Dr. Cuadros – Intravenous Moderate Sedation Protocol

updated May 13, 2015



Phone numbers:

           AIC                 x7163

Pharmacyx 2491

Charge nursex 7069

Anesth techx 7160


Medications:


           From Anesthesia Cart in OR:

                    Atropine

                    Labetalol

                    Narcan (Naloxone)

                    Hydralazine (Appresoline)


          From Pharmacy:

                    Phenylepherine (Neo-synephrine) in pre-filled syringe


          From Pyxis Medstation:

                    x 1 Ondansetron (Zofran) (4mg/2 ml)

                    x 1 Glycophrralote (Robinul)

                    x 1 Romazicon (Flumazenil) (5ml vial)

                    x 2 Fentanyl 2ml vial (50mcg/ml)

                    x 10 Midazolam (Versed) (2mg/2ml)


Arrange all laminated drug cards, emergency drugs, syringes on top of anesthesia cart:

           Labetalol, Narcan, Appresoline, Phenylepherine, Atropine, Robinul, Romazicon


Pre-op medications and holding area process:


Make sure patient is on Dr. Cuadros Stryker eye bed with Baer hugger turned on.


Make sure IV is on RIGHT side and is set to TKO to avoid giving too much fluids.


Ask if patient needs to go to bathroom. Obtain sign out from preop nurse.


Confirm pre-op drugs given by Pre-Op nurse. i.e.

           Decadron (if bleph, brow or temporal lift), Ancef, Valium, Demerol, Clonidine if BP high.


Take a Salter nasal cannula to pre-op (in case the pre-op nurse did not put one on).


Take warm EKG pads, Bovie pad, Temp probe, O2 sat probe, wrist straps to pre-op and place on

patient while in pre-op holding.


Take syringe of Versed to pre-op area to begin dosing at Doctor's orders, Versed (0.5 to 1mg)


Cover patient with 2 warm blankets for transport to OR.


Process and charting notes:

Draw up Versed in 5ml syringes (1mg/1ml) x 2 syringes. Hold all others.


Draw up Fentanyl (2ml/vial) in two: 1ml syringes (50mcg/1ml) Dose-5mcg/ 0.1ml


Place Lidocaine gel 28fr nasal trumpet and tongue blade on top of anesthesia cart for potential

airway complications. (All are in anesthesia cart)


EPIC charting and set up:

At beginning of case open patient's record and open "conscious sedation" > top row of tabs "show

device data; little down arrow" > "associate devices" > choose both monitors...(remember to remove

these at end of the case/day). Associate the monitoring devices only when patient is in the room to

avoid recording apnea and low 02 until you are ready.


Set the auto record to capture vitals q 5 minutes in both "conscious sedation" and "vital" tabs. (if you

log out you must reset these to 5 minutes when you log back on).


Obtain paper patient record on clipboard (blue cart). Start records.


In Room:

Turn on EKG monitor, associate the monitoring devices, attach O2 sat monitor, and BP cuff (start first BP on monitor), Salter O2 tubing to capture on monitor, Oxygen on 2L/min, Axillary temp probe.


Keep IV at KVO unless flushing IV meds. (Keep IV fluids under 400ml for the entire case).

Use hub closest to IV site for quicker action time.


Give "loading dose" of Versed and Fentanyl on Doctor's order.


Record all meds immediately on paper charting and transfer data to intra-op medication record.


Begin a sedation note beginning of case, every 30 minutes, and end of each procedure. Intra-op >

left side bar > NOTES > choose either "OR nurse or Sedation note". State patient on gurney,

monitors applied and patient's respirations. Intra-op notes should address any change you note in pt.

and Dr. Cuadros response and your actions. (Change time of action if this note is posted at a

different time).


Record first Alderete score at start of case.


Chart all medications in "intra-op medications"; make sure they cross over to the MAR. Add

medications if needed as verbal order in "Orders". Versed is a PRN order! Confirm that Versed and

fentanyl agree with "intra-op medications" and the paper chart.



Notes:

Make sure vital signs are recording and fill in necessary info such as respirations, BP, and LOC

score.


Highlight all "blue" info, right click, and "file" to save.


During the case, be ready to give Versed every 15-20 minutes to patient's comfort and surgeon

request. Inform Dr. Cuadros when that time occurs. Fentanyl will be given for "fidgets" or loading

before lidocaine injections.


Hold patient's hands throughout procedure and especially during injections to determine patient

response with R-1 to R-3 scale. (Response: is a squeeze on your hand of 1-3 intensity). There is also

an "S", "P", and "AL" score.


Speak slowly and calmly to the patient when Dr. Cuadros is injecting medications.


End of Case:

Type a final "Note" that planned procedure completed with EBL. Record a final Aldrete Score.


Ensure all medications are charted and accounted for. Total Versed, Fentanyl and write on a note

card for Dr. Cuadros (include Ancef, decadron, etc).


Waste any Fentanyl or Versed with circulator and record in Accudose. Waste first, then return.

Sedation nurse must sign in first and cannot be witness because this "flags" management negatively.


Communication Codes:

R (Response) 1 to 5

S (Snore)        1 to 3 (1 is light snore; 2 requires jaw thrust; 3 is apnea)

F (Fidgety)      1 to 3 (sign to give Fentanyl, a.k.a. ‘vitamin F’)

P (Puff)           1 to 2 (good indicator of adequate sedation and amnesia)

T (Talking)      1 to 2 (patient may be too awake, give more Versed or Fentanyl PRN)

“O" Sign         nicely relaxed - watch for obstruction


AL Score:

          AL 1 = Great, come back anytime

          AL 2 = Maybe more sedation next time

          AL 3 = NO Way conscious sedation

          AL 4 = Next time, general anesthesia and the sedation nurse is "ON Vacation"