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Administration/What emergency meds should be kept in stock?

QUESTION:

I am a nurse working in an Infertility office. I'd appreciate very much if you could give me feedback on which medicines should be keptin stock for emergency.  Our Anesthesia staff is currently using Versed, Fentanyl and Diprivan for IV sedation during egg retrievals.

-- From Karen R. Rich, Thousand Oaks, CA

REPLY:

The number of procedures undertaken outside the OR suite requiring IV sedation has increased exponentially. In many instances non-anesthesiology staff are involved in rendering sedation. Needless to say, irrespective who the provider is, it is imperative that patients be adequately monitored and cared for in these situations.

The Definition of General Anesthesia and Levels of Sedation/Analgesia, as approved by the ASA House of Delegates on October 13, 1999, is shown in the following table.

Definition of General Anesthesia and Levels of Sedation/Analgesia

	Minimal Sedation (Anxiolysis)	Moderate Sedation/ Analgesia ("Conscious Sedation")	Deep Sedation/ Analgesia	General Anesthesia
Responsiveness	Normal response to verbal stimulation	Purposeful response to verbal or tactile stimulation	Purposeful response following repeated or painful stimulation	Unarousable even with painful stimulus
Airway	Unaffected	no intervention required	Intervention may be required	Intervention often required
Spontaneous Ventilation	Unaffected	Adequate	May be inadequate	Frequently inadequate
Cardiovascular Function	Unaffected	Usually maintained	Usually maintained	May be impaired

Individual patients differ in their response to medications and so do surgeons in their requests to keep patients sedated . Given this scenario it is not surprising that patients may pass from one level of sedation to the other all too quickly and only vigilant adequate monitoring and timely intervention will provide a safe environment for our patients.

In achieving this goal we need to choose appropriate patient populations who are to undergo IV sedation. We also need to ensure that the following are present:

1. Adequate IV access and monitoring, including but not limited to: NIBP, HR, SpO₂, RR and possibly end-tidal CO₂
2. Various means of delivering oxygen
3. Functioning suction
4. Equipment to deal with emergency airway management and medical personnel adept at establishing an airway
5. IV medications as required by ACLS protocols immediately available
6. Antidotes to medications used in IV sedation, including Narcan for Fentanyl, Flumazenil for Midazolam

It is today a JCAHO requirement that all staff involved in administering Deep Sedation, be certified. Many hospitals have and are implementing this requirement, some more expeditiously than others.

I do think that human patient simulators have a role to play in training medical personnel for deep sedation. We use them in our institution for that purpose.

It would also be interesting to see what role monitors of ‘levels of consciousness' like BIS, Entropy, etc., may play in safely sedating patients.

-- From Suhas Kalghatgi, MBBS, MD (Anes.), Iowa City, IA

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