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Procedural sedation is the administration of medication to obtund, dull, or reduce the intensity of pain or awareness associated with a therapeutic or diagnostic procedure. Because registered nurses play a key role in ensuring patient safety during procedural sedation, it is essential they have the requisite knowledge and skills to provide safe, quality care. This paper describes the development, implementation, and outcomes of a course designed for nurses providing care to patients undergoing procedural sedation., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Optimising sedation use is key to timely extubation. Whilst sedation protocols may be used to guide critical care nurses' management of sedation, sedation management and decision-making is complex, influenced by multiple factors related to patients' circumstances, intensive care unit design and the workforce., Aim: To explore (i) critical care nurses' experiences managing sedation in mechanically ventilated patients and (ii) the factors that influence their sedation-related decision-making., Design: Qualitative descriptive study using semi-structured interviews. Data were analysed using Braun and Clarke's six-step thematic analysis., Setting and Participants: This study was conducted in a 26-bed level 3 accredited ICU, in a private hospital in Melbourne, Australia. The majority of patients are admitted following elective surgery. Critical care nurses, who were permanently employed as a registered nurse, worked at least 16 h per week, and cared for ventilated patients, were invited to participate., Findings: Thirteen critical care nurses participated. Initially, participants suggested their experiences managing sedation were linked to local unit policy and learning. Further exploration revealed that experiences were synonymous with descriptors of factors influencing sedation decision-making according to three themes: (i) Learning from past experiences, (ii) Situational awareness and (iii) Prioritising safety. Nurses relied on their cumulative knowledge from prior experiences to guide decision-making. Situational awareness about other emergent priorities in the unit, staffing and skill-mix were important factors in guiding sedation decision-making. Safety of patients and staff was essential, at times overriding goals to reduce sedation., Conclusion: Sedation decision making cannot be considered in isolation. Rather, sedation decision making must take into account outcomes of patient assessment, emergent priorities, unit and staffing factors and safety concerns., Implications for Clinical Practice: Opportunities for ongoing education are essential to promote nurses' situational awareness of other emergent unit priorities, staffing and skill-mix, in addition to evidence-based sedation management and decision making., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: One author is an Associate Editor for Intensive & Critical Care Nursing and was not involved in the editorial review or the decision to publish this article., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Penile plication is commonly performed for Peyronie's disease under general or spinal anesthesia. Conscious sedation (CS) offers decreased anesthetic risks, cost-effectiveness, and the ability to perform the procedure in outpatient settings with shorter wait times. We sought to compare tolerability of penile plication under deep intravenous sedation (DIS) administered by anesthesiologists and nursing-administered CS (NACS)., Methods: Tolerability for penile plication was prospectively evaluated, excluding revision surgeries and those with hourglass or hinge deformities. DIS included midazolam and ketamine with infusion of propofol and remifentanil. NACS consisted of midazolam and fentanyl. Baseline characteristics, procedural information, and patient- and surgeon-reported pain assessments were collected. Patients were administered a standardized tolerability questionnaire on follow-up., Results: Forty patients were enrolled (23 DIS; 17 NACS) with similar baseline characteristics. Median curvature of the DIS cohort was 55° (interquartile range = 43.75-76.25) and 45° (interquartile range = 45-60) in NACS. There was a 100% success rate with no procedure abortion or conversion to general anesthetic. On follow-up, all patients had functional curvature (<20°), and 100% of patients in the DIS and NACS cohorts reported that they would recommend CS to others. Over 93% of patients in both cohorts would choose CS over general anesthetic in the future, with no differences in perioperative and postoperative pain between groups., Conclusions: Penile plication with CS, whether administered by an anesthesiologist or nursing, is well tolerated with no differences in pain or complications. This indicates that outpatient penile plication with trained nursing staff administering CS can safely reduce costs, risks, and wait times.

Introduction: Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is a new nonanesthesia propofol delivery method for gastrointestinal endoscopy. NAPCIS is adopted from the computer-assisted propofol sedation (CAPS) protocol. We evaluated the effectiveness, efficiency, and safety of NAPCIS in low-risk subjects., Methods: Between December 2016 and July 2017, patients who underwent esophagogastroduodenoscopy or colonoscopy with NAPCIS at our center were compared against 2 historical control groups of similar patients who had undergone procedures with CAPS or midazolam and fentanyl (MF) sedation., Results: The mean age of the NAPCIS cohort (N = 3,331) was 55.2 years (45.8% male) for 945 esophagogastroduodenoscopies and 57.8 years (48.7% male) for 2,386 colonoscopies. The procedural success rates with NAPCIS were high (99.1%-99.2%) and similar to those seen in 3,603 CAPS (98.8%-99.0%) and 3,809 MF (99.0%-99.3%) controls. NAPCIS recovery times were shorter than both CAPS and MF (24.8 vs 31.7 and 52.4 minutes, respectively; P < 0.001). On arrival at the recovery unit, 86.6% of NAPCIS subjects were recorded as "Awake" compared with 82.8% of CAPS and 40.8% of MF controls (P < 0.001). Validated clinician and patient satisfaction scores were generally higher for NAPCIS compared with CAPS and MF subjects. For NAPCIS, there were only 4 cases of oxygen desaturation requiring transient mask ventilation and no serious sedation-related complications. These low complication rates were similar to those seen with CAPS (8 cases of mask ventilation) and MF (3 cases)., Discussion: NAPCIS seems to be a safe, effective, and efficient means of providing moderate sedation for upper endoscopy and colonoscopy in low-risk patients.

Background and Aims: As on-call anesthesiologist administered propofol sedation (OAPS) is costly and not readily available in all endoscopy units, endoscopy nurse administered propofol sedation (NAPS) can be an effective alternative. This study aimed to compare the dosage of propofol used by NAPS versus OAPS, cardiopulmonary adverse events and recovery time in low risk patients undergoing outpatient elective colonoscopy., Methods: A retrospective propensity score-matched cohort study was conducted. Electronic medical records of elective colonoscopies performed by 3 experienced endoscopists from January 2016 to December 2019 were retrieved. OAPSs were performed by 10 certified anesthesiologists while NAPSs were performed by 8 experienced registered endoscopy nurses. Baseline characteristics, performing endoscopist, cecal intubation time, withdrawal time, propofol dosage per procedure, and adverse events were collected and analyzed using 3:1 (NAPS:OAPS) propensity score matching by age, performing endoscopist and difficulty of colonoscopy as co-variates with standardized mean deviation of <0.1., Results: 278 eligible patients were included. After propensity score matching, there were 189 patients in NAPS and 63 in OAPS group for analysis. Demographic data were not different between the two groups. All procedures were technically successful with no difference in cecal intubation time (6.0±4 min vs 6.8±4 min; p=0.13) or total procedural time (17.2±16 min vs 16.3±6 min; p=0.66). Propofol dosage/kg/hour were significantly lower in the NAPS group, (11.4±4 mg/kg/hour vs. 16.6±8 mg/kg/hour; p<0.001). There were less minor cardiopulmonary adverse events in NAPS when compared to the OAPS group (2.2% vs 4.7%; p=0.014)., Conclusions: NAPS in elective colonoscopy in low-risk patients is as effective as OAPS but requires a significant lower dosage of propofol. Minor cardiopulmonary adverse events were recorded in the NAPS group compared to OAPS.

Purpose: Analgesia and sedation protocols (ASPs) reduce duration of mechanical ventilation (MV) in the medical intensive care unit (ICU), but data in the surgical ICU (SICU) are limited. The objective of this study was to determine the impact of a nursing-driven ASP with criteria for infusion initiation in the SICU., Materials and Methods: A single-center, retrospective study compared ventilator-free days at day 28 from start of MV (VFD28) before and after ASP implementation. Secondary endpoints included cumulative opioid and sedative requirements, level of sedation, incidence of delirium, SICU and hospital length of stay., Results: One hundred thirty two patients were included (66 per group). The protocol group had greater VFD28 compared to the control group (21 vs. 14.5 days, p = .04). Lower rates of benzodiazepine (42.4% vs. 84.8%, p < .001) and opioid (24.2 vs. 78.8, p < .001) infusion use occurred in the protocol group, resulting in lower cumulative doses per ventilator-day through day 7. The protocol group had more documented sedation scores within target range. There were no differences in ICU delirium, SICU or hospital length of stay., Conclusions: A nursing-driven ASP with criteria for infusion initiation in mechanically-ventilated SICU patients may increase ventilator-free time, maintain patients at the target sedation goal, and reduce opioid and benzodiazepine utilization., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aims and Objectives: To examine the common meanings of opioid-induced sedation and shared practices in the context of post-operative pain management in expert Post-Anesthesia Care Unit nurses during patient's pain management with opioids., Background: Within the clinical setting, linear pain and sedation scales are not enough to support clinical judgement with acute pain management. Because sedation measurement rests along a fluctuating continuum, it is possible for a patient to be sedated and then shift to increasing alertness, and then to drift back to a sedated state. This potential for acute clinical transition can be challenging to nurses of all levels, even for expert nurses., Design: Interpretive phenomenology., Methods: Twenty expert Post-Anesthetic Care Unit nurses, with more than 7 years of nursing experience, participated in qualitative interviews regarding their lived experiences. Interviews were analysed using a modified seven-stage process for interpretation by Diekelmann, Allen and Tanner. The manuscript was developed utilising the COREQ guidelines for reporting qualitative studies., Results: Four themes identified through the participant's stories were recognising every patient is different, engaging in iterative knowing, walking a fine line, and looking beyond and anticipating. This study identified a constitutive pattern of interpreting sedation by integrating practical understanding and anticipating beyond., Conclusions: This study indicates a deeper complexity in the way opioid-induced sedation is assessed and balanced with pain management by nurses in the Post-Anesthetic Care Unit., Relevance to Practice: Nurses in the study adapted their practices around pain management with opioids, in response to their patient's level of sedation; incorporating practices such as giving small, incremental doses and changing the drug. Nurses valued the importance of having "eyeballs on everybody" and being ready to meet the needs of their patient. They appreciate the time to watch and wait for their patient to respond, to better judge the result of their interventions., (© 2018 John Wiley & Sons Ltd.)

Background and Aim of the Work: Numerous negative outcomes of inadequate pain management among children have been cited in the literature. Inadequate pain management may be particularly detrimental to children and adolescents facing life-threatening injury or illness on a Paediatric Intensive Care Unit (PICU). It is therefore absolutely necessary that professionals utilize effective and efficient tools in order to evaluate a person's sensations of pain in the most objective way possible. The COMFORT-B scale is recognised as the gold standard in such patients. However, the use of this instrument in the clinical PICU setting is disputed. It requires long periods of observation to ensure an adequate utilization. Boerlage et al. noted that nurses are often impatient and do not always observe the patient for the recommended 2 minutes period. The Behavioral Pain Scale (BPS), instead, is considered to be the gold standard for pain assessment in deeply sedated, mechanically ventilated adult patients. This observational pain scale requires shorter observation time compared to the COMFORT-B. Moreover, BPS three subscales are included in other observational pain scales for paediatric patients. Therefore, the objective of this study was to assess the applicability of the BPS for use with paediatric patients., Methods: Firstly, a questionnaire was administered to physicians and nursing staff that work in the units where the study was conducted in order to investigate the actual use of observational pain scales in their units. A second questionnaire was administered to a group of experts regarding the BPS, to assess both face validity and content validity, and to gain opinions on the relative appropriateness of each item. A descriptive, comparative design was used. A convenience sample of non-verbal, sedated and mechanically ventilated critical care paediatric patients was included. 39 observations were collected from 9 patients, all in their first year of age. Patient pain was assessed concurrently with the three observational scales, before, during and after routine procedures that are considered painful and non-painful., Results: The data collected through questionnaires for professionals gave a useful insight into pain assessment in the investigated units: only 46% of respondents stated that they assessed patients' pain levels, with an average of 2.8 times per shift; 60% of respondents declared to be unhappy with the observational scales that they utilise. Regarding the observations, internal consistency was α = .865. Correlations between BPS and the other instruments were high, demonstrating a good concurrent validity of the test. T test and ROC curves demonstrated a good discriminant validity as well., Conclusions: Although the current study is based on a small sample of participants, these first results encourage us to continue working in the validation of the BPS in paediatric patients.

Aims and Objectives: To explore aspects related to the fulfilment of the role of nurses in palliative sedation., Background: Palliative sedation demands knowledge and a proper attitude for maintaining comfort, preserving dignity and contributing to a peaceful death. In some developed countries, nurses have a well-established role in palliative sedation. However, studies on their role and its fulfilment are limited, particularly in the developing world., Design: An exploratory, mixed, qualitative and quantitative study was conducted. A self-administered questionnaire was used to examine the level of knowledge of palliative sedation and the level of confidence in skills and knowledge about palliative sedation. Also, focus groups were conducted to explore the emotional impact and the perceived role of nurses., Methods: Forty-one nurses from three advanced-care hospitals with palliative care units in Colombia completed the questionnaire. Also, four focus groups were conducted with 22 participants selected from the first phase., Results: A high level of knowledge regarding palliative sedation was found, but the level of confidence in skills was higher than the confidence in knowledge. The participants expressed their belief that their knowledge was derived from experience but believed that it was not enough to fulfil their role with confidence. A negative emotional impact about the patients' condition was found. For some, it served as motivation to provide better care. For others, it was difficult to face, especially when assisting children. They also expressed satisfaction and gratification about providing relief from suffering through sedation., Conclusions: The role of nursing is essential in palliative sedation. Although the nurses' knowledge is adequate, it primarily derives from experience and not from formal training, which impacts on their perceived confidence and their distress., Relevance to Clinical Practice: Formal training for the optimal fulfilling of the nursing role in palliative sedation is crucial to provide better end-of-life care, particularly in developing countries., (© 2018 John Wiley & Sons Ltd.)

Rapid tranquillization is a pharmacological intervention sometimes employed in mental health care for the management of acute behavioural disturbance. It is a form of restrictive practice, which, along with seclusion and restraint, is a conventional and controversial intervention in the therapeutic management of risk in mental health settings. This study surveyed mental health nurses practice in rapid tranquillization. A self-report questionnaire was utilized which addressed aspects such as definitions of rapid tranquillization, presence of rapid tranquillization policy, types of incidents where it is used and postintervention monitoring. The results demonstrate that rapid tranquillization is an intervention used in the management of acute behavioural disturbance in various mental health settings in Ireland. Respondents showed a basic understanding of rapid tranquillization as an intervention; however, some areas reported not having a specific rapid tranquillization policy. There was some evidence of a variation in postrapid tranquillization monitoring of psychiatric/mental health and physical health. Service user debriefing following rapid tranquillization was reported to be common; however, the content of this was not elaborated on. In the light of variations in practice, specific training and the development of rapid tranquillization policies are recommended., (© 2018 Australian College of Mental Health Nurses Inc.)

Introduction: Critical care nurses are responsible for administering sedative medications to mechanically ventilated patients. With significant advancements in the understanding of the impact of sedative exposure on physiological and psychological outcomes of ventilated patients, updated practice guidelines for assessment and management of pain, agitation, and delirium in the intensive care unit were released in 2013. The primary aim of this qualitative study was to identify and describe themes derived from critical care nurses' comments regarding sedation administration practices with mechanically ventilated patients., Methods: This is a qualitative content analysis of secondary text data captured through a national electronic survey of members of the American Association of Critical-Care Nurses. A subsample (n = 67) of nurses responded to a single, open-ended item at the end of a survey that evaluated nurses' perceptions of current sedation administration practices., Findings: Multiple factors guided sedation administration practices, including individual patient needs, nurses' synthesis of clinical evidence, application of best practices, and various personal and professional practice perspectives. Our results also indicated nurses desire additional resources to improve their sedation administration practices including more training, better communication tools, and adequate staffing., Conclusions: Critical care nurses endorse recommendations to minimise sedation administration when possible, but a variety of factors, including personal perspectives, impact sedation administration in the intensive care unit and need to be considered. Critical care nurses continue to encounter numerous challenges when assessing and managing sedation of mechanically ventilated patients., (Copyright © 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Pain and sedation protocols are suggested to improve the outcomes of patients within paediatric intensive care. However, it is not clear how protocols will influence practice within individual units., Objectives: Evaluate a nurse led pain and sedation protocols impact on pain scoring and analgesic and sedative administration for post-operative cardiac patients within a paediatric intensive care unit., Methods: A retrospective chart review was performed on 100 patients admitted to a tertiary paediatric intensive care unit pre and post introduction of an analgesic and sedative protocol. Stata12 was used to perform Chi-squared or Student's t-test to compare data between the groups., Results: Post protocol introduction documentation of pain assessments increased (pre protocol 3/24h vs post protocol 5/24h, p=0.006). Along with a reduction in administration of midazolam (57.6mcg/kg/min pre protocol vs 24.5mcg/kg/min post protocol, p=0.0001). Children's pain scores remained unchanged despite this change, with a trend towards more scores in the optimal range in the post protocol group (5 pre protocol vs 12 post protocol, p=0.06)., Conclusions: Introducing a pain and sedation protocol changed bedside nurse practice in pain and sedation management. The protocol has enabled nurses to provide pain and sedation management in a consistent and timely manner and reduced the dose of midazolam required to maintain comfort according to the patients COMFORT B scores. Individual evaluation of practice change is recommended to units who implement nurse led analgesic and sedative protocols to monitor changes in practice., (Copyright © 2017 Australian College of Critical Care Nurses Ltd. All rights reserved.)

Objective: To evaluate the provision of procedural sedation during abortion by expert nurses and to describe the factors that are associated with time to discharge for women who receive this sedation., Design: Retrospective chart review., Methods: Descriptive statistics were generated to describe a retrospective cohort of women presenting for abortion under procedural sedation. Analysis of variance was used to determine significant characteristics that influenced time to discharge., Setting: A single clinical site that employs seven expert nurses., Participants: A total of 194 medical records were available for this analysis., Results: All women were discharged home with accompaniment, and no incidents of respiratory distress or other adverse complications occurred. Most women (n = 136) received at least 150 μg fentanyl and 3 mg midazolam, and 71% of women in the first trimester and 83% of women in the second trimester entered the recovery area with no pain. Variables significantly associated with time spent in the recovery area were gestational age at time of abortion (t = -2.68, p = .008), pain at entry to recovery area (t = -0.254, p = .008), and pain at 15 minutes (t = 0.25, p = .038)., Conclusion: Expert nurses can administer procedural sedation for pain control associated with abortion and are capable of monitoring women and helping them return to baseline status after the procedure., (Copyright © 2017 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Background: A variety of terms and attitudes surround palliative sedation (PS) with little research devoted to hospice and palliative care (HPC) clinicians' perceptions and experiences with PS. These factors may contribute to the wide variability in the reported prevalence of PS., Objective: This study was designed to better identify hospice and palliative care (HPC) clinician attitudes toward, and clinical experiences with palliative sedation (PS)., Methods: A 32-question survey was distributed to members of the American Academy of Hospice and Palliative Medicine (n = 4678). The questions explored the language clinicians use for PS, and their experiences with PS., Results: Nine hundred thirty-six (20% response rate) responded to the survey. About 83.21% preferred the terminology of PS compared with other terms. A majority felt that PS is a bioethically appropriate treatment for refractory physical and nonphysical symptoms in dying patients. Most felt PS was not an appropriate term in clinical scenarios when sedation occurred as an unintended side effect from standard treatments. Hospice clinicians use PS more consistently and with less distress than nonhospice clinician respondents. Benzodiazepines (63.1%) and barbiturates (18.9%) are most commonly prescribed for PS., Conclusion: PS is the preferred term among HPC clinicians for the proportionate use of pharmacotherapies to intentionally lower awareness for refractory symptoms in dying patients. PS is a bioethically appropriate treatment for refractory symptoms in dying patients. However, there is a lack of clear agreement about what is included in PS and how the practice of PS should be best delivered in different clinical scenarios. Future efforts to investigate PS should focus on describing the clinical scenarios in which PS is utilized and on the level of intended sedation necessary, in an effort to better unify the practice of PS.

Background: Inappropriate sedation assessment can jeopardize patient comfort and safety. Therefore, nurses' abilities in assessing and managing sedation are vital for effective care of mechanically ventilated patients., Aims and Objectives: This study assessed nurses' sedation scoring and management abilities as primary outcomes following educational interventions. Nurses' perceived self-confidence and barriers to effective sedation management were assessed as secondary outcomes., Design: A post-test-only quasi-experimental design was used. Data were collected at 3 and 9 months post-intervention., Methods: A total of 66 nurses from a 14-bed intensive care unit of a Malaysian teaching hospital participated. The educational interventions included theoretical sessions, hands-on sedation assessment practice using the Richmond Agitation Sedation Scale, and a brief sedation assessment tool. Nurses' sedation scoring and management abilities and perceived self-confidence level were assessed at both time points using self-administered questionnaires with case scenarios. Sedation assessment and management barriers were assessed once at 9 months post-intervention., Results: Median scores for overall accurate sedation scoring (9 months: 4·00; 3 months: 2·00, p = 0·0001) and overall sedation management (9 months: 14·0; 3 months: 7·0, p = 0·0001) were significantly higher at 9 months compared to 3 months post-intervention. There were no significant differences in the perceived self-confidence level for rating sedation level. Overall perceived barrier scores were low (M = 27·78, SD = 6·26, possible range = 11·0-55·0). Patient conditions (M = 3·68, SD = 1·13) and nurses' workload (M = 3·54, SD = 0·95) were the greatest barriers to effective sedation assessment and management. Demographic variables did not affect sedation scoring or management abilities., Conclusions: Positive changes in nurses' sedation assessment and management abilities were observed, indicating that adequate hands-on clinical practice following educational interventions can improve nurses' knowledge and skills., Relevance to Clinical Practice: Educational initiatives are necessary to improve ICU practice, particularly in ICUs with inexperienced nurses., (© 2015 British Association of Critical Care Nurses.)

Background: Despite recent advances in palliative medicine, sedating a terminally ill patient is regarded as an indispensable treatment to manage unbearable suffering. With the prospect of widespread use of palliative sedation, the feelings and representations of health care providers and staff (carers) regarding sedation must be carefully explored if we are to gain a better understanding of its impact and potential pitfalls. The objective of the study was to provide a comprehensive description of the opinions of carers about the use of sedation practices in palliative care units (PCU), which have become a focus of public attention following changes in legislation., Methods: Data were collected using a qualitative study involving multi-professional focus groups with health care providers and staff as well as personal narratives written by physicians and paramedical staff. A total of 35 medical and paramedical providers volunteered to participate in focus group discussions in three Palliative Care Units in two French hospitals and to write personal narratives., Results: Health care provider and staff opinions had to do with their professional stance and competencies when using midazolam and practicing sedation in palliative care. They expressed uncertainty regarding three aspects of the comprehensive care: biomedical rigour of diagnosis and therapeutics, quality of the patient/provider relationship and care to be provided. Focusing on the sedative effect of midazolam and continuous sedation until death, the interviewed health care providers examined the basics of their professional competency as well as the key role played by the health care team in terms of providing support and minimizing workplace suffering. Nurses were subject to the greatest misgivings about their work when they were called upon to sedate patients., Conclusions: The uncertainty experienced by the carers with regard to the medical, psychosocial and ethical justification for sedation is a source of psychological burden and moral distress, and it has proved to be a major source of suffering in the workplace. Lastly, the study shows the uncertainty can have the positive effect of prompting the care team to devise ways to deal with it.

Objectives: To evaluate the impact of a nurse-driven sedation protocol on the length of mechanical ventilation, total daily doses of sedatives, and complications of sedation., Design: A single-center prospective before and after study was conducted from October 2010 to December 2013., Setting: Twelve-bed surgical and medical PICU of the university-affiliated hospital in Nantes, France., Patients: A total of 235 patients, between 28 days and 18 years old, requiring mechanical ventilation for at least 24 hours were included in the study; data from 194 patients were analyzed., Interventions: During the first study phase, no protocol was used. During the second phase, patients were sedated according to a nurse-driven protocol., Measurements and Main Results: In the whole population, the length of mechanical ventilation did not differ between protocol and control groups (protocol, 4 [3-8] vs control, 5 [3-7.5]; p = 0.44). Analyzing age subgroups, the length of mechanical ventilation was significantly shorter in the protocol group than in the control group in children older than 12 months (4 [3-8] vs 5 [2.75-11.25] d; p = 0.04). Daily dose of midazolam decreased during the protocol phase compared with the control phase (1 [0.56-1.8] and 1.2 [0.85-2.4] mg/kg/d, respectively; p = 0.02). No differences were shown regarding other daily dose of drugs. In the control group, 68% of children had more than 20% of COMFORT-behavior scale assessment under the target (oversedation) versus 59% in the protocol group (p = 0.139)., Conclusions: Implementation of a nurse-driven sedation protocol in a PICU is feasible and safe, allowed a decrease in daily dose of benzodiazepines, and decreased the duration of mechanical ventilation in older patients.

Nursing management of pain, agitation, and delirium in mechanically ventilated patients is a challenge in critical care. Oversedation can lead to delayed extubation, prolonged ventilator days, unnecessary neurologic testing, and complications such as weakness and delirium. Undersedation can lead to self-extubation, invasive line removal, unnecessary patient distress, and injury to self or others. Acquiring an optimal level of sedation requires the bedside nurse to be more vigilant than ever with patient assessment and medication titration. This article provides a historical perspective of the management of pain, agitation, and delirium, and disseminates information contained in revised Society for Critical Care Medicine Clinical Practice Guidelines (January 2013) to promote their implementation in day-to-day nursing care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: To reevaluate the effect of a nursing-driven sedation protocol for mechanically ventilated patients on analgesic and sedative medication dosing durations. We hypothesized that lack of continued quality improvement efforts results in increased sedation exposure, as well as mechanical ventilation days, and ICU length of stay., Design: Quasi-experimental, uncontrolled before-after study., Setting: Forty-five-bed tertiary care, medical-surgical-cardiac PICU in a metropolitan university-affiliated children's hospital., Patients: Children requiring mechanical ventilation longer than 48 hours not meeting exclusion criteria., Interventions: During both the intervention and postintervention periods, analgesia and sedation were managed by nurses following an algorithm-based sedation protocol with a targeted comfort score., Measurement and Main Results: The intervention cohort includes patients admitted during a 12-month period following initial protocol implementation in 2008-2009 (n = 166). The postintervention cohort includes patients meeting identical inclusion and exclusion criteria admitted during a 12-month period in 2012-2013 (n = 93). Median duration of total sedation days (IV plus enteral) was 5 days for the intervention period and 10 days for the postintervention period (p < 0.0001). The postintervention cohort received longer duration of mechanical ventilation (6 vs 5 d; p = 0.0026) and ICU length of stay (10 vs 8.5 d; p = 0.0543). After adjusting for illness severity and cardiac and surgical status, Cox proportional hazards regression analysis demonstrated that at any point in time, patients in the postintervention group were 58% more likely to be receiving sedation (hazard ratio, 1.58; p < 0.001) and 34% more likely to remain in the ICU (hazard ratio, 1.34; p = 0.019)., Conclusions: Sedation quality improvement measures related to the use of opiate infusions, total days of sedation exposure, PICU length of stay, and mechanical ventilation days all deteriorated following initial successful implementation of a PICU sedation protocol. Implementation of a protocol alone may not lead to sustained quality improvement without routine monitoring and ongoing education to ensure effectiveness.

The sedation-assessment conundrum is the struggle to balance the need for sedation against the need to awaken the patient and perform a neurologic examination. This article discusses the nuances of the sedation-assessment conundrum as well as approaches to resolve this and reduce the negative impact of abruptly stopping sedative infusions. Both oversedation and undersedation affect critically ill patients. This article discusses methods of assessing sedation and interpreting individualized patient responses to sedation. The use of neurofunction monitors and periods of sedation interruption are discussed within the context of addressing the sedation-assessment conundrum., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background/aims: The efficacy of bispectral index (BIS) monitoring during colonoscopic sedation is debated. We aimed to determine whether BIS monitoring was useful for propofol dose titration, and to evaluate differences in sedative administration between expert and inexperienced medical personnel during colonoscopy procedures that required moderate sedation., Methods: Between February 2012 and August 2013, 280 consecutive patients scheduled to undergo a screening colonoscopy participated in this study and were randomly allocated to the expert or inexperienced endoscopist group. Each group was further divided into either a BIS or a modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) subgroup. Trained nurses administered combined propofol sedation and monitored sedation using either the BIS or MOAA/S scale., Results: The mean BIS value throughout the procedure was 74.3 ± 6.7 for all 141 patients in the BIS group. The mean total propofol dose administered in the BIS group was higher than that in the MOAA/S group, independently of the endoscopists' experience level (36.9 ± 29.6 and 11.3 ± 20.7, respectively; p < 0.001). The total dose of propofol administered was not significantly different between the inexperienced endoscopist group and the expert endoscopist group, both with and without the use of BIS (p = 0.430 and p = 0.640, respectively)., Conclusions: Compared with monitoring using the MOAA/S score alone, BIS monitoring was not effective for titrating the dose of propofol during colonoscopy, irrespective of colonoscopist experience.

Aims and Objectives: The aim of this study was to explore factors influencing practices in assessing, titrating and managing sedation for the critically ill intubated patients, from the perspective of emergency nurses., Background: The number of critically ill patients presenting to Australian public Emergency Departments has increased by over 30% since 1980. Emergency nurses are increasingly relied upon to manage sedation of critically ill intubated patients. There is little evidence within international literature relating to how emergency nurses accomplish this., Design: Descriptive qualitative study., Method: A purposive sample of 15 experienced emergency nurses participated in semi-structured face-to-face interviews. Transcribed data were analysed using thematic analysis., Results: The qualitative analysis yielded five themes: becoming the resuscitation nurse; becoming confident as the resuscitation nurse; communicating about sedation; visual cues and the vanishing act. The safety and quality of sedation experienced by critically ill intubated patients in ED was the responsibility of emergency nurses, yet uncertainties and barriers were evident., Conclusion: Patient continuity of care, including optimisation of comfort relies upon the knowledge, skills and expertise of the emergency nurse allocated to the resuscitation area. For most nurses transitioning into the resuscitation nurse role, it represents the first time they will have had contact with patients with highly complex needs and sedation. The use of self-directed clinical workbooks and supervised clinical practice alone may be insufficient to adequately prepare nurses for the spectrum of critically ill sedated patients managed in the resuscitation area; a situation made worse in the presence of poor team communication., Relevance to Clinical Practice: The findings of this study should assist in the development of policy and formal education of emergency nurses transitioning into the resuscitation area and the management of continuous intravenous sedation to critically ill mechanically ventilated patients is required., (© 2015 John Wiley & Sons Ltd.)

The Society for Gastroenterology Nurses and Associates (SGNA) launched a nurse fellowship program in 2011 to promote evidence-based practice. Each accepted applicant was challenged to select a relevant topic, explore the current research, and translate this information to daily practice. The author, an SGNA Fellow, selected the topic, nurse-administered propofol sedation, that has been a prevailing subject in endoscopy for many years. A significant amount of literature has been written on the drug's safety and efficacy. This article explores a brief history of the practice and the future of this controversial drug for procedural sedation. A review of current literature is explored with an emphasis on the past 5 years as well as a discussion on regulatory limitations that have been placed on the practice of non-anesthesiologist-administered propofol sedation.

Background: Critically ill mechanically ventilated patients in ED have complex needs; chief among these is adequate sedation in addition to effective pain-relief. Emergency nurses are increasingly responsible sedation and analgesia for this complex cohort of patients. The aim of this review was to examine (1) the evidence around assessing, monitoring and managing continuous intravenous sedation for critically ill adult patients, and (2) the implications for emergency nursing practice., Study Design: Systematic review., Method: The review of literature extended from 1946 to 2013 and examined peer review journal articles, policy and guidelines to provide a more complex understanding of a phenomenon of concern. A total of 98 articles were incorporated and comprehensively examined., Results: Analysis of the literature identified several implications for emergency nursing practice and the management of continuous intravenous sedation: workload, education, monitoring and assessing sedation and policy., Conclusion: Limited literature was found that directly addressed Australasian emergency nursing practices' in managing on-going intravenous sedation and analgesia for patients. Balancing patient sedation and analgesia requires highly complex knowledge, skills and expertise; the degree of education and training required is above that obtained during pre-registration nurse training. No state or national models of education or training were identified to support ED nurses' practices in managing sedation. Little research has addressed the safety of continuous sedation use in ED., (Copyright © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.)

Introduction: Non-anaesthesiologist-administered propofol sedation (NAPS/NAAP) is increasingly used in many countries. Most regimens aim for light or moderate sedation. Little evidence on safety of deep NAPS sedation is available. The aim of this study was to explore the safety of intermittent deep sedation with NAPS in patients undergoing gastroenterologic endoscopic procedures., Methods: This was a retrospective case-control study. All patients sedated with NAPS for colonoscopies, sigmoidoscopies and oesophagogastroduodenoscopies from May 2007 through December 2012 were included. Cases were defined as patients developing an adverse event (oxygen saturation < 92%, a drop in mean arterial pressure of > 30% or a drop in systolic blood pressure of > 50 mmHg). The remaining patients served as controls., Results: A total of 6,840 consecutive patients undergoing 7,364 procedures were included. The mean propofol dose was 331.6 mg (standard deviation = 179.4 mg). The overall rate of hypoxia was 3.2%, and the rate of hypotension was 3.1%. Assisted ventilation was needed in 0.5%. Age (p < 0.001), American Society of Anesthesiologists (ASA) class 3 (p = 0.017) and total propofol dose (p = 0.001) were associated with a higher rate of adverse events., Conclusion: Safety during intermittent deep sedation with NAPS was good. Age, ASA class 3 and total propofol dose were correlated with a higher rate of adverse events. Patients aged 60 years or more needed more handling during adverse events., Funding: Arvid Nilsson's Foundation provided funding for this study. The founders did not have any influence on the design or the presentation of the study., Trial Registration: not relevant.

Background: International studies show that the majority of patients undergoing treatment in ICUs report moderate to strong levels of pain. It has been established that undetected or insufficiently treated pain can cause severe physical and emotional distress. Therefore, early and effective pain assessment is a primary treatment goal of intensive care, which is a challenge with patients having cognitive impairment., Aim: This article shows how using the Zurich Observation Pain Assessment (ZOPA(©)) as part of a standardized assessment can close this gap., Method: An interpretive single case study evaluates the use of ZOPA(©) in nursing practice and its influence on pain management., Results: The study case involved an intensive care patient with a severe subarachnoid haemorrhage for whom a total of 126 single ZOPA(©) assessments were analyzed. A total of 19 assessments showed behavioral characteristics indicative of pain. Immediate interventions to alleviate pain were taken in three quarters of these assessments. The study ICU has used ZOPA(©) for the past five years. This unit has a standard medication procedure, so nurses can administer analgesics on an "as needed" basis and take their responsibility in implementing pain management., Conclusion: This study supports the finding that ZOPA(©) can contribute to early and effective detection of pain in cognitively impaired patients, resulting in improved pain treatment.

Background: Modern concepts for sedation and analgesia and guidelines recommend light analgesia and sedation, so that patients on mechanically ventilation are more awake, compared to previous concepts. Hence, these patients are more alert and able to experience their situation on the ventilator and their endotracheal tube (ETT)., Problem: There is currently no convincing evidence of how patients tolerate the tube under present conditions, which interventions could help them, or whether they want to be sedated deeper because of the tube. Based upon our own observations, a broad range of reactions are possible., Purpose: The tolerance of the ETT in intensive care patients was explored., Method: A systematic literature research without time constraints in the databases PubMed and CINAHL was performed. Included were quantitative and qualitative studies written in German or English that investigated tolerance of the ETT in adult intensive care patients. Excluded were anesthetic studies including in- and extubation immediately before and after operations., Results: Of the 2348 hits, 14 studies were included, including 4 qualitative studies about the experience of intensive care, 8 quantitative studies including 2 randomized controlled studies, and 2 studies with a mixed approach. Within the studies different aspects could be identified, which may in- or decrease the tolerance of an ETT. Aspects like breathlessness, pain during endotracheal suctioning and inability to speak decrease the tolerance. Information, the presence of relatives and early mobilization appear to increase the tolerance., Conclusion: Tolerance of the ETT is a complex phenomenon. A reflected and critical evaluation of the behavior of the patient with an ETT is recommended. Interventions that increase the tolerance of the ETT should be adapted to the situation of the patient and should be evaluated daily.

Aim: This paper reports a systematic literature review examining the range of published observational sedation-scoring instruments available in the assessment, monitoring and titration of continuous intravenous sedation to critically ill adult patients in the Emergency Department, and the extent to which validity, reliability, responsiveness and applicability of the instruments has been addressed., Background: Emergency nurses are increasingly responsible for the ongoing assessment, monitoring and titration of continuous intravenous sedation, in addition to analgesia for the critically ill adult patient. One method to optimise patient sedation is to use a validated observational sedation-scoring tool. It is not clear however what the optimal instrument available is for use in this clinical context., Methods: A systematic literature review methodology was employed. A range of electronic databases were searched for the period 1946-2013. Search terms incorporated "sedation scale", "sedation scoring system", "measuring sedation", and "sedation tool" and were used to retrieve relevant literature. In addition, manual searches were conducted and articles retrieved from those listed in key papers. Articles were assessed using the Critical Appraisal Skills Program (CASP) making sense of evidence tools., Results: A total of 27 observational sedation-scoring instruments were identified. Sedation-scoring instruments can be categorised as linear or composite, the former being the most common. A wide variety of patient behaviours are used within the instruments to measure depth and quality of patient sedation. Typically sedation-scoring instruments incorporated three patient behaviours, which were then rated to generate a numerical score. The majority of the instruments have been subjected to validity and reliability testing, however few have been examined for responsiveness or applicability., Conclusions: None of the 27 observational sedation-scoring instruments were designed or trialled within ED. The Richmond Agitation and Assessment Scale was identified as most suitable to be trialled prospectively within an Australian ED., (Copyright © 2014 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.)

Neonates are exposed to repetitive pain and stress during their stay in a NICU, which can lead to chronic complications related to their neurodevelopment and neurobehavior. Approximately 20 percent of all neonates in a NICU are intubated, mechanically ventilated, and require suctioning, which can cause both acute and chronic pain. Pain management in the neonate can be challenging. Nurses and other caregivers need to be well trained to assess pain in the neonate to effectively identify and provide appropriate pain management strategies. There is a lack of evidence to support routine administration of opiates in the neonate. As with any medication, the possibility of short- and long-term adverse reactions must be considered. Nonpharmacologic therapy should be used as much as possible.

Background: Pharmacological sedation is a necessary tool in the management of critically ill, mechanically ventilated patients. The intensive care unit (ICU) sedation strategy is to use the least amount of medication to meet safety and comfort goals. Titration of pharmacological agents is currently guided by clinical assessment tools. The purpose of this study was to determine whether the addition of a neurophysiological monitor, bispectral index (BIS), aided the ICU nurse in reducing the amount of drug used, compared to a clinical tool alone, in a general critical care population., Methods: In this prospective clinical trial, mechanically ventilated adults (N=300) were randomised to sedation assessment using only the observational assessment tool (RASS) or a combination of observational and physiologic measures (RASS+BIS). Subjects were enrolled from a medical ICU (N=154), a trauma ICU (N=72) and a general mixed-use ICU (N=74)., Results: BIS-augmented sedation was only associated with the reduction of drug use when patients were sedated with propofol or narcotic agents (propofol [1.61 mg/kg/h vs. 1.77 mg/kg/h; p<0.0001], fentanyl [54.73 mcg/h vs. 66.81 mcg/h; p<0.0001], and hydromorphone [0.97 mg/h vs. 4.00 mg/h: p<0.0001] compared to RASS alone. In contrast, patients sedated with dexmedetomidine or benzodiazepines were given higher doses under the BIS-augmented dexmedetomidine [0.46 mcg/kg/h vs. 0.33 mcg/kg/h; p<0.0001], lorazepam [4.13 mg/h vs. 3.29 mg/h p<0.0001], and midazolam [3.73 mg/h vs 2.86 mg/h; p<0.0001]) protocol compared to clinical assessment alone., Conclusion: The clinical evaluation of depth of sedation remains the most reliable method for the titration of pharmacological sedation in the critical care unit. However, BIS-augmented assessment is helpful in reducing the amount of propofol and narcotic medication used and may be considered an adjunct when these agents are utilised., (Copyright © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Knowledge of current trends in nurse-administered procedural sedation and analgesia (PSA) in the cardiac catheterisation laboratory (CCL) may provide important insights into how to improve safety and effectiveness of this practice., Objective: To characterise current practice as well as education and competency standards regarding nurse-administered PSA in Australian and New Zealand CCLs., Design: A quantitative, cross-sectional, descriptive survey design was used., Methods: Data were collected using a web-based questionnaire on practice, educational standards and protocols related to nurse-administered PSA. Descriptive statistics were used to analyse data., Results: A sample of 62 nurses, each from a different CCL, completed a questionnaire that focused on PSA practice. Over half of the estimated total number of CCLs in Australia and New Zealand was represented. Nurse-administered PSA was used in 94% (n=58) of respondents CCLs. All respondents indicated that benzodiazepines, opioids or a combination of both is used for PSA (n=58). One respondent indicated that propofol was also used. 20% (n=12) indicated that deep sedation is purposefully induced for defibrillation threshold testing and cardioversion without a second medical practitioner present. Sedation monitoring practices vary considerably between institutions. 31% (n=18) indicated that comprehensive education about PSA is provided. 45% (n=26) indicated that nurses who administer PSA should undergo competency assessment., Conclusion: By characterising nurse-administered PSA in Australian and New Zealand CCLs, a baseline for future studies has been established. Areas of particular importance to improve include protocols for patient monitoring and comprehensive PSA education for CCL nurses in Australia and New Zealand., (Copyright © 2013 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: Nurse Administered Propofol Sedation (NAPS) contributes to a deeper sedation of the patients, making them unable to respond to pain and an increased incidence of perforations has been speculated. The objective of this study was to evaluate the risk of perforations during colonoscopies performed with either NAPS or conventional sedation regimes., Material and Methods: Data were retrospectively retracted from medical journals from 1 January 2007 to 31 December 2011. All journals were examined and cross-referenced to reveal any perforations. We analyzed all colonoscopies in regard to nature of the procedure (diagnostic vs therapeutic), experience of the endoscopist and ASA-classification of the patients., Results: A total of 6371 colonoscopies were performed, of which 3155 were performed under propofol sedation. There were 16 perforations (0.25%); 10 of these performed during NAPS and 6 during conventional colonoscopy (p = 0.454, OR: 1.7 (95% CI: 0.6-5.7)). There were 4874 diagnostic and 1497 therapeutic colonoscopies, with a majority of the perforations (94%) occurring during a diagnostic procedure (p = 0.389). No statistically difference was found in the incidence of perforations caused by an experienced or less experienced endoscopist (p = 0.589)., Conclusion: The risk of colonic perforations during colonoscopy was not found to be significantly higher in patients undergoing NAPS compared to patients undergoing conventional sedation, although a tendency may exist. Furthermore, we found no correlation to neither experience of the endoscopist, nature of the procedure nor sex of the patients. Larger and prospective studies are needed to further evaluate on this subject.

Objective: To describe and analyze the development and psychometric properties of subjective sedation scales developed for critically ill adult patients., Data Sources: PubMed, MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, CINAHL, Scopus, ISI Web of Science, and the International Pharmaceutical Abstracts., Study Selection: English-only publications through December 2012 with at least 30 patients older than 18 years, which included the key words of adult, critically ill, subjective sedation scale, sedation scale, validity, and reliability., Data Extraction: Two independent reviewers evaluated the psychometric properties using a standardized sedation scale psychometric scoring system., Data Synthesis: Among the 19,000+ citations extracted for the 2013 Society of Critical Care Medicine's Clinical Practice Guidelines for the Management of Pain, Agitation and Delirium and from December 2010 to 2012, 36 articles were identified compassing 11 sedation scales. The scale development process, psychometric properties, feasibility, and implementation of sedation scales were analyzed using a 0-20 scoring system. Two scales demonstrated scores indicating "very good" published psychometric properties: Richmond Agitation-Sedation Scale (19.5) and the Sedation-Agitation Scale (19). Scores with "moderate" properties include the Vancouver Interaction and Calmness Scale (14.3), Adaptation to the Intensive Care Environment (13.7), Ramsay Sedation Scale (13.2), Minnesota Sedation Assessment Tool (13), and the Nursing Instrument for the Communication of Sedation (12.8). Scales with "low" properties included the Motor Activity Assessment Scale (11.5) and the Sedation Intensive Care Score (10.5). The New Sheffield Sedation Scale (8.5) and the Observer's Assessment of Alertness/Sedation Scale (3.7) demonstrated "very low" published properties., Conclusions: Based on the current literature, and using a predetermined psychometric scoring system, the Richmond Agitation-Sedation Scale and the Sedation-Agitation Scale are the most valid and reliable subjective sedation scales for use in critically ill adult patients.

Background: Side effects of the medications used for procedural sedation and analgesia in the cardiac catheterisation laboratory are known to cause impaired respiratory function. Impaired respiratory function poses considerable risk to patient safety as it can lead to inadequate oxygenation. Having knowledge about the conditions that predict impaired respiratory function prior to the procedure would enable nurses to identify at-risk patients and selectively implement intensive respiratory monitoring. This would reduce the possibility of inadequate oxygenation occurring., Aim: To identify pre-procedure risk factors for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory., Design: Retrospective matched case-control., Methods: 21 cases of impaired respiratory function were identified and matched to 113 controls from a consecutive cohort of patients over 18 years of age. Conditional logistic regression was used to identify risk factors for impaired respiratory function., Results: With each additional indicator of acute illness, case patients were nearly two times more likely than their controls to experience impaired respiratory function (OR 1.78; 95% CI 1.19-2.67; p = 0.005). Indicators of acute illness included emergency admission, being transferred from a critical care unit for the procedure or requiring respiratory or haemodynamic support in the lead up to the procedure., Conclusion: Several factors that predict the likelihood of impaired respiratory function were identified. The results from this study could be used to inform prospective studies investigating the effectiveness of interventions for impaired respiratory function during nurse-administered procedural sedation and analgesia in the cardiac catheterisation laboratory.

Objective: To evaluate the implementation of a neonatal pain and sedation protocol at 2 ICUs., Methods: The intervention started with the evaluation of local practice, problems, and staff satisfaction. We then developed and implemented the Vienna Protocol for Neonatal Pain and Sedation. The protocol included well-defined strategies for both nonpharmacologic and pharmacologic interventions based on regular assessment of a translated version of the Neonatal Pain Agitation and Sedation Scale and titration of analgesic and sedative therapy according to aim scores. Health care staff was trained in the assessment by using a video-based tutorial and bedside teaching. In addition, we performed reevaluation, retraining, and random quality checks. Frequency and quality of assessments, pharmacologic therapy, duration of mechanical ventilation, and outcome were compared between baseline (12 months before implementation) and 12 months after implementation., Results: Cumulative median (interquartile range) opiate dose (baseline dose of 1.4 [0.5-5.9] mg/kg versus intervention group dose of 2.7 [0.4-57] mg/kg morphine equivalents; P = .002), pharmacologic interventions per episode of continuous sedation/analgesia (4 [2-10] vs 6 [2-13]; P = .005), and overall staff satisfaction (physicians: 31% vs 89%; P < .001; nurses: 17% vs 55%; P < .001) increased after implementation. Time on mechanical ventilation, length of stay at the ICU, and adverse outcomes were similar before and after implementation., Conclusions: Implementation of a neonatal pain and sedation protocol at 2 ICUs resulted in an increase in opiate prescription, pharmacologic interventions, and staff satisfaction without affecting time on mechanical ventilation, length of intensive care stay, and adverse outcomes.

The American Society for Pain Management Nursing convened a taskforce to develop guidelines on monitoring for opioid-induced sedation and respiratory depression. Part of the guideline development was the determination of nursing practice patterns related to monitoring and preventing respiratory depression during the administration of analgesics for pain. One hundred and forty-seven responses were received from 90 unique institutions across the United States. Monitoring adults with intermittent pulse oximetry while using intravenous patient-controlled analgesia (IV PCA) was 58%. Adults were monitored with continuous pulse oximetry by 25% of respondents. When using continuous epidural analgesia, 56% of patients were monitored intermittently, and 40% were monitored continuously. The use of end tidal CO2 (ETCO2) monitoring was much less, with 2.2% patients on epidural therapy, and 1.5% of institutions were using ETCO2 with IV PCA. The survey also included the location of the alarm, respiratory parameters for alarms, changes in procedures reported by institutions, and definitions of high-risk patients., (Copyright © 2013 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)