Detect early signs of reactions to sedation
Detect early signs of reactions to sedation
During a procedural sedation, your patient is "always at risk" for having adverse reactions, warns Jennifer Conrad, RN, an ED nurse at St. John's Mercy Medical Center in St. Louis, MO.
Before the procedure, review the patient's chart for these potential risk factors, advises Conrad: allergies to medications, lab results, the last time the patient ate or drank, and prior problems with sedation. Conrad says to be ready for these side effects:
- Nausea and vomiting. "This increases risk for aspiration," says Conrad. "Suction equipment and nausea medications should be at the bedside."
- Dizziness. "Intravenous fluids should be running into the patient's IV site, in case of the need for fluid resuscitation," says Conrad.
- Anaphylaxis. "In this situation, emergency equipment and/or the crash cart would be needed," says Conrad.
"Vital signs are one of our most valuable resources when dealing with procedural sedation in the ED," says Conrad.
Frequently compare vital signs with the patient's baseline to detect early warning signs of deterioration, she says. Watch for decreased oxygenation, increase or decrease in blood pressure or heart rate, and decreased respiratory drive.
"Emergency resuscitation equipment should be at the bedside prior to the procedure and available in case the patient deteriorates," says Conrad.
Signs of deterioration include respiratory depression, decrease in oxygen saturation, decrease in mental status, slow recovery from anesthesia, and change in vital signs, says Conrad. (See stories on eliminating complications with propofol, right, and pulse oximetry readings, below.)
The ED at Providence St. Vincent Medical Center in Portland, OR, performs about 40 to 60 procedural sedations per month, says Wayne Schmedel, RN, CCRN, an ED nurse. The patient's heart rate, blood pressure, respiratory rate, oxygen saturation, pain scale, and Ramsay Sedation Scale score showing the level of sedation are monitored continuously throughout the entire procedure.
These steps are taken to avoid problems:
- Each patient is preoxygenated patient prior to the procedure.
- Each procedural sedation patient has an Ambu bag right next to the patient, with oral suction working.
- The rapid sequence intubation kit and various sizes of endotracheal tubes are next to the patient.
- The history of the last meal, as well as any oral liquid consumed, is recorded on the sedation record at the bedside.
- A computer printout of all emergent medication dosages, based on the weight of the patient, is the bedside.
"Close monitoring with direct observation and frequent vital sign measurements are the most reliable means to detect any of the early warning signs of decompensation," says Schmedel.
Decompensation is more likely to occur when the patient's level of sedation reaches a 6 on the Ramsay Sedation Scale and does not decrease after a few minutes, he says. In this case, consider a jaw thrust remover for apnea and/or using the Ambu bag for ventilation, Schmedel says.
"If the decompensation includes hypotension, then an IV bolus of normal saline would be given," says Schmedel. "Deeper levels of sedation, and perhaps the occasional oversedation, increases the likelihood of decompensation."
Source
For more information on procedural sedation in the ED, contact:
- Wayne Schmedel, RN, CCRN, Emergency Department, Providence St. Vincent Medical Center, Portland, OR. Phone: (503) 216-2361. E-mail: [email protected].
ED gets complications with propofol to zero The most frequently used sedating agent used in the ED at Providence St. Vincent Medical Center in Portland, OR, is propofol, says Wayne Schmedel, RN, CCRN, an ED nurse. "Most clinicians have historically felt that propofol always promotes a deep level of sedation," says Schmedel. "In fact, we have seen that tight titration of the propofol can promote a moderate level of sedation." The ED bases the propofol dose on the American Society of Anesthesiologists (ASA) score and the patient's age, using this equation: Propofol dose in mg = Ramsay Sedation Scale score multiplied by the patient's weight in kilograms "This tighter control, with a more specifically targeted dose, has completely eliminated any complications associated with oversedation using propofol," says Schmedel. He notes that the most common, although rarely observed, complications of propofol include apnea and hypotension. "We find that it is very easy to use and very safe within the guidelines of its use," says Schmedel. The guidelines include close monitoring, with vital signs taken every five minutes. "There always two physicians in the room until recovery from the sedation agent has occurred," says Schmedel. "Our complication rate with propofol has been very rare and is now essentially non-existent." |
How ED nurses can avoid misleading oximeter reads Have you obtained an oximeter measurement from the patient's fingers or toes? If so, remember that "the reading is actually delayed from the core, or central body, for two to three minutes," says Tia Valentine, RN, CEN, clinical nurse educator for the ED at University of California San Diego Medical Center. "So, if the reading on the finger is 90%, that means that the core oxygen saturation is actually more like 85%." Remember this tip for patients with peripheral vascular disease: "You may get false readings when the oximeter is placed on the finger or toe," Valentine says. Also make sure that the plethysmographic waveform is correlating to the ECG waveform. "If it is dampened or not following the ECG, then any readings that are obtained from the oxygen saturation monitor cannot be relied upon for accuracy," says Valentine. |
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