Conscious and Deep Sedation in the ICU

First Things First (assess & treat for the following)

• Determine depth of sedation/analgesia required for procedure/intervention:
  • Minimal sedation (anxiolysis)
    • Responsiveness: normal response to verbal stimuli
    • Airway: unaffected
    • Spontaneous ventilation: unaffected
    • Cardiovascular function: unaffected
  • Moderate sedation (conscious sedation)
    • Responsiveness: purposeful response (not withdrawal) to verbal or tactile stimulation
    • Airway: no intervention required
    • Spontaneous ventilation: adequate
    • Cardiovascular function: usually maintained
  • Deep sedation/analgesia
    • Responsiveness: purposeful response (not withdrawal) to repeated or painful stimuli
    • Airway: intervention may be required
    • Spontaneous ventilation: may be inadequate
    • Cardiovascular function: usually maintained
  • General anesthesia
    • Responsiveness: unarousable even w/ painful stimuli
    • Airway: intervention often required
    • Spontaneous ventilation: frequently inadequate
    • Cardiovascular function: may be impaired
• Who will monitor pt during conscious sedation?
  • A designated individual, other than the practitioner performing the procedure, should monitor the pt throughout the procedure for moderate to deep sedation.
  • During moderate sedation, may assist w/ minor interruptible tasks once level of sedation is stable
  • During deep sedation, should be responsible only for monitoring pt
• Who should provide sedation/analgesia for conscious sedation?
  • Individual must:
    • Understand pharmacology of agents to be used
    • Understand role of pharmacologic antagonists
    • Recognize associated complications, to include ventilatory insufficiency, airway obstruction, excessive level of sedation
  • Individual present capable of establishing airway & positive-pressure ventilation
  • Individual w/ advanced life support skills must be immediately available (< 5 min) for moderate sedation & in room for deep sedation
• What equipment should be available during conscious sedation?
  • Appropriate sizes of following items for infants, pediatrics, adults:
  • IV equipment
    • IV fluids
    • Catheters, tourniquets, gloves, etc.
  • Basic airway mgt equipment
    • Source of compressed oxygen
    • Suction, suction catheters
    • Face masks
    • Self-inflating breathing bag-valve set
    • Oral/nasal airways
    • Lubricant
  • Advanced airway mgt equipment
    • Laryngeal mask airway
    • Laryngoscope handles/blades
    • ETTs
    • Stylet
  • Pharmacologic antagonists
    • Naloxone
    • Flumazenil
  • Emergency meds
    • Epinephrine, ephedrine, vasopressin, atropine
    • Nitroglycerin, amiodarone, lidocaine
    • Glucose 50%
    • Diphenhydramine
    • Hydrocortisone or dexamethasone
    • Diazepam or midazolam