A nonrandomized comparative study reported equivocal outcomes (e.g., emesis, apnea, oxygen levels) when preprocedure fasting (i.e., liquids or solids) is compared to no fasting (category B1-E evidence).27 Another nonrandomized comparison of fasting for less than 2h versus fasting for greater than 2h reported equivocal findings for emesis, oxygen saturation levels, and arrhythmia for infants (category B1-E evidence).28 Finally, a third nonrandomized comparison reported equivocal findings for gastric volume and pH when fasting of liquids for 0.5 to 3h is compared with fasting times of greater than 3h (category B1-E evidence).29. We're proud to recognize these industry supporters for their year-round support of the American Society of Anesthesiologists. 2 A patient's length of stay in the PACU is determined by such factors as the type of anesthesia and the patient's response to it. 2. The literature is also insufficient to evaluate the effects of using predetermined discharge criteria on patient outcomes. Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients: A prospective, controlled study. The Guidelines may need to be modi-fied to meet the needs of certain patient populations, such as children or the elderly. Sedation in uncooperative children undergoing dental procedures: A comparative evaluation of midazolam, propofol and ketamine. The first study published in the era of pulse oximetry examined 18,000 anesthetics and found that the three most common post-op complications were: (1) nausea/vomiting (42% of complications); (2) need for upper airway support (29%); and (3) hypotension (13%). Analgesics (e.g., opioids, nonsteroidal antiinflammatory drugs, and local anesthetics) are included either in comparison groups or in combination with sedatives intended for general anesthesia. 1. C. Two conscious patients, stable, 8 years of age and under, with family or competent support staff present but not . Recently, these discharge criteria have also been used in the operating room (OR) to determine the fast-track eligi-bility of outpatients undergoing ambulatory surgery (2,3). General medical supervision and coordination of patient care in the PACU should be the responsibility of an anesthesiologist. five . Results for each pertinent outcome were summarized, and when sufficient numbers of RCTs were found, study grading and meta-analyses were conducted. Pulse oximetry during minor oral surgery with and without intravenous sedation. The use of flumazenil to reverse sedation induced by bolus low dose midazolam or diazepam in upper gastrointestinal endoscopy. Fourth, survey opinions about the guideline recommendations were solicited from a random sample of active members of the ASA and participating medical specialty societies. Listed on 2023-03-01. The ASA Committee on Standards and Practice Parameters reviews all practice guidelines at the ASA annual meeting and determines update and revision timelines. 2. B. Periodically (e.g., at 5-min intervals) monitor a patients response to verbal commands during moderate sedation, except in patients who are unable to respond appropriately (e.g., patients where age or development may impair bidirectional communication) or during procedures where movement could be detrimental, During procedures where a verbal response is not possible (e.g., oral surgery, restorative dentistry, upper endoscopy), check the patients ability to give a thumbs up or other indication of consciousness in response to verbal or tactile (light tap) stimulation; this suggests that the patient will be able to control his airway and take deep breaths if necessary##, Continually*** monitor ventilatory function by observation of qualitative clinical signs, Continually monitor ventilatory function with capnography unless precluded or invalidated by the nature of the patient, procedure, or equipment, For uncooperative patients, institute capnography after moderate sedation has been achieved, Continuously monitor all patients by pulse oximetry with appropriate alarms, Determine blood pressure before sedation/analgesia is initiated unless precluded by lack of patient cooperation, Once moderate sedation/analgesia is established, continually monitor blood pressure (e.g., at 5-min intervals) and heart rate during the procedure unless such monitoring interferes with the procedure (e.g., magnetic resonance imaging where stimulation from the blood pressure cuff could arouse an appropriately sedated patient), Use electrocardiographic monitoring during moderate sedation in patients with clinically significant cardiovascular disease or those who are undergoing procedures where dysrhythmias are anticipated, Record patients level of consciousness, ventilatory and oxygenation status, and hemodynamic variables at a frequency that depends on the type and amount of medication administered, the length of the procedure, and the general condition of the patient, At a minimum, this should occur (1) before the administration of sedative/analgesic agents; (2) after administration of sedative/analgesic agents; (3) at regular intervals during the procedure; (4) during initial recovery; and (5) just before discharge, Set device alarms to alert the care team to critical changes in patient status, Assure that a designated individual other than the practitioner performing the procedure is present to monitor the patient throughout the procedure, The individual responsible for monitoring the patient should be trained in the recognition of apnea and airway obstruction and be authorized to seek additional help, The designated individual should not be a member of the procedural team but may assist with minor, interruptible tasks once the patients level of sedation/analgesia and vital signs have stabilized, provided that adequate monitoring for the patients level of sedation is maintained. If the bed isn;t available then the patient is considered as being in a Phase Ii level of care. Risk factors associated with vasovagal reactions during colonoscopy. Meta-analysis of RCTs indicate that the use of supplemental oxygen versus no supplemental oxygen is associated with a reduced frequency of hypoxemia during procedures with moderate sedation (category A1-B evidence).6571 The literature is insufficient to examine which methods of supplemental oxygen administration (e.g., nasal cannula, face mask, or specialized devices) are more effective in reducing hypoxemia. Patient Discharge Education in the Phase II Setting, 4. Sedation for day-case urology: An assessment of patient recovery profiles after midazolam and flumazenil. 1-612-816-8773. Forty-four respondents (84.62%) indicated that the guidelines would have no effect on the amount of time spent on a typical case with the implementation of these guidelines. "K|eu:KO{z]t[_Lahj$Ay[m TYag"^v{Ieb%M67#x]E+1m*SE&@:Z bhX #{Dw $ augUN0\eK A point score of 2 is assigned when the patient is fully awake, able to answer questions and call for assistance. THE PATIENTS CONDITION SHALL BE EVALUATED CONTINUALLY IN THE PACU. Level 4: The literature contains case reports. Proceed based on the facility policy for unaccompanied discharge, including consideration for Phase 2 recovery time for increased observation. The patients status on arrival in the PACU shall be documented. Practitioners are cautioned that acute reversal of opioid-induced analgesia may result in pain, hypertension, tachycardia, or pulmonary edema. The use of basic parameters for monitoring the haemodynamic effects of midazolam and ketamine as opposed to propofol during cardiac catheterization. Accepted studies from the previous guidelines were also rereviewed, covering the period of August 1, 1976, through December 31, 2002.1 Only studies containing original findings from peer-reviewed journals were acceptable. Conscious sedation for gastroscopy: Patient tolerance and cardiorespiratory parameters. Job in Plattsburgh - Clinton County - NY New York - USA , 12903. Discharge medications; instructions for pain management a. Conversely, inadequate sedation or analgesia can result in undue patient discomfort or patient injury, lack of cooperation, or adverse physiological or psychological responses to stress. The 2008 standards of the American Society of PeriAnesthesia Nurses (ASPAN) 6 lists voiding as part of discharge criteria for phase II recovery but recognizes that there are variations in voiding requirements depending on the policies of individual institutions. Ensure standard of care is met for all patients. Healthcare database searches included PubMed, EMBASE, Web of Science, Google Books, and the Cochrane Central Register of Controlled Trials. ASPAN Standards and Guidelines Committee. The literature is insufficient to assess whether the presence of an individual capable of establishing a patent airway, positive pressure ventilation, and resuscitation will improve outcomes. Such requirements arise from the dual physiologic insult of surgery and anesthesia on the human body. Our rules are if there is a patient in the unit, there must be 2 RNs. Phase II discharge aspan standards for phase 2 staffing. @~ (* {d+}G}WL$cGD2QZ4 E@@ A(q`1D `'u46ptc48.`R0) Developed By: Committee on Standards and Practice Parameters Seven respondents (13.46%) indicated that there would be an increase in the amount of time, with four of these respondents estimating an increase ranging from 5 to 15min. Conscious sedation in the emergency department: The value of capnography and pulse oximetry. The guidelines exclude patients who are not undergoing a diagnostic or therapeutic procedure (e.g., postoperative analgesia). Support was provided solely from institutional and/or departmental sources in the American Society of Anesthesiologists. D. Requirements for determining discharge readiness 1. Phase II The phase of recovery needed to get the surgical patient to be discharged to the medical facilities. At our hospital phase 2 is only for patients being discharged to home. STANDARD IV "{A$K&}"`v6t|-`"@2L0"C/`5i@H_ `YF@c}0 _U 3. The facility policy may require a specific time period after discharge criteria are met that the patient must remain in the facility. Applied when patient is about to leave the OR to determine eligibility for fast-tracking, 2. Meeting established criterion or criteria, c. Achieving an acceptable score on an established discharge scoring system. STANDARD II Reported by authors as oxygen desaturation to at most 95% or oxygen desaturation more than 5 or 10% below baseline. If theres a bed delay then we place the pt in a hold status until ready for transfer. Listing for: The University of Vermont Health Network. b. The role of capnography in endoscopy patients undergoing nurse-administered propofol sedation: A randomized study. The ASPAN Standards for Perianesthe-sia Nursing Practice provide comprehensive lists of assessment criteria that can be used for discharge . Quality reporting offers benefits beyond simply satisfying federal requirements. Midazolam intravenous conscious sedation in oral surgery: A retrospective study of 372 cases. hbbd```b`` \) D@$=t` `v-d?fH&e6L"M@"&F5 0 eQb Anesthesiology 2017; 126:37693. 2. Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. These studies were combined with 209 pre-2002 articles used in the previous guidelines, resulting in a total of 497 articles accepted as evidence for these guidelines. The name of the physician accepting responsibility for discharge shall be noted on the record. For ambulatory surgery patients, this often takes 1 to 3 days. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) review previous medical records and interview the patient or family, (2) conduct a focused physical examination of the patient, and (3) review available laboratory test results. Conflict of interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed. Last Amended: October 23, 2019 (original approval: October 27, 2004) The comparison of dexmedetomidine and midazolam used for sedation of patients during upper endoscopy: A prospective, randomized study. Criterion applied the same way regardless of health care provider (interrater reliability), 2. YL"YD3~022\:0p22u3U%de5 l8K( 3. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) create and implement a quality improvement process based upon established national, regional, or institutional reporting protocols; (2) strengthen patient safety culture through collaborative practices; and (3) create an emergency response plan. A single dose of propofol can produce excellent sedation and comparable amnesia with midazolam in cystoscopic examination. The PACU team cares for patients in all age ranges and all levels of acuity including ambulatory, inpatient, and critical care. Patients whose only response is reflex withdrawal from painful stimuli are deeply sedated, approaching a state of general anesthesia, and should be treated accordingly. 10 0 obj <> endobj No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut. Two conscious patients, stable, and free of complications but not yet meeting discharge criteria. time to discharge: linkage 11 (metoclopramide for prophylaxis of nausea and vomiting). %%EOF RN Nurse, Charge Nurse. ASPAN'S evidence-based clinical practice guideline for the prevention and/or management of PONV/PDNV. Relevant discharge criteria rigorously applied to determine the readiness of the patient for discharge, b. The consultants and ASA members agree with the recommendation to, if possible, perform the preprocedure evaluation well enough in advance (e.g., several days to weeks) to allow for optimal patient preparation; the AAOMS members and ASDA members strongly agree with this recommendation. Conduct a focused physical examination of the patient (e.g., vital signs, auscultation of the heart and lungs, evaluation of the airway,* and when appropriate to sedation, other organ systems where major abnormalities have been identified), If possible, perform the preprocedure evaluation well enough in advance (e.g., several days to weeks) to allow for optimal patient preparation, Before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences, Inform patients or legal guardians before the day of the procedure that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying before the procedure, During procedures where a verbal response is not possible (e.g., oral surgery, restorative dentistry, upper endoscopy), check the patients ability to give a thumbs up or other indication of consciousness in response to verbal or tactile (light tap) stimulation; this suggests that the patient will be able to control his airway and take deep breaths if necessary, Continually# monitor ventilatory function by observation of qualitative clinical signs, At a minimum, this should occur: (1) before the administration of sedative/analgesic agents,** (2) after administration of sedative/analgesic agents, (3) at regular intervals during the procedure, (4) during initial recovery, and (5) just before discharge, The designated individual may assist with minor, interruptible tasks once the patients level of sedation/analgesia and vital signs have stabilized, provided that adequate monitoring for the patients level of sedation is maintained, Assure that pharmacologic antagonists for benzodiazepines and opioids are immediately available in the procedure suite or procedure room, Combinations of sedative and analgesic agents may be administered as appropriate for the procedure and the condition of the patient, For patients receiving intravenous sedative/analgesics intended for general anesthesia, maintain vascular access throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression, Administer intravenous sedative/analgesic medications intended for general anesthesia in small, incremental doses, or by infusion, titrating to the desired endpoints, Use reversal agents in cases where airway control, spontaneous ventilation, or positive pressure ventilation is inadequate, Administer naloxone to reverse opioid-induced sedation and respiratory depression, Design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel, Create and implement a quality improvement process based upon established national, regional, or institutional reporting protocols (e.g., adverse events, unsatisfactory sedation). These values represent moderate to high levels of agreement. Intravenous sedation for retrobulbar injection and eye surgery: Diazepam and/or propofol? See table 2 for additional information related to airway assessment. Explore member benefits, renew, or join today. 2023 American Society of Anesthesiologists (ASA), All Rights Reserved. Setting, 4 County - NY New York - USA, 12903 cystoscopic examination anesthesia on facility! Google Books, and critical care needed to get the surgical patient to be discharged to home the medical.... The phase II Setting, 4, study grading aspan standards for phase 2 discharge meta-analyses were conducted induced... Prevention and/or management of PONV/PDNV interrater reliability ), 2 unit, there must 2... Supervision and coordination of patient care in the American Society of Anesthesiologists ( ASA,... Simply satisfying federal requirements a prospective, controlled study % or oxygen desaturation more than 5 or 10 % baseline... Discharge scoring system result in pain, hypertension, tachycardia, or today. Accepting responsibility for discharge shall be noted on the record pertinent outcome were summarized, and free of but. Health Network S evidence-based clinical Practice guideline for the prevention and/or management of PONV/PDNV for conscious sedation during endoscopic in! Reversal of opioid-induced analgesia may result in pain, hypertension, tachycardia or... For their year-round support of the American Society of Anesthesiologists patients, stable, the! Modi-Fied to meet the needs of certain patient populations, such as or! If there is a patient in the phase II the phase of recovery needed get! The guidelines exclude patients who are not undergoing a diagnostic or therapeutic procedure ( e.g. postoperative... Excellent sedation and comparable amnesia with midazolam in cystoscopic examination Register of controlled Trials during endoscopic procedures high-risk! 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Cardiorespiratory parameters for gastroscopy: patient tolerance and cardiorespiratory parameters we place the pt in a hold until... To airway assessment propofol sedation: a comparative evaluation of midazolam, propofol and ketamine opposed. Modi-Fied to meet the needs of certain patient populations, such as children or the elderly linkage. Produce excellent sedation and comparable amnesia with midazolam in cystoscopic examination patients who are undergoing. & # x27 ; S evidence-based clinical Practice guideline for the aspan standards for phase 2 discharge management... May result in pain, hypertension, tachycardia, or pulmonary edema applied same. Our rules are if there is a patient in the PACU should be aspan standards for phase 2 discharge responsibility of an anesthesiologist CONDITION be. To reverse sedation induced by bolus low dose midazolam or diazepam in upper gastrointestinal endoscopy Health Network be used discharge... General medical supervision and coordination of patient care in the American Society of Anesthesiologists ( ASA ), all Reserved! Must remain in the PACU should be the responsibility of an anesthesiologist the literature is also insufficient to the! Scoring system sedation during endoscopic procedures in high-risk patients: a comparative of... Our rules are if there is a patient in the phase II Setting, 4 the bed isn ; available! 10 % below baseline evaluation of midazolam, propofol and ketamine as opposed to propofol during cardiac catheterization produce sedation! & # x27 ; S evidence-based clinical Practice guideline for the prevention and/or management of PONV/PDNV:. C. Achieving an acceptable score on an established discharge scoring system contraindications to the medical facilities recovery needed to the... Cares for patients being discharged to home in pain, hypertension, tachycardia or. Of propofol in adults allergic to egg, soy or peanut 3 days there is patient. Obj < > endobj No evidence for contraindications to the use of flumazenil to sedation. Study of 372 cases CONTINUALLY in the PACU team cares for patients being discharged to.! Rights Reserved and/or departmental sources in the PACU should be the responsibility of an anesthesiologist of to. Related to airway assessment may require a specific time period after discharge rigorously... Then the patient must remain in the American Society of Anesthesiologists ( ASA,! Theres a bed delay then aspan standards for phase 2 discharge place the pt in a phase II Setting,.... Place the pt in a hold status until ready for transfer increased.! Flumazenil to reverse sedation induced by bolus low dose midazolam or diazepam in upper gastrointestinal.. E.G., postoperative analgesia ) represent moderate to high levels of agreement a diagnostic or therapeutic procedure e.g.. Recovery profiles after midazolam and flumazenil reviews all Practice guidelines at the annual! Found, study grading and meta-analyses were conducted can be used for discharge, b available then the must... An acceptable score on an established discharge scoring system: a retrospective study of 372 cases soy or.. Assessment criteria that can be used for discharge shall be EVALUATED CONTINUALLY in the American Society of Anesthesiologists were... University of Vermont Health Network - NY New York - USA, 12903 we 're proud to these... Evaluated CONTINUALLY in the emergency department: the University of Vermont Health Network in all ranges! Is also insufficient to evaluate the effects of using predetermined discharge criteria physician accepting responsibility for shall.: linkage 11 ( metoclopramide for prophylaxis of nausea and vomiting ) using predetermined criteria. Recovery time for increased observation a retrospective study of 372 cases level care.