward pressure is applied to elevate the mandible which will lift the tongue from the posterior pharynx.
- Both devices maintain a patent airway by preventing the tongue from resting against the posterior pharyngeal wall
- Oropharyngeal airway (OPA)
- Curved, firm, hollow tube used to maintain a conduit between the mouth and the glottis and to prevent obstruction by the tongue
- Should be used in unconscious (unresponsive) patients as they are quite stimulating and generate a gag reflex
- In responsive patients OPAs can cause vomiting and aspiration
Incorrect insertion of an airway can push the tongue into the back of the throat causing airway obstruction
- To select the proper size OPA, place it against the side of the face. When the tip of the OPA is at the corner of the mouth, the phalange is at the angle of the mandible
- Nasopharyngeal airway (NPA)
- Also called a "nasal trumpet," is a soft rubber or plastic hollow tube that is passed through the nose into the posterior pharynx just above the epiglottis
- Are better tolerated by patients compared to OPA
- Can be used when OPA placement is difficult, such as when the patient's jaw is clenched or the patient is semiconscious and cannot tolerate an OPA.
- The length of the NPA should be the same as the distance from the tip of the patient’s nose to the earlobe.
- Bag-mask ventilation is a basic but critical airway management skill
- Successful bag-mask ventilation depends on three things:
- Patent airway. Airway patency can be established using airway maneuvers and airway conduits described above.
- Adequate mask seal
- In order to secure a good seal, the mask must be placed and held correctly
- The nasal portion of the mask should be spread slightly and placed on the bridge of the patient's nose
- The body of the mask is then placed onto the patient's face covering the nose and mouth
- The provider's wrists or the mask cushion should not rest on the patient's eyes during bag-mask ventilation
- Proper ventilation (i.e., proper volume, rate, and cadence)
- The three key errors to avoid when performing bag-mask ventilation are:
- Excessive tidal volumes: A volume just large enough to cause chest rise
- During cardiopulmonary resuscitation (CPR), even smaller tidal volumes are adequate (5 to 6cc/kg) due to the reduced cardiac output of such patients
- Forcing air too quickly: The bag should not be squeezed explosively. It should be squeezed steadily over approximately one full second
- Ventilating too rapidly. The ventilatory rate should not exceed 10 to 12 breaths per minute
Advanced Airway Management
Cases where non-invasive means are insufficient to provide adequate oxygenation and ventilation, a clinician may need to use one of the following advanced airways:
- Endotracheal tube (ETT)
- Indicated for airway protection in a comatose patient for example, for mechanical ventilation, and if pulmonary toilet is necessary
- It is the definitive method to secure a compromised airway, prevent aspiration, and initiate mechanical ventilation
- Placement typically requires laryngoscopy
The pre-procedure physical examination should include the following assessments to evaluate the patient’s airway and uncover physical traits that could contribute to respiratory complications:
- Oral cavity inspection – The patient's oral cavity should be carefully inspected for the following abnormalities prior to sedation. Findings should be documented in the patient's record
- Small mouth opening (less than 3cm in an adult)
- Protruding incisors
- Loose or capped teeth
- Enlarged tongue
- Missing teeth
- Dental appliances such as crowns, bridges, and dentures
- Enlarged tonsils
- Non-visible uvula
- Tumor that could obstruct air flow
- Document Mallampati score base on the following:
- Mallampati Airway Classification System:
- This system is a method for quantifying the degree of difficulty of endotracheal intubation based on amount of posterior pharynx that can be visualized
- The exam is performed with the patient sitting with the head in a neutral position and the mouth open as wide as possible
Class I: soft palate, fauces, uvula, pillars visible. No difficulty.
Class II: soft palate, fauces, portion of the uvula visible. No difficulty.
Class III: soft palate, base of uvula visible. Moderate difficulty.
Class IV: hard palate only. Severe difficulty.
- Assessment of the movement through flexion, extension, and side to side is necessary before sedation is initiated
- Significant obesity especially in the region of the neck and face
- Short, immobile neck
- Recessed or protruding jaw
The ASA score is a subjective assessment of a patient’s overall health that is based on five classes (I to V). It is a risk index classification of the American Society of Anesthesiology (ASA).
I. Patient is a completely healthy fit patient.
II. Patient has mild systemic disease.
III. Patient has severe systemic disease that is not incapacitating.
IV. Patient has incapacitating disease that is a constant threat to life.
V. A moribund patient who is not expected to live 24 hour with or without surgery.
E. Emergency surgery, E is placed after the Roman numeral.
Monitoring should be in place and clinicians should always be prepared to rescue patients who move to the next, deeper level of sedation.
The standard monitoring parameters for sedated patients specified in the ASGE Guidelines for
Conscious Sedation and Monitoring during Gastrointestinal Endoscopy include measurement and recording of:
- Oxygenation saturation
- Heart rate
- Respiratory frequency and ventilation
- Blood pressure
- Level of consciousness:
- Patient response to verbal commands and stimuli is a guide to the level of consciousness
- Apatient under moderate sedation should be able to respond to verbal commands and light tactile stimuli.
- Scoring systems (see RASS and Ramsey examples) can help detect adverse drug responses so they can be treated in a timely manner, thus reducing risks for both moderate and deep sedation
- Drug-induced respiratory depression is the primary cause of morbidity associated with sedation and analgesia
- The risk of adverse outcomes can be reduced by monitoring ventilatory function through:
- Observation or auscultation (including thoracic palpation, observation of abdominal/chest excursions and sensation of exhaled air)
- Monitoring via capnography may reduce risks during moderate and deep sedation
- The risk of adverse events such as cardiac arrest and death can be decreased through the use of pulse oximetry with appropriate alarms for the early detection of hypoxia
- Pulse oximetry has been shown to be more effective in detecting oxygen desaturation and hypoxemia during sedation/analgesia than clinical assessment alone
- Regular monitoring of vital signs reduces the likelihood of adverse outcomes
- Sedative and analgesic agents may interfere with the appropriate autonomic compensation for hypovolemia and procedure-related stressors
- Inadequate sedation or analgesia, on the other hand, may result in patients developing dangerous autonomic stress responses such as tachycardia and hypertension
- The risk of these complications may be reduced with early detection of changes in heart rate and blood pressure that lead to interventions to avert serious problems
- Vital signs should be monitored every 3-5 minutes once a stable level of sedation has been established
- Continuous electrocardiogram monitoring can be used to reduce risks during deep sedation and for high-risk patients (significant cardiovascular disease or dysrhythmias) during moderate sedation.
- There is no clear opinion supporting the use of electrocardiography in normal-risk patients during moderate sedation
- Continuous analysis and recording of carbon dioxide (CO2) concentrations in respiratory gases throughout respiration
- The measurement of end-tidal carbon dioxide (ETCO2) offers the clinician a useful adjunct to other monitoring methods in determining if hypercarbia is present
- Capnography may be able to detect hypoventilation before pulse oximetry indicates oxygen desaturation
- It has also been shown to be a more sensitive gauge of hypoventilation than visual observation.
||Violent, immediate danger to staff
||Pulls or removes tube(s) or catheter(s); aggressive
||Frequent non-purposeful movement, fights ventilator
||Anxious, apprehensive but movements not aggressive or vigorous
|Alert & Calm
||Not fully alert, but has sustained awakening to voice (eye opening & contact ≥ 10 sec)
||Briefly awakens to voice (eye opening & contact < 10 sec)
||Movement or eye-opening to voice (but no eye contact)
||No response to voice, but movement or eye opening to physical stimulation
||No response to voice or physical stimulation
Source: Pain Management Nursing ©2009 W.B. Saunders
||Description (level of sedation)
||Test to follow
|Awake: Patient is anxious and agitated, or restless, or both.
||Observe the patient.
|Awake: Patient is cooperative, oriented and tranquil.
||Observe the patient. Does the patient make eye contact and respond to commands?
|Awake: Patient responds to commands only.
||Talk to the patient. Does the patient make eye contact and respond to commands?
|Asleep: Patient reacts with a brisk response to a light glabellar tap or a loud auditory stimulus.
||Physically stimulate the patient by shaking the shoulder while speaking loudly. Does the patient respond within 10 seconds?
|Asleep: Patient reacts with a sluggish response to a light glabellar tap or a loud auditory stimulus.
||Physically stimulate the patient by shaking the shoulder while speaking loudly. Does the patient respond after 10 seconds?
|Asleep: Patient does not respond to pain.
||Use painful stimuli. No response.
- Response during deep sedation will require more profound stimuli
- A patient whose only response is reflex withdrawal from painful stimuli are deeply sedated, bordering on general anesthesia
- The purpose of post-sedation monitoring is to ensure that the patient has returned to an acceptable level of functioning as described below before being discharged.
- The time needed for recovery prior to discharge will vary depending on:
- Type and length of the procedure that was performed
- Types of sedation/analgesic agents used and the quantity administered
- The presence of procedural complications
- Age and physiologic condition of the patient
- Consciousness level, hemodynamic parameters, oxygenation, and pain level should be measured at regular intervals until all values have returned to baseline. Vital signs should be documented every 5 minutes at the minimum.
- Since the effects of naloxone and flumazenil are of shorter duration than those of the benzodiazepines and opioids they reverse, a more extended monitoring period (up to 2 hours) may be required if these reversal agents have been used.
- A standardized score discharge scoring system such as the Aldrete Score should be employed to determine the patient’s recovery.
Modified Aldrete Scoring System
Able to move four extremeties voluntarily on comand
Able to move two extremeties voluntarily on command
Unable to move
Able to deep breathe and cough freely
Dyspneic or limited breathing
BP and HR ± 20% of preanesthetic level
BP and HR ± 20% to 50% or preanesthetic level
BP and HR + 50% of preanesthetic level
Fully awake (able to answer questions)
Arousable on calling (arousable only to calling)
Able to maintain O2 saturation > 92% on room air
Needs O2 inhalation to maintain saturation > 90%
O2 saturation < 90% even with O2 supplement
- A patient can be deemed suitable for discharge when the physiologic criteria are met and he or she is able to dress and walk independently
- The patient does not need to be evaluated for tolerance of fluids or solids before being discharged home
- Upon discharge, all patients need to receive verbal and written:
- Instructions outlining diet
- Follow-up recommendations
- A 24-hour contact number should be provided to the patient in the event of complications
- The patient must be released only into the care of a responsible adult who can accompany him home
Cardiopulmonary complications (intra- and post-procedural)
Cardiopulmonary events related to sedation and analgesia is the most frequent cause of GI endoscopy-related morbidity/mortality. These complications range in severity from transient, minor oxygen desaturation, to life threatening events such as apnea, shock/hypotension and myocardial infarction.
- Elderly (older than age 65)
- Preexisting cardiopulmonary disease
- Morbidly obese
- Uncontrolled Diabetes (Pre-procedure glucoses <80 or >300)
- Potential Perioperative Risks: ASA 3 or greater – consider anesthesia assistance
||Sleep apnea; obesity; short neck; reduced mouth opening; large tongue Mallampati score of 3 or 4; anatomical abnormalities
|Risks of aspiration
||Acute upper gastrointestinal bleeding; gastric outlet obstruction; delayed gastric emptying; achalasia
|Reuced tolerance / paradoxical reactions to standard sedatives
||Tobacco, alcohol, or substance abuse; previous adverse experience with sedation; neuropsychiatric disorder; allergies; drug interactions
- Respiratory depression
- Cardiac complications
- Paradoxical reactions – i.e. excessive talkativeness, movement and emotional release. Precipitated by benzodiazepines. Predisposing patient characteristics for paradoxical reaction:
- Young and advanced age
- Genetic predisposition
- Alcoholism or drug abuse
- Psychiatric and/or personality disorders
- Methemoglobinemia – precipitated by topical anesthesia
The appropriate guidelines and policies governing sedation at the hospital or ambulatory surgical facility where it is performed should be maintained at all times. The American Society of Anesthesiologists Guidelines for Ambulatory Anesthesia and Surgery specifies that at minimum:
The physicians who provide medical care in the facility should be organized into a medical staff. This group will assume responsibility for credential review, delineation of privileges and responsibilities, quality assurance and peer review. There must be adequate personnel and equipment available to manage emergencies. The facility must have established policies and procedures to handle unanticipated patient transfer to an acute care hospital.
- A licensed physician should be in attendance in the facility at all times during patient treatment, recovery, and discharge
- The facility must be established, equipped, constructed, and operated in accordance with applicable federal, state, and local laws
- Staff in attendance should be adequate to meet patient and facility needs and must consist of:
- Professional staff including physicians, nurses, and other practitioners who are duly licensed and qualified
- Administration staff
- Housekeeping and maintenance staff
According to the American Society of Anesthesiologists Guidelines for Ambulatory Anesthesia and Surgery, patient care shall include:
- Preoperative instructions and patient preparation
- An appropriate history and physical exam by a physician prior to sedation
- Preprocedure studies as outlined in the American Society for Gastrointestinal Endoscopy Position Statement on Laboratory Testing Before Ambulatory Elective Endoscopic Procedures
- Procedural sedation shall be administered by or under the direction of a qualified physician
- General anesthesia shall be administered by the appropriate anesthesiology personnel
- The physician is responsible for directing discharge criteria
- Patients must be provided with written postoperative and follow-up instructions
- Medical records must be accurate, confidential and current
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