Registered Nurses Engaged in the Administration of Sedation and Analgesia

Formerly Considerations for Policy Development Number 4.2

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Although the safest care for patients receiving sedation and analgesia is provided by a qualified anesthesia professional, a large number of registered nurses are involved in the administration of sedation and analgesia.  To promote safe care during sedation and analgesia and to address questions which have been raised by nursing organizations and healthcare institutions with respect to the necessary qualifications of registered nurses involved in this care, the American Association of Nurse Anesthetists (AANA) suggests the following policy considerations. These considerations do not supersede or give the effect to more restrictive relevant laws, regulations, judicial and administrative decisions and interpretations, accepted standards and scopes of practice established by professional nursing organizations, or institutional policies applicable to registered nurses, which should be reviewed prior to the development of any sedation and analgesia policy.

Definition
Sedation and analgesia describes a pharmacologically controlled state of depressed consciousness that allows protective reflexes to be maintained.  The patient retains the ability to independently maintain his or her airway and to respond purposefully to verbal commands and/or tactile stimulation.  The American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia has developed Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists which states "sedation and analgesia describes a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and tactile stimulation."  The task force decided that the term sedation and analgesia more accurately defines this therapeutic goal than does the more commonly used but imprecise term of "conscious sedation."  Those patients whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than encompassed by sedation and analgesia.

The Joint Commission on Accreditation of Healthcare Organizations has introduced to its standards definitions for four levels of sedation and anesthesia.  Minimal sedation, where the patient responds normally; moderate sedation/analgesia (conscious sedation), where an airway and cardiovascular function is maintained; deep sedation/analgesia, in which the patient is not easily aroused; and anesthesia, in which the patient requires assisted ventilation.  Sedation and analgesia may easily be converted to deep sedation with loss of consciousness because of the agents used and the physical status and drug sensitivities of the individual patient.  The administration of sedation and analgesia requires constant monitoring of the patient and the ability of the administrator to respond immediately to any adverse reaction or complication.  Vigilance of the administrator and the ability to recognize and intervene as event complications or undesired outcomes arise are essential requirements for individuals administering sedation and analgesia.

A. Qualifications  

  1. The registered nurse is allowed by state law and institutional policy to administer sedation and analgesia.
  2. The healthcare facility shall have in place an educational/credentialing mechanism which includes a process for evaluating and documenting the individual’s competency relating to the management of patients receiving sedation and analgesia.  Evaluation and documentation occur on a periodic basis.  
  3. The registered nurse managing and monitoring the care of patients receiving sedation and analgesia is able to:
    1. Demonstrate the acquired knowledge of anatomy, physiology, pharmacology, cardiac arrhythmia recognition, and complications related to sedation and analgesia and medications.
    2. Assess the total patient care requirements before and during the administration of sedation and analgesia, including the recovery phase.
    3. Understand the principles of oxygen delivery, transport and uptake, and respiratory physiology, as well as understand and use oxygen delivery devices.
    4. Recognize potential complications of sedation and analgesia for each type of agent being administered.
    5. Possess the competency to assess, diagnose, and intervene in the event of complications and to institute appropriate interventions in compliance with orders or institutional protocols.
    6. Demonstrate competency, through advanced cardiac life support (ACLS) or pediatric cardiac life support (PCLS), in airway management and resuscitation appropriate to the age of the patient. 
    7. The registered nurse administering sedation and analgesia understands the legal ramifications of providing this care and maintains appropriate liability insurance. 

B. Management and Monitoring

Registered nurses who are not qualified anesthesia providers may be authorized to manage and monitor sedation and analgesia during therapeutic, diagnostic or surgical procedures if the following criteria are met.  These criteria should be interpreted in a manner consistent with the remainder of this document.

  1. Guidelines for patient monitoring and drug administration and protocols for dealing with potential complications or emergency situations, developed in accordance with accepted standards of anesthesia practice, are available.
  2. A qualified anesthesia professional or attending physician selects and orders the agents to achieve sedation and analgesia.
  3. Registered nurses who are not qualified anesthesia professionals should not administer agents classified as anesthetics, including but not limited to ketamine, propofol, etomidate, sodium thiopental, methohexital, nitrous oxide and muscle relaxants.
  4. The registered nurse managing and monitoring the patient receiving sedation and analgesia shall have no other responsibilities during the procedure.
  5. Venous access shall be maintained for all patients having sedation and analgesia.
  6. Supplemental oxygen shall be available for any patient receiving sedation and analgesia, and when appropriate in the post-procedure period.
  7. Documentation and monitoring of physiologic measurements including but not limited to blood pressure, respiratory rate, oxygen saturation, cardiac rate and rhythm, and level of consciousness should be recorded at least every five minutes.
  8. An emergency cart must be immediately accessible to every location where sedation and analgesia is administered.  This cart must include emergency resuscitative drugs, airway and ventilatory equipment, a defibrillator, and a source for administration of 100 percent oxygen.  A positive pressure breathing device, oxygen, suction, and appropriate airways must be placed in each room where sedation and analgesia is administered.
  9. Back-up personnel who are experts in airway management, emergency intubations, and advanced cardiopulmonary resuscitation must be available.
  10. A qualified professional capable of managing complications is present in the facility and remains in the facility until the patient is stable.
  11. A qualified professional authorized under institutional guidelines to discharge the patient remains in the facility to discharge the patient in accordance with established criteria of the facility. 
References  
  1. American Academy of Pediatrics guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics. 1992; 89:1110-1114.
  2. Barr J, Donner A. Optimal intravenous dosing strategies for sedatives and analgesics in the intensive care unit. Critical Care Clinics. 1995; 11:827-847.
  3. Finnie G. Conscious sedation and plastic surgery. Specialty Nursing Forum. 1990; 2:8.
  4. Gunn IP. The many issues regarding IV conscious sedation. Specialty Nursing Forum. 1990; 2:2.
  5. Harvard minimal monitoring standards. Journal of the American Medical Association. 1986; 256:8.
  6. Holzman RS, Cullen DJ, Eichhorn JK, Philip JH. Guidelines for sedation by non-anesthesiologists during diagnostic and therapeutic procedures. Journal of Clinical Anesthesia. 1994; 6(4):265-276.
  7. Joint Commission on Accreditation of Health Care Organizations. Care of patients-examples for use of anesthesia and conscious sedation.  JCAHO Accreditation Manual for Hospitals. 1996; 194-201.
  8. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive Accreditation Manual for Hospitals, the official handbook. 2000.
  9. Kallar SK.  Conscious sedation for outpatient surgery. Wellcome Trends in Anesthesiology. 1991; 9:8-9.
  10. Kingsbury JA.  IV conscious sedation: JCAHO and hospital issues. Specialty Nursing Forum 1990; 2:7-8.
  11. Nemiroff MS. IV conscious sedation: essential techniques of monitoring. Trends in Health Care, Law & Ethics. 1993; 8:87-94.
  12. Society of Gastroenterology Nurses and Associates, Inc.  Nursing Care of the Patient Receiving Conscious Sedation in the Gastrointestinal Endoscopy Setting. Rochester, New York; 1991.
  13. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 1996; 84;459-71.
  14. American Association of Nurse Anesthetists. Qualified Providers of Conscious Sedation Position Statement 2.2.  Park Ridge, IL: American Association of Nurse Anesthetists; 1996.
  15. American Nurses Association.  Position Statement on the Role of the Registered Nurse (RN) in the Management of Patients Receiving IV Conscious Sedation for Short-Term Therapeutic, Diagnostic, or Surgical Procedures—ANA Collaborative Statement. Washington, DC: American Nurses Association; 1991.
  16. Spry CC.  Perioperative nurses should keep monitoring within their specialty. AORN Journal. 1990; 51:1071-1072.
  17. Watson DS. Recommended practices for monitoring and administering IV conscious sedation. Specialty Nursing Forum. 1990; 2:3.

  


Approved by AANA Board of Directors June 1996.
Revised by AANA Board of Directors June 2003 and November 2005.