Joint Commission Standards January, 2006
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Provision of Care, Treatment, and Services
The Administration of Moderate or Deep Sedation or Anesthesia
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The standards for sedation and anesthesia care apply when patients in any setting receive, for any purpose, by any route, the following:
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Because sedation is a continuum, it is not always possible to predict how an individual patient receiving sedation will respond. Therefore, each hospital develops specific, appropriate protocols for the care of the patients receiving sedation. These protocols are consistent with professional standards and address at least the following:
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Appropriate monitoring of vital signs, including, but not limited to, heart rates and oxygenation, using pulse oximetry equipment, respiratory frequency and adequacy of pulmonary ventilation . . .
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Standard PC.13.30-.40
Patients are monitored during and immediately after the procedure and/or administration of moderate or deep sedation or anesthesia
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Elements of Performance
Appropriate methods are used to continuously monitor oxygenation, ventilation, and circulation during procedures that may affect the patient?s physciological status.
Each patient?s physiological status, mental status, and pain level are monitored
Monitoring is at a level consistent with the potential effect of the procedure and/or sedation or anesthesia.
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The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy
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Capnography more readily identifies patients with apneic episodes and when used to guide sedation results in less CO2 retention. Capnography is a superior way to evaluate ventilation, compared with pulse oximetry measurement, which assesses oxygenation.
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Waring JP, Baron TH, Hirota WK, Goldstein JL, Jacobson BC, Leighton JA, Mallery JS, Faigel DO. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc?2003 Sep;58(3):317-22. ?
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American College of Emergency Physicians
Consider capnometry to provide additional information regarding early identification of hypoventilation.
Godwin SA, Caro DA, Wolf SJ, Jagoda AS, Charles R, Marett BE, Moore J, Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med?2005 Feb;45(2):177-96.
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ASA Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists
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In circumstances in which patients are physically separated from the caregiver, the Task Force believes that automated apnea monitoring (by detection of exhaled carbon dioxide or other means) may decrease risks during both moderate and deep sedation
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Monitoring oxygenation by pulse oximetry is not a substitute for monitoring ventilatory function.
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Monitoring of exhaled carbon dioxide should be considered for all patients receiving deep sedation and for patients whose ventilation cannot be directly observed during moderate sedation.
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Appendix II: Summary of Guidelines
Except as noted, recommendations apply to both moderate and deep sedation.
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Monitoring
(Data to be recorded at appropriate intervals before, during, and after procedure)
Exhaled carbon dioxide monitoring considered when patients separated from caregiver
For deep sedation:
Exhaled CO2 monitoring considered for all patients
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American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology?2002 Apr;96(4):1004-17.
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Summary of ASA Practice Guidelines for the Perioperative management of patients with Obstructive Sleep Apnea ? October 25, 2005
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Intraoperative Management:
CO2 monitoring should be used during moderate or deep sedation for patients with OSA.
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If moderate sedation is used, ventilation should be continuously?monitored by capnography or another automated method if feasible because of the increased risk of undetected airway obstruction in these patients.
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Postoperative Management:
OSA patients should be monitored for a median of 3 hours longer than the non-OSA counterparts before discharge.? Monitoring of OSA patients should continue for a median of? 7 hours after the last episode of airway obstruction of hypoxemia.
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Post-operative concerns include the exacerbation of respiratory depression on the third or fourth postoperative day as sleep patterns are reestablished and "REM rebound" occurs.?
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OSA patients should not be discharged from the recovery room to an unmonitored setting until they are no longer at risk for postoperative respiratory depression
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STATEMENT ON SAFE USE OF PROPOFOL
(Approved by ASA House of Delegates on October 27, 2004)
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During the administration of propofol, patients should be monitored without interruption to assess level of consciousness, and to identify early signs of hypotension, bradycardia, apnea, airway obstruction and/or oxygen desaturation. Ventilation, oxygen saturation, heart rate and blood pressure should be monitored at regular and frequent intervals. Monitoring for the presence of exhaled carbon dioxide should be utilized when possible, since movement of the chest will not dependably identify airway obstruction or apnea.
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American Academy of Pediatrics, American Academy of Pediatric Dentistry
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Expired carbon dioxide monitoring is valuable to diagnose the simple presence or absence of respirations, airway obstruction, or respiratory depression, particularly in patients sedated in less-accessible locations, such as MRI or computerized axial tomography devices or darkened rooms. The use of expired carbon dioxide monitoring devices is encouraged for sedated children particularly in situations where other means of assessing the adequacy of ventilation are limited.
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Cote CJ, Wilson S, Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics?2006 Dec;118(6):2587-602.
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