Current Standards. A prospective study evaluating the usefulness of continuous supplemental oxygen in various endoscopic procedures. They integrate current scientific literature and the opinion of groups of experts, including, separately, the (1) members of the ASA Taskforce (a group of anesthesiologists and epidemiologists); (2) PACU consultants; and (3) ASA members at large. Preprocedure patient evaluation consists of the following strategies for reducing sedation-related adverse outcomes: (1) reviewing previous medical records for underlying medical problems (e.g., abnormalities of major organ systems, obesity, obstructive sleep apnea, anatomical airway problems, congenital syndromes with associated medical/surgical issues, respiratory disease, allergies, intestinal inflammation); sedation, anesthesia, and surgery history; history of or current problems pertaining to cooperation, pain tolerance, or sensitivity to anesthesia or sedation; current medications; extremes of age; psychotropic drug use; use of nonpharmaceuticals (e.g., nutraceuticals); and family history; (2) a focused physical examination; and (3) preprocedure laboratory testing (where indicated). Pulse oximetry and upper intestinal endoscopy in infants and children. Moderate and deep sedation or general anesthesia may be achieved via any route of administration. The purpose of the modern PACU is to address these matters and other common ailments before they inflict significant mortality and/or morbidity. Comparison of sedation, amnesia, and patient comfort produced by intravenous and rectal diazepam. Residual neuromuscular blockade contributes to upper airway obstruction and hypoventilation. FQ"bNJ,p*113W|&)( "9#~LwW 34 DOgp> EYG*Pi2AH#aDq \PKd(*"J!!biUeU'|nq>^%mU1-f3W@yQc&tSW)O>4^K;ow9FWQx~?h4Q3/pe2%#ti>]$1p[,["ctlaO Qa4'9X@9Av'(, Anterior shoulder dislocation reduction managed either with midazolam or propofol in combination with fentanyl. STANDARD III (Task Force Co-Chair), Farmington, Connecticut; Richard T. Connis, Ph.D. (Chief Methodologist), Woodinville, Washington; Madhulika Agarkar, M.P.H., Schaumburg, Illinois; Donald E. Arnold, M.D., St. Louis, Missouri; Charles J. Cot, M.D., Boston, Massachusetts; Richard Dutton, M.D., Dallas, Texas; Christopher Madias, M.D., Boston, Massachusetts; David G. Nickinovich, Ph.D., Bellevue, Washington; Paul J. Schwartz, D.M.D., Dunkirk, Maryland; James W. Tom, D.D.S., M.S., Los Angeles, California; Richard Towbin, M.D., Phoenix, Arizona; and Avery Tung, M.D., Chicago, Illinois. These evidence categories are further divided into evidence levels. Arterial oxygen saturation in sedated patients undergoing gastrointestinal endoscopy and a review of pulse oximetry. The Post Anesthesia Care Unit (PACU) utilizes ASPAN standards to provide Preoperative, Phase 1, and Phase 2 (discharge) post anesthesia care for our surgical and procedural patients. * Under extenuating circumstances, the responsible anesthesiologist may waive the requirements marked with an asterisk (*); it is recommended that when this is done, it should be so stated (including the reasons) in a note in the patients medical record. a. The effect of supplemental oxygen on apnea and oxygen saturation during pediatric conscious sedation. Evidence-Based Practice and Nursing Research, PeriAnesthesia Nursing Core Curriculum Preprocedure. Midazolam-associated alterations in cardiorespiratory function during colonoscopy. Analgesics administered with sedatives include opioids such as fentanyl, alfentanil, remifentanil, meperidine, morphine, and nalbuphine. Last Amended: October 23, 2019 (original approval: October 27, 2004) Meta-analysis of RCTs indicate that the use of continuous end-tidal carbon dioxide monitoring (i.e., capnography) is associated with a reduced frequency of hypoxemic events (i.e., oxygen saturation less than 90%) when compared to monitoring without capnography (e.g., practitioners were blinded to capnography results) during procedures with moderate sedation (category A1-B evidence).3034 Findings for this comparison were equivocal for RCTs reporting severe hypoxemic events (i.e., oxygen saturation less than 85%)30,32,33 and for oxygen saturation levels of 92, 93, and 95% (category A2-E evidence).31,3436 Observational studies indicate that pulse oximetry is effective in the detection of oxygen saturation levels in patients administered sedatives and analgesics (category B3-B evidence).3763 Observational studies also indicate that electrocardiography monitoring is effective in the detection of arrhythmias, premature ventricular contractions, and bradycardia (category B3-B evidence).46,49,64. (lvl 1 vs 2) 2:1 for stable patients and 1:1 for unstable and pediatric (12 . There shall be a policy to assure the availability in the facility of a physician capable of managing complications and providing cardiopulmonary resuscitation for patients in the PACU. 4. Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac. Accueil Uncategorized aspan standards for phase 2 staffing. Create well-written care plans that meets your patient's health goals. At our hospital phase 2 is only for patients being discharged to home. Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. HV0+h See table 3 and/or refer to: American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report. Healthcare database searches included PubMed, EMBASE, Web of Science, Google Books, and the Cochrane Central Register of Controlled Trials. Phase 3 (Late): continues at home until the patient returns to their preoperative psychomotor state. hb``e`` Central nervous system depressants also put patients at risk of laryngospasm. A response limited to reflex withdrawal from a painful stimulus is not considered a purposeful response and thus represents a state of general anesthesia. Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicating the findings). Apply to all registered nurses in clinical practice C. Standards of care: describe a competent level of nursing care 1. A postanesthesia care unit (PACU) is a specialized intensive care ward that serves the brief, yet intense medical needs of patients after a surgical procedure. This document replaces the Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: An Updated Report by the American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia by Non-Anesthesiologists, adopted in 2001 and published in 2002.1. The detrimental effects of all of these drugs are exaggerated in the elderly, obese, and those with obstructive sleep apnea. HV=0+Jv!g\ Titrated sedation with propofol or midazolam for flexible bronchoscopy: A randomised trial. STANDARD I Finally, the literature is insufficient to determine the benefits of rescue support availability during moderate procedural sedation/analgesia. Titration of drug to effect is an important concept; one must know whether the previous dose has taken full effect before administering additional drug. All routes of administration were considered, including oral, nasal, intramuscular, rectal, transdermal, sublingual, iontophoresis, and nebulization. See table 3 and/or refer to: American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report. Comparison of propofol-based sedation regimens administered during colonoscopy. Alfentanil for conscious sedation during colonoscopy. Since 1997, allnurses is trusted by nurses around the globe. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. Pages 357-258, 1252-1253. A double-blind, randomised, placebo-controlled trial of oral midazolam plus oral ketamine for sedation of children during laceration repair. Technical report: Oxygen saturation monitoring during sedation for chemonucleolysis. (xm/cK0'=&x;A=6B[3Nvd` !0;p_S&{qfLt5] y3YaN87IRA)Euk&krU|Ea A5.%.l4jjk@)c]OpR)VUr1Y$2,o7Zk90l"o ' |jkI9x"9P,UD4c Define terminology describing discharge definitions. Meta-analyses from other sources are reviewed but not included as evidence in this document. If the patient response results in deeper sedation than intended, these sedation practices can be associated with cardiac or respiratory depression that must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest, or death. When discharge criteria are used, they must be approved by the Department of Anesthesiology and the medical staff. Reversing intravenous sedation with flumazenil. Many of the complications associated with moderate sedation and analgesia may be avoided if adverse drug responses are detected and treated in a timely manner (i.e., before the development of cardiovascular decompensation or cerebral hypoxia). . They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. She served on the ASPAN Board of Directors for 2 terms as the Director for Education and has been a long time member of the Education Provider committee. Conscious sedation for interventional neuroradiology: A comparison of midazolam and propofol infusion. Intravenous conscious sedation use in endoscopy: Does monitoring of oxygen saturation influence timing of nursing interventions? Process Revision and additions to Phase II discharge criteria in the electronic medical record to include all the applicable ASPAN Standards. Specializes in Post Anesthesia, Pre-Op. Procedural sedation for fracture reduction in children with hyperactivity. Literature comparing propofol with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) Meta-analysis of RCTs report faster recovery times for propofol versus midazolam after procedures with moderate sedation (category A1-B evidence),9599 with equivocal findings for patient recall,95,100103 and frequency of hypoxemia (category A1-E evidence).96,100,102,103 One RCT reports shorter sedation time, a lower frequency of recall and higher recovery scores for propofol versus diazepam (category A3-B evidence).104 (2) RCTs comparing propofol versus benzodiazepines combined with opioid analgesics report shorter sedation and recovery times for propofol alone (category A2-B evidence),105,106 with equivocal findings for pain, oxygen saturation levels, and blood pressure (category A2-E evidence).107109 (3) RCTs comparing propofol combined with benzodiazepines versus propofol alone report equivocal findings for recovery and procedure times, pain with injection, and restlessness (category A2-E evidence).110112 One RCT comparing propofol combined with midazolam versus propofol alone reports deeper sedation levels and more episodes of deep sedation for the combination group (category A3-H evidence).112 RCTs comparing propofol combined with opioid analgesics versus propofol alone report lower pain scores for the combination group (category A2-B evidence),113,114 with equivocal findings for sedation levels, oxygen saturation levels, and respiratory and heart rates (category A2-E evidence).113116 (4) One RCT comparing propofol combined with remifentanil versus remifentanil alone reports deeper sedation, less recall (category A3-B evidence), and more respiratory depression (category A3-H evidence) for the combination group.117 (5) RCTs comparing propofol combined with sedatives/analgesics not intended for general anesthesia versus combinations of sedatives/analgesics not intended for general anesthesia report equivocal findings for outcomes including sedation time, patient recall, pain scores, recovery time, oxygen saturation levels, blood pressure, and heart rate (category A2-E evidence).118136 (6) RCTs comparing propofol with ketamine report equivocal findings for sedation scores, pain during the procedure, recovery, oxygen saturation levels, respiratory rate, blood pressure, and heart rate (category A2-E evidence).137,138 (7) One RCT comparing propofol versus ketamine combined with midazolam reports equivocal findings for recovery agitation, oxygen saturation levels, respiratory rate, blood pressure, and heart rate (category A3-E evidence).139 (8) One RCT comparing propofol versus ketamine combined with fentanyl reports shorter recovery times and less recall for propofol alone (category A3-E evidence).140 (9) RCTs comparing propofol combined with ketamine versus propofol alone report deeper sedation for the combination group (category A3-B evidence),141 with more respiratory depression and a greater frequency of hypoxemia (category A3-H evidence).142, Literature comparing ketamine with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) RCTs comparing ketamine with midazolam report equivocal findings for sedation scores, recovery time, and oxygen saturation levels (category A2-E evidence).87,143,144 (2) One RCT comparing ketamine versus nitrous oxide reports longer sedation times and higher levels of sedation (i.e., deeper sedation levels) for ketamine (category A3-H evidence).145 (3) One RCT comparing ketamine with midazolam combined with fentanyl reports a lower depth of sedation for ketamine (category A3-B evidence), with equivocal findings for recall, pain scores and frequency of hypoxemia (category A3-E evidence).146 (4) RCTs comparing ketamine combined with midazolam versus ketamine alone or midazolam alone report equivocal findings for sedation scores, sedation time, recovery, and recovery agitation (category A2-E evidence).143,147,148 (5) One RCT comparing ketamine combined with midazolam versus midazolam combined with alfentanil reports a lower frequency of hypoxemia (category A3-B evidence) and increased disruptive movements, longer recovery times, and longer times to discharge for ketamine combined with midazolam (category A3-H evidence).149 (6) RCTs comparing ketamine with propofol report equivocal findings for sedation scores, pain during the procedure, oxygen saturation levels, and recovery scores (category A2-E evidence).137,138 RCTs comparing ketamine with etomidate report less airway assistance required and lower frequencies of myoclonus with ketamine (category A2-B evidence).150,151 (7) RCTs comparing ketamine combined with propofol versus propofol combined with fentanyl report equivocal findings for recovery times, oxygen saturation levels, respiratory rate, and heart rate (category A3-H evidence).152154, Literature comparing etomidate with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) One RCT comparing etomidate with midazolam reports shorter sedation times for etomidate (category A3-B evidence), with equivocal findings for recovery agitation, oxygen saturation levels, and apnea (category A3-E evidence).155 (2) One RCT comparing etomidate with pentobarbital reports shorter sedation times for etomidate (category A3-B evidence), with equivocal findings for recovery agitation and hypotension (category A3-B evidence).156 (3) One RCT comparing etomidate combined with fentanyl versus midazolam combined with fentanyl reports deeper sedation (i.e., higher sedation scores) for the combination group (category A3-B evidence), with equivocal findings for sedation times, recovery times, frequency of oversedation, and oxygen saturation levels (category A3-E evidence), and a higher frequency of myoclonus (category A3-H evidence).157 (4) One RCT comparing etomidate combined with morphine and fentanyl versus midazolam combined with morphine and fentanyl reports shorter sedation times for the etomidate combination (category A3-B evidence), with equivocal findings for oxygen saturation levels, apnea, hypotension, and recovery agitation (category A3-E evidence), and a higher frequency of patient recall and myoclonus (category A3-H evidence).158, One RCT reports shorter sedation onset times, shorter recovery times, and fewer rescue doses administered for intravenous ketamine when compared with intramuscular ketamine (category A3-B evidence), with equivocal findings for sedation efficacy, respiratory depression, and time to discharge (category A3-E evidence).159 One RCT comparing intravenous versus intramuscular ketamine with or without midazolam reports equivocal findings for sedation time, recovery agitation, and duration of the procedure (category A3-E evidence).148, Observational studies reporting titrated administration of sedatives intended for general anesthesia report the frequency of hypoxemia ranging from 1.7 to 4.7% of patients,14,160163 with oversedation occurring in 0.13%-0.2% of patients.14,161. Preprocedure patient preparation consists of (1) consultation with a medical specialist when needed; (2) patient preparation for the procedure (e.g., informing patients of the benefits and risks of sedatives and analgesics, preprocedure instruction, medication usage, counseling); and (3) preprocedure fasting from solids and liquids. From medical school and throughout your successful careerevery challenge, goal, discoveryASA is with you. Consultants were drawn from the following specialties where moderate procedural sedation/analgesia are commonly administered: anesthesiology, cardiology, dentistry, emergency medicine, gastroenterology, oral and maxillofacial surgery, pediatrics, radiology, and surgery. At our hospital phase 2 is only for patients being discharged to home. 10 0 obj <> endobj 7. endstream endobj 16 0 obj <>stream Criterion applied the same way regardless of health care provider (interrater reliability), 2. C. Upon arrival in the PACU, the anesthesia team member should reevaluate the patient and provide a verbal report to the accepting PACU nurse. The authors declare no competing interests. If the bed wasn't available the patient would be considered as being in an " extended level of care". STANDARD V Comparitive evaluation of propofol and midazolam as conscious sedatives in minor oral surgery. These are ASPAN standards and we follow them. Survey responses were recorded using a 5-point scale and summarized based on median values. Continual monitoring of ventilatory function with capnography to supplement standard monitoring by observation and pulse oximetry. =yb 1. ASPAN "retired" the position statement that said "It is, therefore, the position of ASPAN that two registered nurses, one competent in Phase I postanesthesia nursing, will be in the same unit where the patient is receiving Phase I level of care at all times . Immediately available in the procedure room refers to easily accessible shelving, cabinetry, and other measures to assure that there is no delay in accessing medications and equipment during the procedure. No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut. We need help! Ensure standard of care is met for all patients. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. RCTs report comparative findings between clinical interventions for specified outcomes. The medical aspects of care in the PACU (or equivalent area) shall be governed by policies and procedures which have been reviewed and approved by the Department of Anesthesiology. For hospitalized inpatients, phases 2 and 3 both occur on an inpatient ward. Although it is established clinical practice to provide access to emergency support, the literature is insufficient to assess the benefits or harms of keeping pharmacologic antagonists or emergency airway equipment available during procedures with moderate sedation and analgesia. 33 0 obj <>/Filter/FlateDecode/ID[<82EC1363F47B6FA4F07401488ABAAFF0><0F1D02B4EFA2BC4DB6E3B193BC57958C>]/Index[10 39]/Info 9 0 R/Length 111/Prev 125561/Root 11 0 R/Size 49/Type/XRef/W[1 3 1]>>stream o. Efficacy and safety profiles of sedation with propofol combined with intravenous midazolam and pethidine versus intravenous midazolam and pethidine administered by trained nurses for ambulatory endoscopic retrograde cholangiopancreatography (ERCP). UPON ARRIVAL IN THE PACU, THE PATIENT SHALL BE RE-EVALUATED AND A VERBAL REPORT PROVIDED TO THE RESPONSIBLE PACU NURSE BY THE MEMBER OF THE ANESTHESIA CARE TEAM WHO ACCOMPANIES THE PATIENT. For these guidelines, sedatives intended for general anesthesia include propofol, ketamine and etomidate. Sedatives not intended for general anesthesia (e.g., benzodiazepines, nitrous oxide, chloral hydrate, barbiturates, and antihistamines) are included either as comparison groups or in combination with sedatives intended for general anesthesia. No interventions are required to maintain a patent airway when . 385 0 obj <> endobj Seven respondents (13.46%) indicated that there would be an increase in the amount of time, with four of these respondents estimating an increase ranging from 5 to 15min. Any patient in phase II PACU requiring 1:1 . phase 2 education These seven evidence linkages are: (1) capnography versus blinded capnography, (2) supplemental oxygen versus no supplemental oxygen, (3) midazolam combined with opioids versus midazolam alone, (4) propofol versus midazolam, (5) flumazenil versus placebo for benzodiazepine reversal, and (6) flumazenil versus placebo for reversal of benzodiazepines combined with opioids (table 6). Opening Document 100% Discharge Criteria for Phase I & II / 7 You are Here: Stanford Medicine School of Medicine Departments Anesthesia Ether Anesthesia Resources DASHBOARD Intranet Information Site Navigation: Nav 1 Nav 2 Nav 2_1 a. Use of discharge criteria shown to decrease discharge delays. Level 2: The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis for the purpose of these Guidelines. Additional interventions excluded from these guidelines include but are not limited to patient-controlled sedation/analgesia, sedatives administered before or during regional and central neuraxis anesthesia, premedication for general anesthesia, interventions without sedatives (e.g., hypnosis, acupuncture), new or rarely administered sedative/analgesics, new or rarely used monitoring or delivery devices, and automated sedative delivery systems. And therapeutic procedures: Update 2016 are exaggerated in the electronic medical record include... Care: describe a competent level of Nursing interventions until the patient would be as! Throughout your successful careerevery challenge, goal, discoveryASA is with you inpatient, and those with obstructive apnea! Of Controlled Trials usefulness of continuous supplemental oxygen on apnea and oxygen saturation influence timing Nursing! 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