Quality Management UNIT

- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 1 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

1-Definitions:
1.1. Anesthesia procedures - consists of general anesthesia and spinal or
major regional anesthesia. It does not include local anesthesia. General
anesthesia is a drug-induced loss of consciousness during which patients
are not arousals, even by painful stimulation. The ability to independently
maintain ventilatory function is often impaired. Patients often require
assistance in maintaining a patent airway, and positive pressure
ventilation may be required because of depressed spontaneous ventilation
or drug-induced depression of neuromuscular function. Cardiovascular
function may be impaired.
1.2. Anesthesia and sedation is the administration to an individual, in any
setting, for any purpose, by any route, medication to induce a partial or
total loss of sensation for conducting an operative or other procedure.
Definitions of four levels of sedation and anesthesia include the
following:
1.2.1. minimal sedation (anxiolysis) A drug-induced state during
which patients respond normally to verbal commands. Although
cognitive function and coordination may be impaired, ventilatory
and cardiovascular functions are unaffected.
1.2.2. procedural (or moderate) sedation (formerly “conscious
sedation”) A drug-induced depression of consciousness during
which patients respond purposefully to verbal commands, either
alone or accompanied by light tactile stimulation. Reflex
withdrawal from a painful stimulus is unconsidered a purposeful
response. No interventions are required to maintain a patent airway,
and spontaneous ventilation is adequate. Cardiovascular function
usually maintained.
1.2.3. deep sedation/analgesia A drug-induced depression of
consciousness during which patients cannot be easily aroused, but
respond purposefully following repeated or painful stimulation.
The ability to maintain independently ventilatory function may be
impaired. Patients may require assistance in maintaining a patent
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 2 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

airway and spontaneous ventilation may be inadequate.

Cardiovascular function usually maintained.
1.2.4. Anesthesia consist of general anesthesia and spinal or major
regional anesthesia. It does not include local anesthesia. General
anesthesia is a drug-induced loss of consciousness during which
patients are not arousable, even by painful stimulation. The ability
to maintain independently ventilatory function is often impaired.
Patients often require assistance in maintaining a patent airway, and
positive pressure ventilation may be required because of depressed
spontaneous ventilation or drug-induced depression of
neuromuscular function. Cardio-vascular function maybe
impaired.
1.3. Types of Conscious Sedation:
1.3.1. Oral sedation as by chloral hydrate in case of children for CT or
MRI procedures.
1.3.2. Intravenous sedation - this is the usual case by intravenous
drugs.
Inhalational sedation – as in some cases of MRI using sevoflurane inhalation
.1.3.3Inhalational sedation – as in some cases of MRI using
sevoflurane inhalation

2- Purpose:
2.1To establish clear definitions, policies, and procedures
2.2To prevent risks to patient as it is high-risk procedure.
2.3It is used for a variety of diagnostic and surgical procedures especially
endoscopy, closed reduction of fractures, and many radiologic procedures.
2.0. SCOPE:
2.1. Moderate sedation shall be utilized in different areas of the hospital
for variety of short diagnostic and therapeutic procedures in Emergency
Room, Endoscopy Unit, Radiology Unit (CT Scan, MRI), Cath. Lab, and
other areas conducting minor procedures. Procedures may include:
cataract extraction, excision biopsy, incision and drainage, etc.
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 3 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

Deep sedation shall be utilized in Main Operating Theatre or Day Surgery

room for major surgeries and other high-risk invasive or diagnostic
procedures.

3. Policy:
Patient selection:
3.1.1 It is not for every patient.
3.1.2 It is used in ASA I&II and may be III.
3.1.3 ASA III done only by the Anesthesiologist
3.1.4 ASA IV or V by the use of deep sedation as Monitored Anesthesia
Care
3.2 Planning and assessment shall include:
3.2.1 Use of sedative premedication
3.2.2 Seniority of the anesthesiologist
3.2.3 Mode of induction
3.2.4 Method of maintenance of anesthesia
3.2.5 Use of neuromuscular blocker, as indicated
3.2.6 Length of anesthesia
3.2.7 Anticipation of occurrence of any critical incidents
3.3 This policy and procedure shall be reviewed, revised, and concurred by
the Chief Anesthetist who will also be responsible to obtain the
management’s approval.
3.4 A pre-sedation assessment shall be conducted by the Anesthesiologist
prior to sedation and to document it in the Anesthesia Pre-Medication
Sheet (Form M___). The following shall be assessed:
3.4.1 Vital signs;
3.4.2 Ability to maintain protective reflexes;
3.4.3 Independent continuous patent airway;
3.4.4 Response to physical stimulation or verbal commands;
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 4 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

3.4.5 Any sensitivity to medications;

3.4.6 Verification of operative site verbalized by the patient; and
3.4.7 Response to complications.

3.5 Performing and assisting conscious sedation requires:

3.5.1
Physicians to be certified in:
3.5.1.1 Basic Life Support (BLS), Advanced Life Support (ALS),
PALS, NALS (as appropriate to age of patient);
3.5.1.2 Privileged to perform conscious sedation; and
3.5.1.3 Competent in:
3.5.1.3.1 techniques of various modes of sedation;
3.5.1.3.2 use of monitoring equipment;
3.5.1.3.3 appropriate monitoring of patient;
3.5.1.3.4 managing patient’s response to
complications; and
3.5.1.3.5 use of reversal agents.
3.5.2 Assisting Nurse or technician shall be:
3.5.2.1 Certified in BLS, (ACLS, PALS, NALS preferably)
according the age of the patient.
3.5.2.2 Competent in:
3.5.2.2.1 Techniques of various modes of sedation;
3.5.2.2.2 Use of monitoring equipment;
3.5.2.2.3 Providing uninterrupted monitoring of
patient’s psychological parameters;
3.5.2.2.4 Assisting in supportive or resuscitative
measures; and
3.5.2.2.5 Managing response to complications
3.6 Areas conducting conscious sedation done should have the necessary
equipments to provide safe care and list of medications (as listed in the
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 5 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

equipments and drugs – 5.1-5.2) used during conscious sedation to be

readily available for use.
3.7 Anesthesia Informed consent should be taken after the physician has
explained to the patient regarding the risks and benefits and alternatives
of moderate sedation. Anesthesiologist should explain further to the
patient on the use of conscious sedation during the procedure. 2.8.
3.8 Before the procedure, the following should be checked:
3.8.1 Consent signed by the patient, guardian or next-of-kin, if unable to
sign.
3.8.2 All required laboratory investigations available on the day of the
procedure.
3.8.3 Infection control guidelines observed at all times by health care
providers in Anesthesia and Operation Room.
3.8.4 Intravenous insertion is done to maintain venous access in case of
emergency.
3.8.5 Physicians should obtain patient’s history and check on the
following:
3.8.5.1 The history of medication allergy.
3.8.5.2 Any history of systemic illness or major organ impairment
that might be risky for the patient.
3.8.5.3 Vital signs including age and weight and ECG findings.
3.8.5.4 Operative site verified and verbalized by the patient.
3.9 Pediatric Moderate sedation program:
3.9.1 Standards are the same for adults with the following considerations.
3.9.2 Components of a sedation program for children.
3.9.2.1 Safe administration;
3.9.2.2 Monitoring during the sedation period;
3.9.2.3 Recovery after procedure and sedation;
3.9.2.4 Safe discharge; and
4 Follow up revisit in the clinic.
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 6 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

5 INSTRUCTIONS TO PATIENTS: The following instructions are provided

for the patient’s general information and to assure safety before, during, and
after anesthetic and procedure. It shall be adhered to strictly.
5.1 Pre-Anesthesia Instructions:
5.1.1 Eating and Drinking:
5.1.1.1 ON THE DAY OF YOUR APPOINTMENT, PATIENT
CANNOT HAVE ANY FOOD TO EAT OR LIQUIDS
TO DRINK FOR AT LEAST 8 HOURS PRIOR TO
YOUR SCHEDULED PROCEDURE. For example, if
the procedure is scheduled for 8 a.m., the last food or drink
should be at 12:00 midnight. It is very important not to
chew gum or consume candy in any form during the same
time of period. Smokers should refrain from smoking for
at least 16 hours prior to the procedure. If it is absolutely
necessary, for a reason, that should be discussed with the
Anesthesiologist prior to sedation procedure. Drinking
water may be allowed no more than 8 oz. of water or a
clear liquid such as apple juice, Gatorade, or Jell-O
(without fruit) up to 4 hours before procedure. If these
guidelines are not followed procedure will most likely
be cancelled.
5.1.2 Transportation: One cannot operate a motor vehicle after
anesthesia. Arrangements should be made prior to arrival at the
hospital for a responsible adult to drive patient home upon
discharge.
5.1.3 Changes in Health Status: Any changes in health status prior to
scheduled procedure, for example, a cold, flu, sore throat, cough,
nausea, vomiting or fever should be notified to the treating
physician as soon as possible for immediate management.
5.1.4 Medications: If patient has prescription medication, it should not
be continued unless assessed by the anesthetist in collaboration
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 7 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

with treating physician that it can be continued for use on the day
of procedure. For oral medication, it must be taken with a small sip
of water. If it is an inhaler, continue it at the regular time. If patient
is diabetic or if have other medical conditions such as high blood
pressure or coronary artery disease, Anesthesiologist will discuss
the exact medications to take after pre-anesthetic interview and
speaking to the treating physician. Avoid aspirin in 2-3 days.
5.1.5 Clothing, Ornaments, and Toiletries: Patient is provided by the
hospital with comfortable, loose fitting surgical gown. Do not wear
lotions, jewelry, or cosmetic hair products. Patient should empty
bladder immediately before anesthetic. Anesthesia can sometimes
relax bladder function in patients with a pre-existing “weak
bladder”, so it is strongly recommend the use of “Depends”-like
urinary incontinence products for patients with “weak bladders” or
for procedures that are expected to last longer than 4 hours.
5.2 Post-Anesthesia Instructions
5.2.1 Transportation after the Procedure: Patient shall arrange prior
to arrival at the hospital for a responsible adult to accompany home
upon discharge as it is not allowed to leave hospital by public
conveyance or taxi after an anesthetic.
5.2.2 At Home: Plan on having a responsible adult stay with patient
during recovery period at home. Patient cannot drive or operate
potentially dangerous equipment for twenty-four (24) hours after
anesthetic procedure.
5.2.3 What to Expect:
5.2.3.1 In general,
5.2.3.2 after Dental Procedure:
5.2.3.2.1 Muscle aches, and a sore throat may occur.
5.2.3.2.2 It is also common to have mild dark
bleeding or clots from one or both nostrils
following dental procedures. This is nothing to be
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 8 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

alarmed about, and will normally stop after 24 to

36 hours.
5.2.3.2.3 Mouth and tongue may be numb following
dental procedures and may have the sensation of
having a lump in the throat. This is perfectly
normal, and will disappear in few hours.
5.2.3.2.4 When and What to Eat: Drink first plain
water, then fruit juice or Gatorade. Avoid
carbonated soft drinks at first. Drink only small
quantities of beverages during the first hour. After
the first hour, eat small portions of food as
tolerated (preferably soft, bland and not hot or
spicy). No smoking for 24 hours.
Pain Medications and Nausea: Dispensing of post-operative pain
medication is the responsibility of the Surgeon. Pain medications, especially
taken on an empty stomach, can often cause nausea. For persistent nausea
and vomiting, difficulty breathing, a fever greater than 37.5 c degrees
within 4 hours of procedure, tenderness and/or redness around the IV site, or
any other anesthesia related concerns within the first 24 hours, or other post-
operative concerns, such as pain, wound swelling or bleeding shall be
reported to the treating physician.

5.3 Responsibility
5.4 Responsible persons
5.4.1 The pediatric patient shall be accompanied to and from the hospital
by a parent, legal guardian or other responsible person.
5.5 NPO Guidelines
5.5.1 No solid food after midnight or at least 8 hours prior to procedure
5.5.2 Milk or formula up to 6 hours
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 9 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

5.5.3 Breast milk up to 4 hours

5.5.4 Clear fluids (water, apple juice, ginger juice) up to 2 hours prior to
the procedure
6 An exception, may be those patients with an NG tube who required long term
nutritional support (e.g. burn patients) SPECIAL CONSIDERATION:
6.1 Any patient still having severe pain, bleeding, or nausea and/or vomiting,
hospitalization for one (1) day is mandatory until it is sure that everything
is under control.
6.2 Patient when discharged should be provided with follow-up instructions
and hospital information to cater for any inquiries he/she may wish to ask
concerning his/her surgery.
Pre-verbal and developmentally and hearing impaired children may not
comprehend, verbal commands thus need to rely physical stimulation.

7 GENARAL RECOMMENDATIONS:
7.1 Consent for the sedation procedure can be obtained verbally from the
parents or guardian and should be carefully documented in the chart.
During such “Ketamine” and “Peroprofol” should be administered in the presence
of an anesthesiologist with accesses to the full range of resuscitative in ventilatory
function may be impaired. Patients required assistance in monitoring a patient cure
way and spontaneous ventilation may be inadequate. Cardiovascular function is
usually maintained

1.1. .5Procedure
1.2. Before the procedure:
1.2.1. Physician performs physical examination and checks for the
following:
1.2.1.1. Age and weight
1.2.1.2. Vital signs
1.2.1.3. ECG findings
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 10 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

1.2.2. An IV access is obtained and secured in place for administration

of medicine and during emergency cases.
1.3. During the procedure:
1.3.1. Anesthesiologist frequently examines the patient and check
intermittently for vital signs.
1.3.2. Anesthesia nurse is at the patient’s bedside at all times;
constantly and continuously monitors the patient.
1.3.3. Physician should be physically present and close by the patient.
1.3.4. Patient is continuously monitored for level of consciousness,
vital signs, oxygen saturation, and skin color
1.3.5. IV line is maintained and kept patent at all times
1.3.6. All observations are properly documented
1.3.6.1. oxygen saturation
1.3.6.2. vital signs (BP, PR, RR)
1.3.6.3. level of consciousness
1.3.6.4. skin color
1.4. After the procedure:
1.4.1. The physician documents the status of the patient post procedure
that includes:
1.4.1.1. vital signs
1.4.1.2. level of consciousness
1.4.1.3. ECG findings
1.4.1.4. Skin color
1.4.1.5. Oxygen saturation
1.4.2. The physician writes a discharge order or transfers the patient
back to the ward with any follow up instructions for the nurses
including vital signs or oxygen saturation
1.4.3. In the Recovery Area, nurse stays beside the patient until patient
is fully recovered
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 Quality Management UNIT
- -2010
Policies & Procedures Manual Document Title: Guidelines for
Originating Entity :ASC Sedation and Analgesia for Diagnostic, Therapeutic
and Invasive Procedures
Page 11 of 11 Document No.: POL – ASC- 06
Date Originated: 4-11-2009 Date Revised: Rev. No.:
Approved By: Next Revision Date :

1.4.4. Equipment such as suction machine and O2 at the bedside

1.4.5. Patient is observed for any bleeding or post anesthesia
manifestations such as nausea or vomiting.
1.5. Discharge:
1.5.1. Patient is discharged according to the following parameters:
1.5.1.1. Appropriate alertness
1.5.1.2. Ambulation (if he/she ambulated before)
1.5.1.3. No nausea or vomiting
1.5.1.4. Able to tolerate oral fluids
1.5.1.5. No respiratory distress
1.5.1.6. No or very minimal bleeding in surgical procedures
1.5.1.7. Pain relief
1.5.1.8. No pain or tolerance to pain
1.5.2. The physician writes a discharge order or transfers the patient
back to the ward that includes:
1.5.2.1. any follow-up instructions for the nurses
observations regarding vital signs and oxygen saturation

. References:

8.1.JCI A 2008 3rd Edition .

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