What is conscious sedation? Conscious sedation, also known as procedural sedation, is a common practice in emergency departments for patients undergoing painful or anxiety-provoking procedures.
It is intended as a less invasive method. Generally, those who undergo this type of sedation can recover more quickly and return to their usual activity. It combines a sedative that helps you relax and another that blocks pain; anesthesia.
The rise of this type of sedation has allowed procedures that would otherwise require more time and money to be performed more effectively and safely.
Types of Conscious Sedation and Uses
Procedural sedation is used in many areas of the medical and dental industry and varies in the intensity of the relaxation induced in the patient. When discussing conscious sedation, two common types can be distinguished:
Mild or Anxiolytic Sedation
This is the minimum level of sedation. Responsiveness to verbal stimulation is high. Airway, spontaneous ventilation and cardiovascular function are not affected.
Conscious Sedation or Moderate Sedation and Analgesia
An intermediate state is provoked in the patient in which they usually fall asleep and do not respond to verbal signals but do respond to tactile stimulation. It does not require airway intervention. Patients often present with eyelid ptosis, bradylalia and dysarthric speech in this state. Amnesia often occurs in this state.
Those who take Hospital Procedures’ ACCME accredited courses will receive a variety of training to accomplish any of these interventions.
Skills Required to Perform Procedural Sedation
Who can administer conscious sedation? A licensed and certified healthcare professional can only administer this type of sedation. Therefore, the American College of Emergency Physicians recommends that personnel administering conscious sedation have specific training and demonstrated competence in patient monitoring and using sedative medications to be part of such procedures.
Conscious Sedation for Surgical Procedures
Conscious sedation is safe and effective for people who need minor surgery or a procedure to diagnose a condition.
Some of the tests and procedures for which conscious sedation may be used are:
- Joint dislocation reduction
- A dental prosthesis or reconstructive surgery
- Bone fracture reductions
- Bone marrow biopsy
- Synchronized cardioversion
- Chest tube placement (tube thoracostomy)
- Procedures to diagnose and treat certain conditions of the stomach (upper endoscopy), colon (colonoscopy), lung (bronchoscopy), and bladder (cystoscopy).
In the case of patients hospitalized in the intensive care area, its application is recommended when a periodic assessment of their state of consciousness is needed due to a critical illness or a complex procedure.
Updates for 2023 Regarding Conscious Sedation
While no major changes in conscious sedation procedures are expected, the rate of physicians and nurses trained to do so is expected to increase. Here are some of the techniques recently explored
Combining Pharmacology and Sensory Stimulation
More and more health professionals are using this technique. Especially those working in pediatric areas. The combination of nitrous oxide sedation and distraction techniques, such as games, helps manage anxiety.
This action generates adequate sedation, increasing tolerance to treatments that are used to cause traumatic situations. In addition, it involves a faster recovery due to the low use of sedatives.
In a study carried out in the United States, 75% of adults stated that they feel some degree of fear of anesthesia. This increases the need for further studies on interventions that can alleviate anxiety. However, its use in adults is still in the research phase since, for the moment, the studies show that age is an important determinant in redirecting the patient’s behavior. It is easier to control the patient’s behavior at a younger age.
Use of Short-Acting Sedatives or Dissociative Agents
There has also been a shift toward reversible, shorter-acting sedatives, such as midazolam and lorazepam. These drugs have a rapid onset. If adverse reactions or complications occur, they can be easily reversed with drugs such as flumazenil. In addition, ketamine is the only drug that produces the four effects necessary for the performance of a painful procedure of short duration: sedation, analgesia, amnesia and immobilization.
Etomidate can be used at sub-intubating doses (0.1 mg/kg IV) for short-term sedation to allow quick procedures such as synchronized cardioversion. If deeper sedation is necessary propofol or the combination of ketamine and propofol (ketofol) can be used for very painful procedures such as tube thoracostomy or fracture/dislocation reductions.
Use of Opioids
Opioids such as morphine or fentanyl given as intermittent boluses can be used for both analgesia and sedation for moderate procedural sedation. Opioids can be easily reversed with naloxone if respiratory depression occurs. Opioids can be used in combination with benzodiazepines but the combination increases the risk of respiratory depression.
Reducing the Risks of Sedation
Although the conscious sedation procedure carries fewer risks than general anesthesia, physicians are still working to reduce them. Some of the most recurrent are:
Respiratory Depression
The drugs used for conscious sedation can depress breathing, so monitoring the patient’s breathing is important. For moderate to deep sedation, patients should be monitored with both continuous oximetry but also with capnometry. Capnometry can detect hypoventilation prior to the development of hypoxia. A possible advance in this field will be to improve patients’ responses to them. Either by administering new sedatives or by the post-sedation practice applied by healthcare professionals.
Allergic Reactions
There is a small risk of allergic reaction to drugs used for conscious sedation. Symptoms of an allergic reaction include hives, rash, itching, difficulty breathing and anaphylaxis can present with hypotension. Increased awareness on the part of physicians regarding pre-sedation testing in conjunction with allergists may reduce allergic reactions.
Cardiovascular Effects
Some drugs used for conscious sedation can affect the heart and blood pressure, so monitoring the patient’s vital signs is important. The clinician should always assure that you have very good vascular access and even consider a bolus of crystalloid solution to minimize the risk of medication-induced hypotension. Moderate to deep procedural sedation should include continuous cardiac rhythm monitoring and frequent blood pressure checks. In addition, behavioral studies and sensory stimulation are currently being worked on to improve the patient’s recovery.
Conclusion
Conscious sedation is perhaps one of the most commonly used procedures in the emergency department of a hospital. It is, therefore, of utmost necessity for all healthcare professionals to receive continuing education and be aware of the latest updates in the area.
Hospital Procedures Consultants and the Postgraduate Institute for Medicine have designed the HPC Hospital and Emergency Procedures course to train and update healthcare professionals on some of the most crucial emergency procedures. The Hospital Procedures Hospital and Emergency Procedures course will teach you how to perform any sedation process and practices, such as endotracheal intubation, stylet-guided intubations, and laryngeal mask airway (LMA) placement, among others.
Contact us today and update your curriculum with the latest medical updates!
References:
Shaw, C. Weaver, C. Shcneider,L. Conscious sedation: a multidisciplinary team approach. Post Anesth Nurs. 1996 (11)1. 13-9
Chawla, N. Boaetng, A. Deshpande, R. Procedural sedation in the ICU and emergency department. Curr Opin Anaesthesiol. 2017. 30(4) 507-512
Pollock, H. Forman, S. Pollock, T. Raccasi, M. Conscious sedation/local anesthesia in the office-based surgical and procedural facility . Clin Plast Surg 2013. 40 (3). 383-8