How to Improve Sedation Outside the OR

Procedural Sedation Outside the OR with Microstream Capnography

More and more, procedures requiring sedation are taking place outside of the operating room.2 Minimally invasive techniques make it possible for patients to receive complex procedures without going to the OR. As procedural sedation increases — alongside a growing and aging patient population — so do new challenges.

Getting sedation right can be complicated. Choosing the appropriate sedation depends on a variety of factors, including procedure type and patient history. And each patient typically has a different response.3 Also, chronic conditions can raise the risk of complications.

Clinicians strive to balance patient safety with comfort during procedural sedation. They tailor sedation to each patient’s needs, and proactively monitor how those needs change over time. They treat sedation as both a science and an art. 

Learn more about how patients are sedated in different care settings — like in interventional radiology and the emergency room. See what clinicians are doing to manage pain, reduce risks, and improve outcomes. And discover how you can help keep sedated patients safe

Issue #1: Balancing Sedation Can Be A Moving Target

Clinicians must consider a number of factors when deciding the appropriate level of sedation for their patient including:

  • Procedure type
  • Medical conditions
  • Specific patient backgrounds — age, metabolism, medical history
  • Comfort level and tolerance for sedation
  • Time between sedation, response, and recovery
  • Level of consciousness throughout the procedure

Sedation is dynamic. A patient’s sedation level can deepen. In one type of procedure, 26 percent of patients became deeply sedated when only moderate sedation was intended. 4

Related: Capnography can alert you to respiratory changes during procedural sedation. See how.

Issue #2: Imbalanced Sedation Can Lead to Adverse Outcomes

Respiratory compromise and inadequate oxygenation pose some of the most common challenges for sedation outside of the OR. One analysis of injury and liability claims linked to oversedation showed that 62 percent could have been prevented with better monitoring.5 Learn more about respiratory compromise. 

Related: Learn more about sedation challenges in different care settings, and how you can help manage them. Visit the resource site. 

Issue #3: Patient Responses and Risk Factors Can Vary Widely

Patients who receive procedural sedation outside of the OR tend to be older — by more than three years — compared to those sedated in the OR.7 Age, metabolism, personal history, and even genetics may all play a role in a patient’s response to sedation. 8

Combining minimally invasive procedures with procedural sedation can improve outcomes for some high-risk patients. For example, patients undergoing transcatheter aortic valve replacement (T-AVR) experienced shorter procedure times and hospital stays with monitored anesthesia.9,10 

For some patients, nondrug options — such as music and aromatherapy — may help reduce or replace the need for analgesics. 11,12 

Related: Discover how you can tailor sedation to meet each patient’s needs. View the infographic.

Three Ways To Help Improve Patient Outcomes During Sedation

  1. Continuous patient monitoring — like capnography — can help reduce the risk of respiratory depression, hypoxemia, and hypoventilation.13 Discover how you can detect complications early. View the reference guide.
  2. At each level of sedation, patients may respond with a variety of behavioral and physiological signs.14 Learn how to evaluate patient responses to sedation and avoid complications. View the infographic.
  3. Incorporating routine capnography monitoring into procedural sedation can help reduce costs. One facility added capnography to GI endoscopy procedures and avoided $304,234 in costs associated with adverse events.15 Learn more about the economic value of capnography. Read the white paper.

Related: Learn more about getting procedural sedation right in your area of care. Visit the resource site.

References:
1. Pino RM. The nature of anesthesia and procedural sedation outside of the operating room. Curr Opin Anaesthesiol. 2007;(4):347-51.
2. Nagrebetsky A, Gabriel RA, Dutton RP, Urman RD. Growth of Nonoperating Room Anesthesia Care in the United States: A Contemporary Trends Analysis. Anesthesia & Analgesia. 2017;124(4):1261–1267.
3. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. http://www.asahq.org/-/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/continuum- ofdepth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia.pdf. Amended Oct. 15, 2014. Accessed March 19, 2019.
4. Patel S, Vargo J, Khandwala F, et al. Deep sedation occurs frequently during elective endoscopy with meperidine and midazolam. Am J Gastroenterol. 2005;100(12):2689–2695.
5. Metzner J, Domino KB. The risk and safety of anesthesia at remote locations: the US closed claims analysis. Current Opinion in Anesthesiology. 2009, 22(4):502–508.
6. Gallagher R, Trotter R, Donoghue J. Preprocedural Concerns and Anxiety Assessment in Patients Undergoing Coronary Angiography and Percutaneous Coronary Interventions. Eur J Cardiovasc Nurs. 2010;9(1):38–44.
7. Nagrebetsky A, Gabriel RA, Dutton RP, Urman RD. Growth of Nonoperating Room Anesthesia Care in the United States: A Contemporary Trends Analysis. Anesthesia & Analgesia. 2017;124(4):1261–1267.
8. Borrat X, Trocóniz IF, Valencia JF, et al. Modeling the influence of the A118G polymorphism in the OPRM1 gene and of noxious stimulation on the synergistic relation between propofol and remifentanil: sedation and analgesia in endoscopic procedures. Anesthesiology. 2013 Jun;118(6):1395-407.
9. Bergmann L, Kahlert P, Eggebrecht H, Frey U, Peters J, Kottenberg E. Transfemoral aortic valve implantation under sedation and monitored anaesthetic care — a feasibility study. Anesthesia. 2011;66(11):977–982.
10. Ben-Dor I, Looser PM, Maluenda G, et al. Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation. Cardiovasc Revasc Med. 2012;13(4):207–210. 
11. Hu PH, Peng YC, Lin YT, Chang CS, Ou MC. Aromatherapy for reducing colonoscopy related procedural anxiety and physiological parameters: a randomized controlled study. Hepatogastroenterology. 2010;57(102–103):1082–1086.
12. Rudin D, Kiss A, Wetz RV, Sottile VM. Music in the endoscopy suite: a meta-analysis of randomized controlled studies. Endoscopy. 2007;39(6):507–510.
13. Long M, Green K, Bland E, et al. Capnography monitoring during procedural sedation in radiology and imaging settings: an integrative review. J Radiol Nurs. 2016;35(3):191–197.
14. American Society of Anesthesiologists. Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of Sedation/Analgesia. http://www.asahq.org/-/media/Sites/ASAHQ/Files/Public/Resources/standards-guidelines/continuum- ofdepth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia.pdf. Amended Oct. 15, 2014. Accessed March 19, 2019.
15. Jopling MW, Kofol T, Heard L. Evaluating the cost-effectiveness of capnography monitoring in procedural sedation: a gastroenterology (GI) suite cost-avoidance model. Gastrointest Endosc. 2015;81(5;suppl 1):AB193. Abstract.

©2019 Medtronic. All rights reserved. Medtronic, Medtronic logo and Further, Together are trademarks of Medtronic. All other brands are trademarks of a Medtronic company. 04/2019-19-PM-0084

Topic: Microstream™ Capnography, Procedural Sedation

About the Author

Ray Mundy

Ray Mundy is a Product Specialist for Microstream™ Capnography and Nellcor™ pulse oximetry at Medtronic. With a background in critical care nursing and more than 15 years’ experience working with Mircostream™ Capnography, he provides technical solution support across the care continuum.

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