The emergency department (ED) was busy and short-staffed when a 5-year-old boy presented with a simple 3-cm laceration to his left eyebrow. The mother requested that some form of sedation be used to help calm her child. After obtaining a thorough history and physical examination, the physician explained the risks and benefits of conscious sedation. The doctor then ordered the medications necessary to provide adequate sedation. The drugs were obtained, but soon after they were administered, the child’s oxygen saturation began to fall. Although it is uncommon, the child was experiencing laryngospasm and was unable to independently maintain adequate oxygenation. As he reached for the bag-valve mask, the doctor noticed that the mask was the wrong size and that the tubing was not connected to the oxygen. Things got worse when the doctor noticed that the child was never attached to the heart monitor.
As the crisis developed it became clear that the nurse — a floor nurse pulled to the ED — was inexperienced in emergency medicine, and the doctor, who had been in practice for seven years, was on his own. The correct mask was obtained, the oxygen tubing was connected, and the laryngospasm resolved. Eventually, the doctor was able to adequately oxygenate and ventilate the child. Though the child ultimately did well, this frightening scenario could have been avoided with better preparation. (To see a conscious sedation form and policy from Trinity Medical Center in Rock Island, IL, click here.)
It’s your license’
You need to know what medications you’re giving, know what response to look for, and know what to do if there is an adverse event, stresses Laura L. Kuensting, MSN, RN, CPNP, an ED pediatric nurse practitioner at St. John’s Mercy Medical Center in St. Louis. "It’s your license, and it’s your patient’s life," she says.
Here are ways to avoid adverse outcomes during conscious sedation:
• Have emergency equipment readily available. You must have immediate access to whatever you’ll need if an unforeseen event such as anaphylaxis should occur, says Kuensting. She gives the following examples:
- When using nitrous oxide, 100% oxygen should be immediately available to counter adverse reactions such as vomiting.
- When using benzodiazepines, flumazenil should be readily available.
- When administering opiates, naloxone should be nearby.
- A bag valve mask and suction always should be readily available.
• Never administer any medication with which you’re unfamiliar. The biggest risk area with conscious sedation is medication error, says Paul Sirbaugh, MD, an ED physician at Children’s Hospital in Houston. He recommends taking a minimalist approach. "Pick a few drugs, and know them well," he says.
• Include any procedures using sedatives or anxiolytics in your policies. While the administration of agents such as nitrous oxide for procedures such as intravenous starts or oral midazolam hydrochloride for computed tomography scans may be considered anxiolysis and not conscious sedation, you should address these agents in your conscious sedation policies, Kuensting says. Because the guidelines from the Joint Commission on the Accreditation of Hospital Organizations are somewhat vague, she recommends erring on the side of caution by developing conscious sedation policies to include all procedures using any sedative or anxiolytic medications.
• Monitor patients during the recovery period. Monitor patients closely after the procedure, Kuensting advises. "This tends to be the time when physicians have left the room, but the patient is entering the peak time of the drug effects," she says. "I have experienced most complications during the recovery period." Keeping stimulation at a minimum, such as turning the lights down, talking softly in the room, and minimal tactile stimulation to the patient, helps to reduce the risk of emergence, Kuensting says. Midazolam hydrochloride is used for the few patients who hallucinate, she says. "But be careful not to give too much as it will suppress their respiratory function," she says.
• Educate parents. Fully explain the procedure to parents and explain potential adverse effects and how these would be handled, Sirbaugh says. If a parent has reservations, explain the other options, he recommends. "Usually they don’t like the alternative, such as go to the operating room to have the laceration sutured, and on their own they choose the conscious sedation," he says. "But I never talk someone into something. They always make an informed decision."
Sources
For more information on conscious sedation, contact:
• Laura L. Kuensting, MSN, RN, CPNP, Pediatric Nurse Practitioner, Pediatric Emergency Medicine, St. John’s Mercy Medical Center, 615 S. New Ballas Road, St. Louis, MO 63141. Fax: (314) 995-4450. E-mail: [email protected].
• Paul Sirbaugh, MD, Emergency Department, Childrens Hospital, 6621 Fannin, Suite A210, MC 1-1481, Houston, TX 77030. Telephone: (832) 824-5459. Fax: (832) 825-5424. E-mail: [email protected].
When dealing with conscious sedation, you need to know what medications youre giving, know what response to look for, and know what to do if there is an adverse event.
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