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Critically ill, mechanically ventilated patients experience pain and anxiety related to a number of factors, including underlying disease processes, invasive procedures, therapeutic devices, immobility, and even routine nursing care such as turning and positioning. Failure to provide adequate analgesia and sedation has been shown to have detrimental physiological consequences, including an increase in sympathetic nervous activity and ventilator dyssynchrony (Young, Knudsen, Hilton & Reves, 2000). Over-sedation has also given rise to concerns related to prolongation of mechanical ventilation, intensive care unit (ICU) length of stay, and cost. The challenge for the ICU team is to provide comfort while avoiding the consequences of both over- and under-sedation. New strategies show promise and focus on a team approach for the management of sedation and analgesia in critically ill, mechanically ventilated patients. These strategies include the use of sedation protocols, which incorporate nurse-driven dose titration directives, sedation scoring systems, and daily interruption of sedative infusions. This article provides a review of three recent studies evaluating these new approaches to the administration of sedation and analgesia in the adult ICU.

The latest technology supplements cardiac care, sedation monitoring, and infection control.

Objectives: Upper GI endoscopy is often performed in patients with chronic liver disease to screen for esophageal and gastric varices. Propofol is currently under evaluation as an alternative to the combination of midazolam and meperidine for sedation during endoscopic procedures. The purpose of this study was to compare nurse-administered propofol to midazolam and meperidine for sedation in patients with chronic liver disease undergoing diagnostic upper GI endoscopy., Methods: Twenty outpatients who had known chronic liver disease (Child-Pugh class A or B) and were undergoing variceal screening were randomized to receive propofol or midazolam plus meperidine for sedation. Administration of sedation was performed by a registered nurse and supervised by the endoscopist. Outcome measures studied were induction and recovery times, efficacy and safety of sedation, patient satisfaction, and return to baseline function., Results: The mean dose of propofol and meperidine/midazolam administered was 203 mg (SD 43.7, range 150-280) and 71.3 mg (SD 17.7, range 50-100)/5.3 mg (SD 0.9, range 3.0-6.0), respectively. The mean time to achieve adequate sedation was 3.6 min (SD 1.2) for the propofol group in comparison to 7.3 min (SD 2.8) for the meperidine/midazolam group (p<0.05). Procedure times between the groups were similar: propofol, 3.9 min (SD 1.9); midazolam/meperidine, 2.7 min (SD 0.8) (p=0.11). The level of sedation achieved by the propofol group was greater (p=0.0001). Time to full recovery was faster in the propofol group: 34.9 min (SD 10.3) versus 51.6 min (SD 18.4) (p<0.05). The mean time to reach a maximal level of alertness on the Observer's Assessment of Alertness and Sedation Scale for the propofol group was 15 min (SD 3.6) versus 29 min (SD 10.5) (p=0.001). Although both groups recorded a high level of satisfaction, patients receiving propofol expressed greater overall mean satisfaction with the quality of their sedation at the time of discharge (p<0.05), and reported a return to baseline function sooner in the majority of cases. Propofol achieved comparable levels of efficacy and safety to meperidine/midazolam in our study group. Both were well tolerated with minimal complications., Conclusions: Propofol sedation administered by registered nurses in the setting of adequate patient monitoring is efficacious and well tolerated in patients with liver disease who are undergoing variceal screening by upper endoscopy. Patients were more satisfied with the quality of sedation, and return to baseline function was usually sooner compared to results achieved with midazolam/meperidine. Propofol offers advantages over meperidine/midazolam in cirrhotic patients.

Background & Aims: Propofol is under evaluation as a sedative for endoscopic procedures. We compared nurse-administered propofol to midazolam plus fentanyl for outpatient colonoscopy., Methods: One hundred outpatients undergoing colonoscopy were randomized to receive propofol or midazolam plus fentanyl, administered by a registered nurse and supervised only by an endoscopist. Endpoints were patient satisfaction, procedure and recovery times, neuropsychologic function, and complications., Results: The mean dose of propofol administered was 277 mg; mean doses of midazolam and fentanyl were 7.2 mg and 117 microg, respectively. Mean time to sedation was faster with propofol (2.1 vs. 6.1 min; P<0.0001), and depth of sedation was greater (P<0.0001). Patients receiving propofol reached full recovery sooner (16.5 vs. 27.5 min; P=0.0001) and were discharged sooner (36.5 vs. 46.1 min; P=0.01). After recovery, the propofol group scored better on tests reflective of learning, memory, working memory span, and mental speed. Six minor complications occurred in the propofol group: 4 episodes of hypotension, 1 episode of bradycardia, and 1 rash. Five complications occurred with the use of midazolam and fentanyl: one episode of oxygen desaturation requiring mask ventilation and 4 episodes of hypotension. Patients in the propofol vs. midazolam and fentanyl groups reported similar degrees of overall satisfaction using a 10-cm visual analog scale (9.3 vs. 9.4, P>0.5)., Conclusions: Nurse-administered propofol resulted in several advantages for outpatient colonoscopy compared with midazolam plus fentanyl, but did not improve patient satisfaction.

Narcotics and benzodiazepines are commonly used for sedation for endoscopy in the United States. Propofol has certain advantages over narcotics and benzodiazepines, but its use is often controlled by anesthesia specialists. This report describes our experience with dosage, safety, patient satisfaction, and discharge time with nurse-administered propofol sedation in 9152 endoscopic cases. The study was performed in a private practice ambulatory surgery center in Medford, Oregon. With the assistance of an anesthesiologist, we developed a protocol for administration of propofol in routine endoscopic cases, in which propofol was given by registered nurses under the supervision of endoscopists or gastroenterologists. We then applied the protocol with 9152 patients. There were seven cases of respiratory compromise (three prolonged apnea, three laryngospasm, one aspiration requiring hospitalization), all associated with upper endoscopy. Five patients required mask ventilation, but none required endotracheal intubation. There were seven colonic perforations (<1 per 1000 colonoscopies), of which three may have involved forceful sigmoid disruption. Of patients who had previously received narcotic or benzodiazepine sedation, 84% preferred propofol. Gastroenterologists strongly preferred propofol. The mean time from completion of procedures to discharge in a sample of 100 patients was 18 min.Nurse-administered propofol sedation in an ambulatory surgery center was safe and resulted in high levels of patient satisfaction and rapid postprocedure recovery and discharge.

Objectives: Propofol, a rapidly-acting hypnotic agent, is increasingly being used for endoscopic sedation. Serious adverse effects, including respiratory and cardiovascular depression, make many endoscopists reluctant to use propofol in critically ill patients. This study characterizes propofol's safety profile in consecutive high-risk patients (American Society of Anesthesiologists [ASA] classes III and IV) compared with matched subjects (ASA classes I and II)., Methods: During a 19-month period, 1370 at risk-patients were sedated with propofol, of whom 47% (614 ASA III, 28 ASA IV) were age matched with 642 consecutive patients of the same gender and age assigned to ASA classes I and II and undergoing the same endoscopic procedures (395 gastroscopies, 201 colonoscopies, 14 combined). Registered nurses performed all sedations by propofol dose titration while carefully monitoring arterial oxygen saturation, heart rate, and blood pressure., Results: No major complications occurred among the critically ill patients. There was, however, an increased risk for a short relevant oxygen desaturation (<90%) of 3.6% for ASA III and IV versus 1.7% for ASA I and II (p = 0.036). In four versus one case, short mask ventilation was necessary. Also, a greater proportion of patients showed a > or =5% oxygen saturation decrease. There was no pronounced influence on arterial pressure or heart rate and no perforations in 336 colonoscopies., Conclusions: With careful monitoring, propofol sedation during GI endoscopies is safe, even for high-risk patients. Considering their higher comorbidity and tendency toward oxygen desaturation, they need particularly careful monitoring, and the required dose is, on mean, 10-20% lower than in ASA classes I and II.

In critically ill patients, the central nervous system remains vulnerable to multiple insults including ischemia, hemorrhagic events, and encephalopathy. The peripheral nervous system is vulnerable in the setting of neuro-muscular blockade (NMB), related drug-drug interactions, and drug-clinical state interactions. Optimal assessment of the nervous system is done by means of the clinical neurological examination. In this manner, orientation, arousal, and responsiveness to stimulation provide feedback on focal and global stability of the central nervous system. Where clinical evaluation is compromised, such as with deep sedation and NMB, risk of undetected seizure activity, and/or progression of neurological injury increases dramatically. A patient receiving NMB risks breakthrough awareness and pain. Long-term complications of NMB including prolonged weakness or paralysis as well as post-traumatic stress dramatically increase morbidity and length of stay. Technologies such as electroencephalogram (EEG) and bispectral index (BIS trade mark ) monitoring are effective for assessing cerebral function as well as level of sedation or arousal, respectively, in patients with a compromised neurological assessment. Neuromuscular transmission (NMT) monitoring by means of peripheral nerve stimulation and assessment of the evoked response may be utilized, within the context of clinical assessment, to determine level of chemical paralysis and minimize dosing of NMB agents. This article explores utilization and differentiates technologies such as EEG, BIS, and NMT monitoring. Monitoring parameters are illustrated using a case study approach.

How can we interact with sedated patients who are seemingly unable to express themselves? On the basis of these questions, we chose to realize a qualitative phenomenological study aimed at comprehending communication with the sedated patient from the perspective of the nurses who take care of those patients. Ten individual interviews were realized with intensive nurses from a Hospital School in S o Paulo. After data analysis, four general thematic categories were revealed: communication with sedated patient x sedation degree; communication with sedated patient x attributed perception capacity; valuation of communication with sedated patient; forms of communication with the sedated patient. This research concluded that the communication with the sedated patient exists and occurs at different moments and in different ways through verbal and non-verbal communication.

This article provides a review of the use of propofol in the mechanically ventilated patient. The indications for the administration of propofol are presented as well as the contraindications, adverse effects, and nursing care.

Sedation which is used for intubated patients may prolong mechanical ventilation by increasing the risk of complications. The aim of the study was to illuminate the specific terminology and unrecognized contextual factors which may influence nurses' and physicians' sedation practices. The main research questions were: How do nurses and physicians describe sedation? and How does the level of nursing skill relate to the level of sedation? The hypotheses were that sedation practices are inconsistent and that experienced nurses provide a better quality of sedation than less experienced nurses. The hypotheses were supported by the study. The research strategy was case study research with triangulation of sources and methods and a multicentre multiple-case design. Four university hospitals in Copenhagen, Denmark, and 14 cases were included in the study. The findings were based on secondary analysis of observation, interviews and chart review. The theoretical framework for the study was the problem-solving model, in which sedation was assumed to be provided according to indication (clinical problem), intervention (clinical decision) and expected outcome (clinical end-point). Indications could be patient-related, ventilator-related, or patient-ventilator related. Interventions could be related to the choice of agent, dose or administration method and the outcome was the level of sedation. Sedative therapy was prescribed by physicians and administered by nurses. The four sites in the study did not use guidelines for sedation and did not use sedation level assessment tools. The study shows that when the terminology is unclear, the indications, interventions and outcomes become unclear.

Purpose: To establish a protocol for credentialed pediatric radiology nurses, with radiologist supervision, to administer ketamine to induce sedation and analgesia during interventional radiologic procedures., Materials and Methods: This study was conducted in two phases. The goal of the first phase was to develop a sedation protocol to replace that of using general anesthesia for specified pediatric interventional procedures. Ketamine was administered intravenously (with intermittent bolus or continuous infusion) or intramuscularly. Sedation induction times, adverse events, doses, and sedation and recovery durations were recorded. In phase 2, the results of phase 1 were reviewed and a formal ketamine protocol was developed., Results: Neither sedation failures nor substantial adverse events occurred in phase 1. Mean duration of all sedations was 52 minutes, and median recovery room time was 0 minutes. In phase 2, the results of phase 1 were reviewed and a sedation protocol was proposed to a hierarchy of hospital committees before final approval from the medical staff executive committee. Subsequently, standard order forms for radiology nurse administration of ketamine with radiologist supervision were prepared for exclusive use by the pediatric interventional radiology department., Conclusion: Ketamine-induced sedation may be a safe and effective alternative to general anesthesia for some interventional radiologic procedures in pediatric patients. Collaboration between anesthesia and radiology departments is important for development of a safe and successful ketamine sedation program. To the authors' knowledge, this is the first report describing the intravenous infusion of ketamine for sedation in pediatric patients and the only report describing the establishment of a protocol for ketamine administration by credentialed radiology nurses with radiologist supervision., (Copyright RSNA, 2002)

A limited number of studies have addressed pain assessment among sedated patients undergoing a gastrointestinal examination. The Colorado Behavioral Numerical Pain Scale is a quick, simple tool that can provide an estimation of the patient's comfort level while sedated. Multiple studies completed in intensive care unit and postanesthesia care unit settings provide ample evidence of the accuracy of behavioral pain scales ratings. In developing the Colorado Behavioral Numerical Pain Scale, experienced endoscopy nurses provided suggestions and modifications of descriptive words for behavioral assessment of pain selected from the relevant literature. Three nurses simultaneously rated pain using the scale for 30 procedures. Interrater reliability was high with 82% of observations in total agreement and 17% having one of the three persons disagreeing on the rating. Nurses from four hospitals and one ambulatory facility also evaluated the Colorado Behavioral Numerical Pain Scale tool. In this evaluation, 98% of the 52 respondents agreed that the words described what they observed during a gastrointestinal examination and 94% felt it was a better descriptor of pain than a patient self-report numerical scale. Assessment of pain for the sedated patient undergoing gastrointestinal procedures is often difficult due to the patient's inability to report pain levels. The sedated patient undergoing painful procedures depends on the nurse to interpret physical signs to quantify his or her distress. The Acute Pain Management Guidelines (AHCPR, 1992) promotes the use of both physiological and behavioral responses to pain for assessment when self-report is absent. While an individual's self-report of pain intensity and distress is the most accurate assessment measurement, the validity of a sedated patient's elicited response about pain is questionable. It is the nurse, through observation, who attempts to assess the sedated individual's pain levels.

The aim of this study was to conduct an evaluation of a sedation protocol that transfers some decision-making authority for analgesia and sedation, within clearly defined parameters, to nurses in a pediatric intensive care unit (PICU). The sedation protocol used in this study was appropriate for any age group. The clinical course of 10 patients admitted to the PICU during a 5-month interval who were on the sedation protocol during their stay was examined using retrospective chart review. Time intervals when patients were on the protocol were compared with clinically comparable time intervals, in terms of acuity, when the same patient received conventional management. Data were collected on the number of days a child was ventilated, the number of days in the PICU, the number of days hospitalized and severity of illness. Additionally, data were collected on the amounts of sedation and analgesia required and the incidence of under-sedation. Physician and nurse satisfaction with the sedation protocol was examined using a self-report survey. The findings of this study indicate that the delegation of decision-making authority for analgesia and sedation to PICU nurses can provide effective and timely management of patient comfort, without an increase in morbidity, in a manner that is more satisfying for physicians and nurses.

Outside the OR, it has become increasingly common for nurses to administer procedural sedation. Now, with capnography, you can monitor patients' respiratory status more closely and accurately.

Objective: To develop a pathway to provide safe, effective, and efficient sedation for pediatric diagnostic imaging studies using non-radiology personnel., Materials and Methods: A multidisciplinary team considered manpower and training requirements and national sedation standards before designing a sedation pathway, which included scheduling, pre-sedation history and physical, medication protocols, and monitoring. Oral and IV medication protocols were developed based on patient age and weight. Sedation delays were defined as >15 min (IV) or >30 min (PO) from start of sedation to start of imaging. A sedation failure resulted in an incomplete diagnostic imaging study. Failure rates of 124 sedations before and 388 sedations after the pathway were compared., Results: The sedation failure rate for 7 months prior to pathway initiation was 15% (19/124). In the first 25 months after pathway initiation, failures were significantly reduced to 1.5% (6/388) ( P<0.0001). Three (50%) of the six failures after pathway initiation were long examinations (>55 min). Deviation from the recommended medication protocol accounted for most of the 115 delays. Only minor adverse events were seen (12/388, 3.1%)., Conclusion: Implementing a pediatric sedation pathway significantly decreases the sedation failure rate. Pediatric residents and nurses can safely, effectively and efficiently sedate pediatric patients for routine diagnostic imaging procedures without the need for a radiology department sedation team in a department with a small-to-moderate volume of pediatric patients.

The Joint Commission on Accreditation of Healthcare Organizations' sedation standards detail the differences between sedation and anesthesia. These standards, however, note that it is important that those applying sedation be trained to rescue patients who may slip from moderate sedation into deep sedation or from deep sedation into anesthesia.

Pain is one of the most common complaints that cause patients to seek care in the emergency department. Research and patient complaints however, continue to demonstrate that pain management needs improvement. This article addresses pain management in emergency care. It presents both pharmacologic and nonpharmacologic methods of pain management.

As sedation assessment continues to evolve towards a more disciplined and standard part of clinical practice, the use of subjective sedation scales and objective sedation tools such as the BIS monitor continues to grow and show promise. The efforts of critical care nurses and their colleagues to better understand the value of these tools is integral to guiding their use and optimizing patient comfort.

In recent years, enormous technological advances have occurred that allow intervention for many congenital heart defects in the pediatric cardiac catheterization laboratory. Therapeutic catheterization procedures, including valvuloplasty, angioplasty, stent implantation, coil embolization, and device occlusion, are employed to treat heart defects in infants and children. This report describes these interventional procedures, outcomes, potential complications, and implications for nursing care., (Copyright 2001 W.B. Saunders Company)

A newborn lies wide-awake, about to be intubated. The infant is able to feel everything, to hear everything--but cannot do anything to change the situation. Big people hold down the newborn and place a laryngoscope blade into the mouth, then a large endotracheal tube into the trachea. As the baby struggles, coughs, chokes, gags, and cries, blood pressure and intracranial pressure increase dramatically, and the heart rate plummets. Infants, like adults, do feel pain and anxiety. Yet recent studies show that NICU staff continue neonatal intubation utilizing only force. In pediatric emergency/critical care settings, rapid-sequence intubation (RSJ), once confined to the environment of the operating room, is now the standard of care. An understanding of commonly administered PSI medications is essential to bring this practice to standard use in the NICU as well. In the pediatric and adult critical care population, rapid-sequence intubation (RSI)--the use of sedatives and chemical paralytics to facilitate tracheal intubation--is considered the standard of care. Use of these medications optimizes intubating conditions and helps to minimize the adverse physiologic effects of intubation. Neonatology has yet to embrace this trend, however. This article addresses the issue of sedation for intubation in the neonatal population.

This descriptive study was undertaken as part of a clinical improvement effort by the ASPAN Research and Education Committees to evaluate adult patients' perception of and satisfaction with the ASPAN Preoperative Patient Teaching videotape on general, regional, and minimum alveolar concentration (MAC)/conscious sedation anesthesia. Research findings on the use of videotapes for preoperative education are mixed. Some studies have reported that the use of videotapes increases knowledge and decreases anxiety, whereas other studies have shown a minimal effect on knowledge and anxiety. A convenience sample of 96 adult patients was chosen from those who were scheduled for surgeries with the above anesthesia techniques in 11 US hospitals and/or surgical centers within 4 ASPAN regional boundaries. Patients viewed the videotape the day(s) before surgery and then completed ASPAN's Preoperative Anesthesia Patient Teaching Questionnaire to measure patient perception and satisfaction. Sixty percent of the patients were women, and 50% had a college degree or higher. The average age of the patients was 51 (+/-17.2). Overall satisfaction scores had a potential range of 10 to 40, with higher scores indicating greater satisfaction. The mean satisfaction score for this study was 35 (+/-6.6). No significant relationships were found between satisfaction with the videotape and age, gender, or educational level. Patients were asked to rank each of 4 teaching methods. Among the choices of individualized instruction, written materials, Internet-based instruction, and videotape, the videotape method was ranked as most preferred. The information obtained from this study will be used to modify and improve the content of the patient education videotape produced by ASPAN., (Copyright 2001 by American Society of PeriAnesthesia Nurses.)

Background: While sedation is necessary for much pediatric imaging, there are new alternatives that may help patients hold still without medication., Objective: We examined the effect of an audio/visual system consisting of video goggles and earphones on the need for sedation during magnetic resonance imaging (MRI)., Materials and Methods: All MRI examinations from May 1999 to October 1999 performed after installation of the MRVision 2000 (Resonance Technology, Inc.) were compared to the same 6-month period in 1998. Imaging and sedation protocols remained constant. Data collected included: patient age, type of examination, use of intravenous contrast enhancement, and need for sedation. The average supply charge and nursing cost per sedated patient were calculated., Results: The 955 patients from 1998 and 1,112 patients from 1999 were similar in demographics and examination distribution. There was an overall reduction in the percent of patients requiring sedation in the group using the video goggle system from 49 to 40% (P < 0.001). There was no significant change for 0-2 years (P = 0.805), but there was a reduction from 53 to 40% for age 3-10 years (P < 0.001) and 16 to 8% for those older than 10 years (P < 0.001). There was a 17% decrease in MRI room time for those patients whose examinations could be performed without sedation. Sedation costs per patient were $80 for nursing and $29 for supplies., Conclusion: The use of this video system reduced the number of children requiring sedation for MRI examination by 18%. In addition to reducing patient risk, this can potentially reduce cost.

Young children may be unwilling or unable to cooperate if they are required to remain motionless for a prolonged period of time. In the hospitalized child, investigative procedures perceived as painful or threatening may need the administration of a sedative. Clinical guidelines, within a large teaching hospital NHS trust in the North of England, were implemented in an attempt to reduce the diversity of the practices of healthcare professionals caring for the child requiring sedation. The guidelines were formulated by a multidisciplinary team and, in conjunction with active dissemination strategies, resulted in a change in practice that included: (1) improved communication and cooperation between departments, (2) implementation of starvation times before the administration of a sedative, and (3) the appropriate referrals to a senior paediatrician to seek advice if contraindications to sedation were identified. Audit was integral to the process, facilitating the comparison of actual practice with the standards developed from the guidelines and ensuring a continuous monitoring programme.

Medication for conscious sedation during gastrointestinal (GI) diagnostic procedures causes amnesia, thereby preventing patients from recalling postprocedure instructions or follow-up appointments. A serious complication after GI diagnostic procedures is bleeding, which can occur if patients take aspirin or nonsteroidal anti-inflammatory agents after the procedure. Past research revealed that 73% of patients did not remember instructions. The purpose of this randomized controlled trial was: (1) to determine if patients with wrist bands remember to read their postprocedure instructions, and (2) to determine what patient demographics are associated with failure to read postprocedure instructions. Sixty-one GI clinic outpatients participated in this Veterans Affairs Medical Center study, received routine written instructions before and after GI diagnostic procedures, and were randomly assigned to one of two groups: control group (standard care plus next-day phone call) or intervention group (wrist band plus standard care plus next-day phone call). A memory test evaluated patients' knowledge of procedure results, date of follow-up appointment, and medications. Results indicated no significant differences in the memory test between the groups (t = 0.9, p = .36). Patients 65 years of age and older had scores indicating memory problems, regardless of the wrist band (r = 0.19, p = .06). The wrist band was ineffective as a reminder to read instructions; rather, the next-day phone call served as the reminder.

Sedation/analgesia for diagnostic and therapeutic procedures in children has been associated with life-threatening adverse events. Reports of adverse events and recognition of wide variability in sedation practices has led to the development of guidelines and standards of care to ensure the safety of sedated children. The safety of sedated children can be enhanced by detailed presedation evaluation, careful patient selection, and the use of drugs with a wide margin of safety that are carefully titrated to desired depth of sedation by trained personnel. Once sedative drugs are administered, stringent monitoring, including continuous pulse oximetry and frequent assessment of vital signs and sedation depth, will permit early recognition of untoward drug effects and permit early intervention. Children with underlying medical conditions, such as airway abnormalities, may not be suitable subjects for sedation and may require consideration for general anesthesia to aid their procedure. Although significant strides have been made in recognition of the risks of sedation and in development of guidelinesfor safe sedation practices, further work must focus on development of newer sedation regimens with shorter-acting drugs and wider margins of safety.

Topic: Despite substantive advances in understanding of genetic and biochemical basis of substance abuse and addiction in the last decade, little information has been translated into alternative treatment models for the addicted patient. Rapid detox, an alternative form of detox treatment, is gaining in both acceptance and popularity., Purpose: To increase readers' understanding of the neurobiology of addiction and the mode of action of new detox approaches for patients addicted to opiate drugs., Sources: A review of the current literature pertaining to rapid detox., Conclusions: Rapid detox is a viable alternative for selected patients attempting to detox from opiate agents of abuse. Increasing knowledge of new treatment approaches allows nurses working to assist addicted patients in planning and receiving treatment based on new awareness of the neurobiology of addiction.

Dexmedetomidine is new sedative being developed for use in postoperative sedation in ICU. It acts at a 2 adrenoceptors to produce sedation, anxiolysis and analgesia. Patients remain easily rousable and do not suffer significant respiratory depression, consequently dexmedetomidine may be continued post extubation.

Purpose: To document the effectiveness and safety of using a combination of oral meperidine, atropine, and pentobarbital for pediatric conscious sedation., Method: Sixty-three patients ages 6 months to 23 years (M = 5 years) undergoing outpatient cardiac catheterization were given an oral premedication consisting of meperidine, atropine, and pentobarbital for sedation. The effectiveness of the medication in providing sedation and the complication of over sedation when using a standard dose based upon weight were analyzed., Results: Seventy six percent of the patients were deemed sedated on arrival to the catheterization laboratory. Forty eight percent did not require any further sedation during the procedure. Need for further sedation was related to the length of the procedure. Three patients (4.8%) incurred complications of sedation; all three had received additional sedation during the procedure., Conclusions: The combination of meperidine, atropine, and pentobarbital is a safe and effective premedication for cardiac catheterization when administered in standard dosage based upon body weight.

Purpose: To measure the safety and effectiveness of conscious sedation in order to assess utilization and the effect on magnetic resonance (MR) imaging examinations., Materials and Methods: A database of conscious sedation records for MR imaging at the Johns Hopkins Hospital, Baltimore, Md, from 1991 to 1998 was searched. Safety data according to medication and procedure duration for each nurse were tabulated for 6,093 patient records. Data were analyzed by using quality control statistical measures to determine time utilization and effectiveness. Break-even costs for the procedure were determined., Results: Of 6,093 patients scheduled for examination, 4,761 patients (78.1%) received conscious sedation by the MR conscious sedation service. Complications were observed in 20 of the 4,761 patients (0.42%). No deaths occurred. The most common complication was oxygen desaturation (n = 8). Diagnostic and complete MR examinations were performed in 4,453 of the 4,761 patients (93.5%). The mean time to sedate the patient (+/- SD) was 23.6 minutes +/- 15.2 for specialized MR sedation nurses and 26.8 minutes +/- 20.1 for general radiology nurses (P: <.001). For inpatient nurses from the inpatient hospital units, the sedation time was considerably longer (47.3 minutes +/- 36.6, P: <.001) and more variable. Break-even costs were 37% ($11 vs $8 for MR room time) more for general radiology nurses than for specialized MR sedation nurses performing the procedure., Conclusion: Conscious sedation is safe and has a high effectiveness rate. A highly specialized nursing staff reduces procedure variability and cost.

Purpose: To determine current European practice in interventional radiology regarding nursing care, anesthesia, and clinical care trends., Methods: A survey was sent to 977 European interventional radiologists to assess the use of sedoanalgesia, nursing care, monitoring equipment, pre- and postprocedural care, and clinical trends in interventional radiology. Patterns of sedoanalgesia were recorded for both vascular and visceral interventional procedures. Responders rated their preferred level of sedoanalgesia for each procedure as follows: (a) awake/alert, (b) drowsy/arousable, (c) asleep/arousable, (d) deep sedation, and (e) general anesthesia. Sedoanalgesic drugs and patient care trends were also recorded. A comparison was performed with data derived from a similar survey of interventional practice in the United States., Results: Two hundred and forty-three of 977 radiologists responded (25%). The total number of procedures analyzed was 210,194. The majority (56%) of diagnostic and therapeutic vascular procedures were performed at the awake/alert level of sedation, 32% were performed at the drowsy/arousable level, and 12% at deeper levels of sedation. The majority of visceral interventional procedures were performed at the drowsy/arousable level of sedation (41%), 29% were performed at deeper levels of sedation, and 30% at the awake/alert level. In general, more sedoanalgesia is used in the United States. Eighty-three percent of respondents reported the use of a full-time radiology nurse, 67% used routine blood pressure/pulse oximetry monitoring, and 46% reported the presence of a dedicated recovery area. Forty-nine percent reported daily patient rounds, 30% had inpatient hospital beds, and 51% had day case beds., Conclusion: This survey shows clear differences in the use of sedation for vascular and visceral interventional procedures. Many, often complex, procedures are performed at the awake/alert level of sedation in Europe, whereas deeper levels of sedation are used in the United States. Trends toward making interventional radiology a clinical specialty are evident, with 51% of respondents having day case beds, and 30% having inpatient beds.

In Part 1, the author explained the four new definitions that are changing the Joint Commission's sedation and anesthesia standards: minimum sedation, moderate sedation/analgesia, deep sedation/analgesia, and anesthesia. Part 2 explains how these definitions will impact the delivery of care in your units.