Clinicians who administer sedation or monitor sedated patients need a working knowledge of the actions, interactions and adverse effects of commonly used medications.
This involves the pharmacology of medications including benzodiazepines and opioid drugs, as well as reversal agents.
Procedural units provide information on:
- their local preferred sedative agents
- standard dosing arrangements
- maximum dosing arrangements
- local clinical emergency response system (CERS) process
- reversal agents, which must be readily available.
This information should be available to the clinical team in a summary sheet.
Interactions with the patients’ regular medications must also be considered.
Before sedation, the sedation plan should be discussed with the clinical team, including the agent, dosage, potential issues and the plan for escalation. The plan should include an upper limit, or ceiling, so that excessive doses are not administered. For example, a typical ceiling for drugs such as midazolam might be 5 milligrams and fentanyl 100 micrograms.
Propofol
Propofol is most frequently used to produce deep sedation or general anaesthesia and carries additional risks of increased respiratory depression, airway obstruction and hypotension. It should only be administered by trained and credentialed users who are experienced in its use.
Intentional deep sedation should only be provided by an anaesthetist, critical care physician (CCP) or other practitioner within their scope of practice.
Propofol or remifentanil infusions should only be used by anaesthetists or CCPs.
Propofol boluses should only be used if there is a separate sedationist and proceduralist, with minimal staffing of 4 people, and local policies allow its use.
Other jurisdictions within Australia have introduced endoscopist-directed nurse-administered propofol sedation. We will continue to monitor the progress and outcomes of these programs with the view to potential introduction in the future if supported by evidence.
Other agents
Facilities should develop local guidelines and credentialing if other drugs are to be used.
For inhaled nitrous oxide and methoxyflurane, adhere to protocols for patient and staff safety. NSW Health provides guidance on the provision of nitrous oxide in NSW health facilities.
Where possible, clinical staff should have access to a locally supported credentialing or knowledge program. Several procedural units have successfully developed and implemented credentialing programs for pharmacology awareness.
Example credentialing programs are available on the Safe Procedural Sedation SharePoint site. Email ACI-Anaesthesia@health.nsw.gov.au to request access.