However, as stated in the American Academy of PediatricsAmerican Academy of Pediatric Dentistry guidelines on the monitoring and management of pediatric patients during sedation (2016), in the case of procedures that may themselves cause airway obstruction (e.g., dental or endoscopic), the practitioner must recognize an obstruction and assist the patient in opening the airway.4. Recently, these discharge criteria have also been used in the operating room (OR) to determine the fast-track eligi-bility of outpatients undergoing ambulatory surgery (2,3). A Randomized clinical trial of intravenous and intramuscular ketamine for pediatric procedural sedation and analgesia. The current edition of ASPAN's Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements (Standards) provides a framework for the expanding scope of care for a diverse patient population of all ages across all perianesthesia settings and phases of care. Anterior shoulder dislocation reduction managed either with midazolam or propofol in combination with fentanyl. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: Update 2016. endstream endobj 386 0 obj <. 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. 3. Conduct a focused physical examination of the patient (e.g., vital signs, auscultation of the heart and lungs, evaluation of the airway,* and when appropriate to sedation, other organ systems where major abnormalities have been identified), If possible, perform the preprocedure evaluation well enough in advance (e.g., several days to weeks) to allow for optimal patient preparation, Before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences, Inform patients or legal guardians before the day of the procedure that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying before the procedure, During procedures where a verbal response is not possible (e.g., oral surgery, restorative dentistry, upper endoscopy), check the patients ability to give a thumbs up or other indication of consciousness in response to verbal or tactile (light tap) stimulation; this suggests that the patient will be able to control his airway and take deep breaths if necessary, Continually# monitor ventilatory function by observation of qualitative clinical signs, At a minimum, this should occur: (1) before the administration of sedative/analgesic agents,** (2) after administration of sedative/analgesic agents, (3) at regular intervals during the procedure, (4) during initial recovery, and (5) just before discharge, The designated individual may assist with minor, interruptible tasks once the patients level of sedation/analgesia and vital signs have stabilized, provided that adequate monitoring for the patients level of sedation is maintained, Assure that pharmacologic antagonists for benzodiazepines and opioids are immediately available in the procedure suite or procedure room, Combinations of sedative and analgesic agents may be administered as appropriate for the procedure and the condition of the patient, For patients receiving intravenous sedative/analgesics intended for general anesthesia, maintain vascular access throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression, Administer intravenous sedative/analgesic medications intended for general anesthesia in small, incremental doses, or by infusion, titrating to the desired endpoints, Use reversal agents in cases where airway control, spontaneous ventilation, or positive pressure ventilation is inadequate, Administer naloxone to reverse opioid-induced sedation and respiratory depression, Design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel, Create and implement a quality improvement process based upon established national, regional, or institutional reporting protocols (e.g., adverse events, unsatisfactory sedation). Butorphanol as a dental premedication in the mentally retarded. This may not be feasible for urgent or emergency procedures. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. 3. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to assure that (1) pharmacologic antagonists for benzodiazepines and opioids are immediately available in the procedure suite or procedure room; (2) an individual is present in the room who understands the pharmacology of the sedative/analgesics administered and potential interactions with other medications and nutraceuticals the patient may be taking; (3) appropriately sized equipment for establishing a patent airway is available; (4) at least one individual capable of establishing a patent airway and providing positive pressure ventilation is present in the procedure room; (5) suction, advanced airway equipment, positive pressure ventilation, and supplemental oxygen are immediately available in the procedure room and in good working order; (6) a member of the procedural team is trained in the recognition and treatment of airway complications, opening the airway, suctioning secretions, and performing bag-valve-mask ventilation; (7) a member of the procedural team has the skills to establish intravascular access; (8) a member of the procedural team has the skills to provide chest compressions; (9) a functional defibrillator or automatic external defibrillator is immediately available in the procedure area; (10) an individual or service is immediately available with advanced life support skills; and (11) members of the procedural team are able to recognize the need for additional support and know how to access emergency services from the procedure room. Implementing ASPAN Standards: Surgery Phase, PACU Phase I, Phase II and Extended Care Discharge criteria UNPLANNED PERIOPERATIVE HYPOTHERMIA Increased length of PACU, setting until discharge from all phases of postanesthesia care. No interventions are required to maintain a patent airway when spontaneous ventilation is adequate. Cardiovascular function is usually maintained. (The preoperative level of consciousness or awareness is documented on the Adult assessment record on admission in EPIC under . Stanford Hospital And Clinics OR REGION DISCHARGE CRITERIA FOR PHASE I & II- POST ANESTHESIA CARE ORAM D 4.05 Issued: 10/02 Last revision/review: 4/10 2 A. In addition, the literature is insufficient to determine the benefits of keeping an individual present to establish intravenous access during procedures with moderate sedation/analgesia. 414 0 obj <>stream Fifth, the task force held open forums at major national meetings to solicit input on its draft recommendations. National organizations representing specialties whose members typically provide moderate sedation were invited to participate in the open forums. Has 10 years experience. Not surprisingly, respiratory incidents comprised the majority of the cases (49 of the 84), whereas cardiovascular incidents represented a minority (9 of 84). The elements to consider for assessments as well as discharge from Phase I, Phase II, or Ex tended Care levels of care are found in the ASPAN 2019-2020 Perianesthesia Nursing Standards, Practice Recommendations and Interpretive Statements , "Practice Recommendation 2-Components of If theres a bed delay then we place the pt in a hold status until ready for transfer. Compliance to discharge criteria must be monitored. ?HYN|Icremkmmy6'YF5s [5 5XY.k,Pz a. American Society of Anesthesiologists (ASA) states in their Standards for Postanesthesia Care that in the absence of the physician responsible for the discharge, the PACU nurse shall determine that the patient meets the discharge criteria., a. a. Patients whose only response is reflex withdrawal from painful stimuli are deeply sedated, approaching a state of general anesthesia, and should be treated accordingly. They are intended to encourage quality patient care, but cannot guarantee any specific patient outcome. Arterial oxygen saturation in sedated patients undergoing gastrointestinal endoscopy and a review of pulse oximetry. When I covered nights I did call in a backup RN and never heard boo from management. Reversal of central benzodiazepine effects by intravenous flumazenil after conscious sedation with midazolam and opioids: A multicenter clinical study. c. Discharge score defining discharge readiness may not be achieved. 2. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation that combinations of sedative and analgesic agents may be administered as appropriate for the procedure and the condition of the patient. Specializes in Post Anesthesia, Pre-Op. e. Institutional policies identify exceptions that must be reported to the physician before transfer. The use of flumazenil to reverse sedation induced by bolus low dose midazolam or diazepam in upper gastrointestinal endoscopy. continue the use of antiembolic stockings if ordered. Statistically significant (P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E). }x3\,2ygt*e.Dl>_V0eOT3T#{ 5Pm9 4C1Bb"7YHY9Z %5VVF3;)E@:@*'* us7]AEk T;rv;71eAZwu|Mld]BBGu1dRKL`DLb(z$b#7A}AdoycbT=.45^P!0gpc_]c_;t8:8Wtim^$fHcO7V>Xu A single dose of propofol can produce excellent sedation and comparable amnesia with midazolam in cystoscopic examination. Inadequate literature cannot be used to assess relationships among clinical interventions and outcomes because a clear interpretation of findings is not obtained due to methodological concerns (e.g., confounding of study design or implementation) or the study does not meet the criteria for content as defined in the Focus of the guidelines. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. The mechanism of mortality may be related to the metabolic burden placed on the heart in this transient hyperdynamic state. Reported by authors as oxygen desaturation to less than 94, 93, or 90%. Literature exclusion criteria (except to obtain new citations): For the systematic review, potentially relevant clinical studies were identified via electronic and manual searches. Continuum of Depth of Sedation, Definition of General Anesthesia, and Levels of Sedation/Analgesia, Airway Assessment Procedures for Sedation and Analgesia, Summary of American Society of Anesthesiologists Recommendations for Preoperative Fasting and Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures, Emergency Equipment for Sedation and Analgesia, Recovery and Discharge Criteria after Sedation and Analgesia, American Association of Oral and Maxillofacial Surgeons Member Survey Responses, American Society of Dentist Anesthesiologists Member Survey Responses. b. The appropriate choice of agents and techniques for moderate sedation/analgesia is dependent upon the experience, training, and preference of the individual practitioner, requirements or constraints imposed by associated medical issues of the patient or type of procedure, and the risk of producing a deeper level of sedation than anticipated. For these guidelines, a systematic search and review of peer-reviewed published literature was conducted, with scientific findings summarized and reported below and in the document. Explore member benefits, renew, or join today. Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: Detection by pulse oximetry. The comparison of dexmedetomidine and midazolam used for sedation of patients during upper endoscopy: A prospective, randomized study. Ineffective ventilation during conscious sedation due to chest wall rigidity after intravenous midazolam and fentanyl. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. In this study, we measured actual and appropriate PACU LOSs and evaluated clinical factors that may influence PACU LOS. These guidelines were developed by an ASAappointed task force of 13 members, consisting of physician anesthesiologists in both private and academic practices from various geographic areas of the United States, a cardiologist, a dentist anesthesiologist, an oral/maxillofacial surgeon, a radiologist, an ASA staff methodologist, and two consulting methodologists for the ASA Committee on Standards and Practice Parameters. When discharge criteria are used, they must be approved by the Department of Anesthesiology and the medical staff. Using a criteria-based scoring system ensures patients are adequately prepared for transfer to PACU phase II extended observation or a nursing unit. Promote efficient use of fiscal and personnel resources. 4. Phase 3 (Late): continues at home until the patient returns to their preoperative psychomotor state. Findings from these RCTs are reported separately as evidence. Evaluation of complications during and after conscious sedation for endoscopy using pulse oximetry. Wqn five . a. hbbd```b``Z"@$f"H 0{-&Y"DH7n"=f$6& H2veo e`g U Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. p";Z-1bV\60PS54&KCi$M\cN tP-A['1ge]a&[kH{M( d(VT,N?\alQIRlT=}&(XYoC |srsgl8WIDpCXA?4 IKo+Lvs>c]H;8[5R0)#GTM}H,5Te`VPDyXv2 Feasibility of a cardiologist-only approach to sedation for electrical cardioversion of atrial fibrillation: A randomized, open-blinded, prospective study. Although it is well accepted clinical practice to continue patient observation until discharge, the literature is insufficient to evaluate the impact of postprocedural observation and monitoring. 10 0 obj <> endobj Second, original published research studies relevant to the guidelines were reviewed and analyzed; only articles relevant to the administration of moderate sedation were evaluated. 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