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Intraoperative Management/How should patients undergoing moderate sedation for GI endoscopy be monitored?

QUESTION:

I am a nurse working in GI Endoscopy. We are updating our protocols and procedures. I would like information regarding cardiac monitoring during GI Endoscopy in a patient receiving moderate sedation. What does the ASA recommend?

-- From Grace Smith, R.N. B.S.N., C.G.R.N., Rochester, NY

REPLY:

This is an excellent question, and an important practical issue. The ASA has developed a set of " Practice Guidelines For Sedation And Analgesia By Non-Anesthesiologists", which can be viewed at http://www.asahq.org/publicationsAndServices/sedation1017.pdf. It was most recently amended in October 2001.

These guidelines were specifically designed to be used for moderate and deep sedation, which were defined as:

Moderate Sedation/Analgesia ("Conscious Sedation") is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

The guidelines state that electrocardiographic monitoring should be used during moderate sedation in patients with significant cardiovascular disease or those undergoing procedures where dysrhythmias are anticipated. It is recommended for all patients undergoing deep sedation.

Other monitors recommended in the guidelines for both moderate and deep sedation are: continuous pulse oximetry, observation and/or auscultation of ventilation "at regular intervals", and blood pressure measurements every 5 minutes. The level of consciousness should also be assessed "at regular intervals" throughout the sedation process. Verbal stimuli should be used for moderate sedation, and more profound stimuli can be used for deep sedation.  

-- From D. Daley, M.D., Houston, TX

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