Aspects of care include assessment . Discharge ready: a multifaceted concept that describes a patients functional and cognitive state as sufficiently recovered from anesthesia and able to leave the PACU and be safely cared for in a less intensive nursing environment, 2. 48 0 obj <>stream 2. o. Phase 2 = 3 patients max, you should not have any critical patients in phase 2 (they should all be awake, talking, with minimal need for intervention). 6. Patient Discharge Education in the Phase II Setting, 4. Specifically, the guidelines recommend regular monitoring for and support of the following: a. Airway patency, respiratory rate, and oxygen saturation, a. Pulse, blood pressure, and/or electrocardiographic monitoring, b. Euvolemia judged by hemodynamics and the balance of fluid intake and output (including the output of urine and surgical drains), a. In this study, we measured actual and appropriate PACU LOSs and evaluated clinical factors that may influence PACU LOS. %%EOF Reflect the ability of the criterion to be sensitive to changes in patient status and able to measure change in patient status appropriately, 5. * This is not intended for application during the recovery of the obstetrical patient in whom regional anesthesia was used for labor and vaginal delivery. Midazolam with meperidine and dexmedetomidine. 9. RCTs report comparative findings between clinical interventions for specified outcomes. 4. Results for each pertinent outcome were summarized, and when sufficient numbers of RCTs were found, study grading and meta-analyses were conducted. Remifentanil, propofol or both for conscious sedation during eye surgery under regional anaesthesia. This is a real challenge for PACU RNs because when you have a mix of phase 1 and phase 2 patients, your attention is always going to be focused on the phase 1 patient who is "by definition" the most vunerable patient within the hospital setting. hb```eI eah``ix1!A}@tgy[|rsGCcGFSj!f`0 . WS1m4F{~&}&oLf{01A#xfd)fPU "' 562 0 obj <>/Filter/FlateDecode/ID[<0D3FE10DC311684CA65BE70439B1C1B9><61B9B247E3C1CF4089E4F3E1D43639DD>]/Index[541 44]/Info 540 0 R/Length 106/Prev 374132/Root 542 0 R/Size 585/Type/XRef/W[1 3 1]>>stream Use supplemental oxygen during moderate procedural sedation/analgesia unless specifically contraindicated for a particular patient or procedure. Residual anesthetics such as opioids and hypnotics can also lower arteriolar and venous tone, resulting in decreased preload and afterload. Although it is well accepted clinical practice to review medical records, conduct a physical examination, and review laboratory test results, comparative studies are insufficient to evaluate the periprocedural impact of these activities. An accurate written report of the PACU period shall be maintained. Standard V: Physician is responsible for the discharge of the patient from the post anesthesia care unit. Supports physician and nursing critical judgment of discharge readiness. Reversal of midazolam sedation with flumazenil following conservative dentistry. A. Fourteen years later, another study of over a thousand patients found a similar 23% overall rate of post-op complications. Specializes in Urology. Developed By: Committee on Standards and Practice Parameters The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. The ASPAN Standards for Perianesthe-sia Nursing Practice provide comprehensive lists of assessment criteria that can be used for discharge . Category A evidence represents results obtained from randomized controlled trials (RCTs), and category B evidence represents observational results obtained from nonrandomized study designs or RCTs without pertinent comparison groups. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the guidelines. COMMONLY USED DESCRIPTORS FOR PACU DISCHARGE CRITERIA, b. These guidelines specifically apply to the level of sedation corresponding to moderate sedation/analgesia (previously called conscious sedation), which is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. c. Discharge score defining discharge readiness may not be achieved. In 1989, Zeitlin published a review of the recovery room cases found in the American Society of Anesthesiologists (ASA) closed claims database. The propensity for combinations of sedative and analgesic agents to cause respiratory depression and airway obstruction emphasizes the need to appropriately reduce the dose of each component as well as the need to continually monitor respiratory function. 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). Intravenous sedation for ocular surgery under local anaesthesia. Reversal of central benzodiazepine effects by flumazenil after intravenous conscious sedation with diazepam and opioids: Report of a double-blind multicenter study. If the patient is a candidate for unaccompanied discharge. Patients receiving moderate procedural sedation may continue to be at risk for developing complications after their procedure is completed. This may not be feasible for urgent or emergency procedures, interventional radiology or other radiology settings. The literature is also insufficient to evaluate the effects of using predetermined discharge criteria on patient outcomes. Current Standards. The use of hypnosis in gastroscopy: A comparison with intravenous sedation. Discharge criteria examples are noted in table 5. Most of these occurred in the era before pulse oximeters became widely used. 1-612-816-8773. hko?#MH\Jn};)R;B[>LssHEpm7HCHKD$Q3 OAb( B4BO/iEYM0*#]z\OAcA0*W M> Xa(1\jnr6qMBo#:uO /_nK(A`j7q1ogV7Io; :s\yzV 1x@1|l9*EMt_>%$H%P~Dz([b}_plh?l5\3{_j~. qjQ8qeaW)+co'~XA9%jYbebo0-lMwFtx2-K0yo0i0ExKd"3 h ^fv&PUJB3 5P^gb~3=y.@O))%BT2*8Oe!RiCJ(T{1T$V*l$'e+YI89.!p3.FbKvy*$o^\gcXX/SZEoQGuX9x%:L!1pS1P*jz$Rnba:m$?6'% IE8gE]g6gvAfwv>. The propensity for combinations of sedative and analgesic agents to cause respiratory depression and airway obstruction emphasizes the need to appropriately reduce the dose of each component, as well as the need to continually monitor respiratory function. Capnographic monitoring reduces the incidence of arterial oxygen desaturation and hypoxemia during propofol sedation for colonoscopy: A randomized, controlled study (ColoCap Study). Listed on 2023-03-01. First, criteria for evidence associated with moderate sedation and analgesia techniques were established. Home; Products. 1. Hypotension with midazolam and fentanyl in the newborn. Ensure patient safety by integrating the Standards as criteria for Phase II discharge. Phase II recovery focuses on preparing patients for hospital discharge, including education regarding the surgeon's postoperative instructions and any prescribed discharge medications. Butorphanol as a dental premedication in the mentally retarded. Relevant discharge criteria rigorously applied to determine the readiness of the patient for discharge, b. Survey findings from task forceappointed expert consultants, a random sample of the ASA membership, and membership samples from the American Association of Oral and Maxillofacial Surgeons (AAOMS) and the American Society of Dentist Anesthesiologists (ASDA) are fully reported in this document. Scientific evidence used in the development of these guidelines is based on cumulative findings from literature published in peer-reviewed journals. There are two patients waiting for discharge to Phase II, and one who is ready for discharge but waiting to void. 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). three nurses. Comparitive evaluation of propofol and midazolam as conscious sedatives in minor oral surgery. The effect of supplemental oxygen on apnea and oxygen saturation during pediatric conscious sedation. endstream endobj 542 0 obj <. Use of an appropriate PACU scoring system is encouraged for each patient on admission, at appropriate intervals prior to discharge and at the time of discharge. "{A$K&}"`v6t|-`"@2L0"C/`5i@H_ `YF@c}0 _U continue the use of antiembolic stockings if ordered. Although hypotension is more immediately life threatening, tachycardia and hypertension are associated with increased risk of ICU admission and mortality. RN Nurse, Charge Nurse. }czMO}J(~JZ/|p+~~ORiAeoCpE0;'5A>xq{NHx~NDM!J;7@G\,~ kx[3`,D>txq!D1=1I@~S iFH-,'8 a/.B4}fXX qUsE:C^2Pi\( 2e5Q_b(Yf6kA (xm/cK0'=&x;A=6B[3Nvd` !0;p_S&{qfLt5] y3YaN87IRA)Euk&krU|Ea A5.%.l4jjk@)c]OpR)VUr1Y$2,o7Zk90l"o Falls in hemoglobin saturation during ERCP and upper gastrointestinal endoscopy. Job in Plattsburgh - Clinton County - NY New York - USA , 12903. These guidelines specifically apply to the level of sedation corresponding to moderate sedation/analgesia (previously called conscious sedation), which is defined as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Impact of flumazenil on recovery after outpatient endoscopy: A placebo-controlled trial. Sedation for pediatric echocardiography: Evaluation of preprocedure fasting guidelines. Intravenous sedation prior to peribulbar anaesthesia for cataract surgery in elderly patients. Dexmedetomidine for procedural sedation in children with autism and other behavior disorders. In this document, only the highest level of evidence is included in the summary report for each interventionoutcome pair, including a directional designation of benefit, harm, or equivocality. The member of the Anesthesia Care Team shall remain in the PACU until the PACU nurse accepts responsibility for the nursing care of the patient. 48 0 obj <>stream Midazolam sedation for outpatient fibreoptic endoscopy: Evaluation of alfentanil supplementation. This study guide will help you focus your time on what's most important. These standards may be exceeded based on the judgment of the responsible anesthesiologist. Midazolam intravenous conscious sedation in oral surgery: A retrospective study of 372 cases. Risk factors associated with vasovagal reactions during colonoscopy. Arterial blood oxygen desaturation in infants and children during upper gastrointestinal endoscopy. Open forum testimony obtained during development of these guidelines, internet-based comments, letters, and editorials are all informally evaluated and discussed during the formulation of guideline recommendations. Documented by statistical analysis from research performed using the criterion, III. Describe commonly used post anesthesia care unit (PACU) discharge criteria. C. Upon arrival in the PACU, the anesthesia team member should reevaluate the patient and provide a verbal report to the accepting PACU nurse. Diagnosis: analyze assessment data to determine nursing diagnosis 3. Surgery results in bleeding, nonhematologic volume losses (e.g., evaporative and interstitial), and inflammation. Midazolam-associated alterations in cardiorespiratory function during colonoscopy. Standard V: Physician is responsible for the discharge of the patient from the post anesthesia care unit. 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. hbbd```b``f +@$4dL`!XMmG^`vL[$cc"V"MAfa`bd`(?CO = This article is featured in This Month in Anesthesiology, page 1A. 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. Sedation in children: Adequacy of two-hour fasting. 4. The mechanism of mortality may be related to the metabolic burden placed on the heart in this transient hyperdynamic state. Continual monitoring of ventilatory function with capnography to supplement standard monitoring by observation and pulse oximetry. RL+tp l xnLnR%d`XpqMg]`M8+F*{M:\$?1. 5. ASA Standards for Postanesthesia Care a. four nurses. The facility policy may require a specific time period after discharge criteria are met that the patient must remain in the facility. Intravenous conscious sedation use in endoscopy: Does monitoring of oxygen saturation influence timing of nursing interventions? No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut. Support was provided solely from institutional and/or departmental sources in the American Society of Anesthesiologists. Use of discharge criteria shown to reduce PACU time by 24%. Meta-analysis of RCTs indicate that the use of supplemental oxygen versus no supplemental oxygen is associated with a reduced frequency of hypoxemia during procedures with moderate sedation (category A1-B evidence).6571 The literature is insufficient to examine which methods of supplemental oxygen administration (e.g., nasal cannula, face mask, or specialized devices) are more effective in reducing hypoxemia. d```n Arterial oxygen desaturation during ambulatory colonoscopy: Predictability, incidence, and clinical insignificance. One respondent (1.92%) estimated a decrease in the amount of time they would spend on a typical case. They may vary depending upon whether the patient is discharged to a hospital room, to the Intensive Care Unit, to a short stay unit or home. b. The results of the surveys are reported in tables 710 and are summarized in the text of the guidelines. that discharge criteria for Phase II did not include all the Standards. Because minimal sedation (anxiolysis) may entail minimal risk, the guidelines specifically exclude it. 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. Efficacy and safety of intravenous propofol sedation during routine ERCP: A prospective, controlled study. 414 0 obj <>stream 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. Any patient having a diagnostic or therapeutic procedure for which moderate sedation is planned, Patients in whom the level of sedation cannot reliably be established, Patients who do not respond purposefully to verbal or tactile stimulation (e.g., stroke victims, neonates), Patients in whom determining the level of sedation interferes with the procedure, Principal procedures (e.g., upper endoscopy, colonoscopy, radiology, ophthalmology, cardiology, dentistry, plastics, orthopedic, urology, podiatry), Diagnostic imaging (radiological scans, endoscopy), Minor surgical procedures in all care areas (e.g., cardioversion), Pediatric procedures (e.g., suture of laceration, setting of simple fracture, lumbar puncture, bone marrow with local, magnetic resonance imaging or computed tomography scan, routine dental procedures), Pediatric cardiac catheterization (e.g., cardiac biopsy after transplantation), Obstetric procedures (e.g., labor and delivery), Procedures using minimal sedation (e.g., anxiolysis for insertion of peripheral nerve blocks, local or topical anesthesia), Procedures where deep sedation is intended, Procedures where general anesthesia is intended, Procedures using major conduction anesthesia (i.e., neuraxial anesthesia), Procedures using sedatives in combination with regional anesthesia, Nondiagnostic or nontherapeutic procedures (e.g., postoperative analgesia, pain management/chronic pain, critical care, palliative care), Settings where procedural moderate sedation may be administered, Radiology suite (magnetic resonance imaging, computed tomography, invasive), All providers who deliver moderate procedural sedation in any practice setting, Physician anesthesiologists and anesthetists, Nursing personnel who perform monitoring tasks, Supervised physicians and dentists in training, Preprocedure patient evaluation and preparation, Medical records review (patient history/condition), Nonpharmaceutical (e.g., nutraceutical) use, Focused physical examination (e.g., heart, lungs, airway), Consultation with a medical specialist (e.g., physician anesthesiologist, cardiologist, endocrinologist, pulmonologist, nephrologist, obstetrician), Preparation of the patient (e.g., preprocedure instruction, medication usage, counseling, fasting), Level of consciousness (e.g., responsiveness), Observation (color when the procedure allows), Continual end tidal carbon dioxide monitoring (e.g., capnography, capnometry) versus observation or auscultation, Plethysmography versus observation or auscultation, Contemporaneous recording of monitored parameters, Presence of an individual dedicated to patient monitoring, Creation and implementation of quality improvement processes, Supplemental oxygen versus room air or no supplemental oxygen, Method of oxygen administration (e.g., nasal cannula, face masks, specialized devices (e.g., high-flow cannula), Presence of individual(s) capable of establishing a patent airway, positive pressure ventilation and resuscitation (i.e., advanced life-support skills), Presence of emergency and airway equipment, Types of airway devices (e.g., nasal cannula, face masks, specialized devices (e.g., high-flow cannula), Supraglottic airway (e.g., laryngeal mask airway), Presence of an individual to establish intravenous access, Intravenous access versus no intravenous access, Sedative or analgesic medications not intended for general anesthesia, Dexmedetomidine versus other sedatives or analgesics, Sedative/opioid combinations (all routes of administration), Benzodiazepines combined with opioids versus benzodiazepines, Benzodiazepines combined with opioids versus opioids, Dexmedetomidine combined with other sedatives or analgesics versus dexmedetomidine, Dexmedetomidine combined with other sedatives or analgesics versus other sedatives or analgesics (alone or in combination), Intravenous versus nonintravenous sedative/analgesics not intended for general anesthesia (all non-IV routes of administration, including oral, nasal, intramuscular, rectal, transdermal, sublingual, iontophoresis, nebulized), Titration versus single dose, repeat bolus, continuous infusion, Sedative/analgesic medications intended for general anesthesia, Propofol alone versus nongeneral anesthesia sedative/analgesics alone, Propofol alone versus nongeneral anesthesia sedative/analgesic combinations, Propofol combined with nongeneral anesthesia sedative/analgesics versus propofol alone, Propofol combined with nongeneral anesthesia sedative/analgesics versus nongeneral anesthesia sedative/analgesics (alone or in combination), Propofol alone versus other general anesthesia sedatives (alone or in combination), Propofol combined with sedatives intended for general anesthesia versus other sedatives intended for general anesthesia (alone or in combination), Propofol combined with other sedatives intended for general anesthesia versus propofol (alone or in combination), Ketamine alone versus nongeneral anesthesia sedative/analgesics alone, Ketamine alone versus nongeneral anesthesia sedative/analgesic combinations, Ketamine combined with nongeneral anesthesia sedative/analgesics versus ketamine alone, Ketamine combined with nongeneral anesthesia sedative/analgesics versus nongeneral anesthesia sedative/analgesics (alone or in combination), Ketamine alone versus other general anesthesia sedatives (alone or in combination), Ketamine combined with sedatives intended for general anesthesia versus other sedatives intended for general anesthesia (alone or in combination), Ketamine combined with other sedatives intended for general anesthesia versus ketamine (alone or in combination), Etomidate alone versus nongeneral anesthesia sedative/analgesics alone, Etomidate alone versus nongeneral anesthesia sedative/analgesic combinations, Etomidate combined with nongeneral anesthesia sedative/analgesics versus etomidate alone, Etomidate combined with nongeneral anesthesia sedative/analgesics versus nongeneral anesthesia sedative/analgesics (alone or in combination), Etomidate alone versus other general anesthesia sedatives (alone or in combination), Etomidate combined with sedatives intended for general anesthesia versus other sedatives intended for general anesthesia (alone or in combination), Etomidate combined with other sedatives intended for general anesthesia versus etomidate (alone or in combination), Intravenous versus nonintravenous sedatives intended for general anesthesia, Titration of sedatives intended for general anesthesia, Naloxone for reversal of opioids with or without benzodiazepines, Intravenous versus nonintravenous naloxone, Flumazenil for reversal or benzodiazepines with or without opioids, Intravenous versus nonintravenous flumazenil, Continued observation and monitoring until discharge, Major conduction anesthetics (i.e., neuraxial anesthesia), Sedatives combined with regional anesthesia, Premedication administered before general anesthesia, Interventions without sedatives (e.g., hypnosis, acupuncture), New or rarely administered sedative/analgesics (e.g., fospropofol), New or rarely used monitoring or delivery devices, Improved pain management (i.e., pain during a procedure), Reduced frequency/severity of sedation-related complications, Unintended deep sedation or general anesthesia, Conversion to deep sedation or general anesthesia, Unplanned hospitalization and/or intensive care unit admission, Unplanned use of rescue agents (naloxone, flumazenil), Need to change planned procedure or technique, Prospective nonrandomized comparative studies (e.g., quasiexperimental, cohort), Retrospective comparative studies (e.g., case-control), Observational studies (e.g., correlational or descriptive statistics). 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