Guideline Update: Are You Anxious About Administering Moderate Sedation?

A review of AORN’s Guideline for Moderate Sedation/Analgesia can help.

Early in my career, I was assigned to a patient scheduled for surgery who was supposed to be under the care of an anesthesiologist, only to be later informed that the patient’s acuity and comorbidities made general anesthesia too risky.

A new role

That part I understood — it was the subsequent plan that always stumped me. Let me get this straight, this patient was too sick for general anesthesia, and now you’re removing the anesthesia provider and placing a nurse (me!) in charge of managing the moderate sedation you’ve prescribed as the alternative? Despite my reservations, I armed myself with information, made friends with a few anesthesia providers for consultation and reviewed my ACLS algorithms to prepare for the challenging case.

Throughout my career I have experienced many shifts in the delivery of moderate sedation/analgesia, from nurses pushing propofol during pain clinic procedures to the introduction of Monitored Anesthesia Care administered by anesthesia providers — and lots of practices in between. The recent shortage of anesthesia providers, combined with the increase in surgical procedures moving to ASCs and HOPDs, makes nurse-administered moderate sedation/analgesia a must for many facilities.

Although it has been years since I’ve administered moderate sedation, I still remember the anxiety associated with balancing adequate comfort while avoiding oversedation. Although you won’t likely be faced with high-acuity patients in the outpatient environment, you still may not be as comfortable with the practice as you would like. The Association of periOperative Registered Nurses (AORN) provides a comprehensive guideline for moderate sedation, offering invaluable insights into protocols, patient assessment, monitoring and intervention strategies. Here are the key points of the AORN Guideline for Moderate Sedation that empower ASC leaders with the knowledge needed to navigate this essential aspect of ambulatory care.

What it is

The objective of moderate sedation/analgesia (MSA) is to induce a mild depression of consciousness using sedatives or a combination of sedatives and analgesics, typically administered intravenously and adjusted to achieve the desired effect. Its primary aim is to alleviate patient anxiety and discomfort, facilitating their tolerance of diagnostic, therapeutic and invasive procedures. MSA may result in partial amnesia for the patient. This state entails a mildly depressed level of consciousness and altered pain perception, characterized by a few key features, which include the patient being able to verbally respond to verbal commands or light tactile stimulation and their vital signs exhibiting only minimal fluctuations.

The scope of nursing practice for administering MSA is defined by your state nursing boards and other regulations that direct the practices of registered nurses. Most states require an anesthesia professional, surgeon, endoscopist or other qualified licensed independent practitioner to supervise the RN who is administering MSA.

Patient selection and assessment

Candidates for outpatient surgery are generally in good health, without significant comorbidities or disease processes and have an ASA score of 1, 2 or stable 3. Your facility’s selection policy should include an assessment for who is appropriate for MSA. A comprehensive pre-sedation assessment should be conducted on patients to evaluate whether MSA is appropriate for them.

Special considerations for eligibility include cannabis use and chronic use of opioids that may affect the metabolism of MSA medications. Nurses should assess the patient’s use of these substances before administering MSA. Patients who use cannabis or opioids can be at risk for development of dysrhythmias, myocardial infarction, stroke, airway obstruction, venous thromboembolism or bleeding and may require increased doses of medication during MSA procedures.

The plan of care for the patient undergoing MSA should be created in collaboration with the patient and the licensed independent practitioner after consultation with an anesthesia provider for any patients who present with a history of airway difficulties, ASA III and above, those with active disease processes, or comorbidities. Cases should be staffed according to AORN recommendations, which including assigning two perioperative RNs to the procedure to ensure the nurse who administers MSA may fully attend to the patient.

The nurse who administers MSA should remain with the patient to provide continual monitoring. This nurse should have unrestricted immediate access to the patient and no competing responsibilities that could distract from monitoring and assessing the patient. Nurses should have access to and knowledge of the proper equipment required to care for and monitor the patient receiving MSA, which includes a pulse oximeter, cardiac monitor, capnography device and a blood pressure measurement device. Nurses should assess and monitor the patient’s level of consciousness when administering MSA and the assessment should include the patient’s ability to respond to verbal commands.

When administering the medication, nurses should be knowledgeable of the medicine’s purpose, the dosage that’s being given, potential adverse reactions and contraindications with other medications being used during the procedure. Dosages should be adjusted appropriately based on the age of the patient, and IV medications must be administered one at a time, in incremental doses, titrated to the desired effect. Non-IV medications should be administered to allow sufficient time for absorption before giving additional medicines. Follow your facility’s discharge policies before allowing MSA patients to go home.

Your facility’s MSA criteria, discharge policies and implementation of AORN Guidelines can help you and your team effectively navigate the challenges associated with moderate sedation while upholding the highest standards of safety, quality and patient-centered care. For training on the safe administration of moderate sedation, visit aorn.us/moderatesedation. OSM