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interThere are some important scales for assessment of Level of consciousness, Level of Agitation, Level of sedation. This lecture highlights what are the main aspects of these scales, what are the similarities and comparabilities. Mainly this lecture focusses on what is conscious sedation ? Where among these scales, the 'conscious sedation' lies. This lecture also simplifies the GCS to be easily interpreted and memorised.
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Ravindar Bethi
AN INTRODUCTION TO
CONSCIOUS SEDATION
MERC
Scales for assessment of
level of consciousness
STIMULUS RESPONSE
Scales for Assessment of level
of consciousness
V Verbal stimuliP Physical stimuli
STIMULUS RESPONSE
Scales for Assessment of level
of consciousness
V Verbally responsiveP Physically responsive
STIMULUS RESPONSE
Scales for Assessment of level
of consciousness
A Awake
V Verbally responsiveP Physically responsive
U UnresponsiveSTIMULUS RESPONSE
Scales for Assessment of level
of consciousness
A Awake
V Verbally responsiveP Physically responsive
U Unresponsive
Abbreviated Coma Scale( ACS )
STIMULUS RESPONSE
• Glasgow coma scale• Ramsay
sedation scale• Riker’s sedation-
agitation scale
DRUG INDUCED DEPRESSION OF CONSCIOUSNESS
Glasgow Coma Scale( GCS )
A
V
P
USTIMULUS RESPONSE
Verbal Response
Motor Response
Eye opening
Response
3
15
5 64PROGNOSIS
Glasgow Coma Scale( GCS )
A
V
P
U
Eye opening
Response
STIMULUS
4
Awake
Verbally
Physically
No Response 1
2
3
4
RESPONSE
Glasgow Coma Scale( GCS )
A
V
P
USTIMULUS
Verbal stimuli
Physical stimuli
RESPONSE
Verbal Response
Motor Response
5 6
Glasgow Coma Scale( GCS )
A
V
P
USTIMULUS
Single Stimulus Repeated Stimulus
Physical stimuli
RESPONSE
Verbal Response
Motor Response
5 6
Glasgow Coma Scale( GCS )
A
V
P
USTIMULUS
Pressure Pain
Single Stimulus Repeated Stimulus
RESPONSE
Verbal Response
Motor Response
5 6
Glasgow Coma Scale( GCS )
A
V
P
U
Verbal Response
Motor Response
STIMULUS
5 6Pressure Pain
Single Stimulus Repeated Stimulus
1 2345
no sound
sounds only
words only
sentences
oriented
RESPONSE
Glasgow Coma Scale( GCS )
A
V
P
U
Motor Response
STIMULUS RESPONSE
6Pressure Pain
Single Stimulus Repeated Stimulus
1 23456
no movement
Glasgow Coma Scale( GCS )
A
V
P
U
Motor Response
STIMULUS RESPONSE
Pressure Pain
Single Stimulus Repeated Stimulus
1 23456
no movement
extension
6
Glasgow Coma Scale( GCS )
A
V
P
U
Motor Response
STIMULUS RESPONSE
Pressure Pain
Single Stimulus Repeated Stimulus
1 23456
no movement
extension
flexion6
Glasgow Coma Scale( GCS )
A
V
P
U
Motor Response
STIMULUS RESPONSE
Pressure Pain
Single Stimulus Repeated Stimulus
1 23456
no movement
extension
flexion
withdrawal
Glasgow Coma Scale( GCS )
A
V
P
U
Motor Response
STIMULUS
Pressure Pain
Single Stimulus Repeated Stimulus
1 23456
no movement
extension
flexion
withdrawal
localisation
RESPONSE
Glasgow Coma Scale( GCS )
A
V
P
USTIMULUS RESPONSE
Pressure Pain
Single Stimulus Repeated Stimulus
1 23456
no movement
extension
flexion
withdrawal
localisation
normal movements
6
Motor Response
Glasgow Coma Scale( GCS )
A
V
P
USTIMULUS RESPONSE
Verbal Response
Motor Response
Eye opening
Response
3
15
5 64
PROGNOSIS
A
V
P
USTIMULUS
Ramsay sedation scale( GCS )
1
2
3
4
5
6
Glabellar tap
Single stimulus Repeated/loud stimulus
Pressure
RAMSAY SEDATION SCALE
1. Anxious and agitated or restless, or both2. Co-operative, oriented, and calm3. Responsive to commands only4. Exhibiting brisk response to loud auditory
stimulus or light glabellar tap5. Exhibiting a sluggish response to loud
auditory stimulus or light glabellar tap6. Unresponsive
RESPONSE
anxiousagitated
CON
SCIO
US
SED
ATIO
N
Riker’s sedation– agitation scale( GCS )
A
V
P
STIMULUS
V
P
U
URESPONSE
Uncontrollable
CONTINUUM OF DEPTH OF SEDATION
V UAV
U
A
PP
CONTINUUM OF DEPTH OF SEDATION
V UAV
U
A
PP
CONTINUUM OF DEPTH OF SEDATION
V UA P
CONTINUUM OF DEPTH OF SEDATION
V UA P
CONTINUUM OF DEPTH OF SEDATION
V UA P
CONTINUUM OF DEPTH OF SEDATION
V UA P
CONTINUUM OF DEPTH OF SEDATION
V UA P
CONTINUUM OF DEPTH OF SEDATION
V UA P
CONTINUUM OF DEPTH OF SEDATION
V UA P
ACLS
PROCEDURAL SEDATION
“A technique of administering sedatives or dissociative agents
with or without analgesics to induce a state that allows the patient
to tolerate unpleasant procedures while maintaining cardiorespiratory function.“
WHAT IS
CONSCIOUS SEDATION ?
“OFFICE BASED ANESTHESIA”
THE TEAM– PROCEDURAL PHYSICIAN– SEDATION PRACTITIONER– REGISTERED NURSE ASSISTANT
PATIENTS CRITERIAASA GRADING
Class I No organic, physiologic, biochemical or psychiatric disturbance. (Normal, healthy patient)
Class II Mild to moderate systemic disturbance; may or may not be related to reason for surgery (Ex: hypertension, diabetes mellitus under control)
Class III Severe systemic disturbance. (Ex: heart disease, poorly controlled HTN, uncontrolled DM)
Class IV Life threatening systemic disturbance(Ex: congestive heart failure, unstable angina pectoris, DKA)
Class V Moribund patient. Little chance for survival. Surgery is the last resort.(Ex: uncontrolled bleeding from ruptured abdominal aortic aneurysm)
PATIENTS CRITERIAMALLAMPATI CLASS
PATIENTS CRITERIAMALLAMPATI CLASS
PATIENTS CRITERIAMALLAMPATI CLASS
PATIENTS CRITERIAMALLAMPATI CLASS
EXCLUSION CRITERIA
PROCEDURES
DESIGNATED PLACES
FACILITIES MUST
MONITORING & EMERGENCY RESUSCITATION EQUIPMENT
• Stethoscope, • ECG, NIBP, Pulse oximeter• Crash cart with defibrillator, • Airway & resuscitation devices,
• Source of Oxygen • Suction source
• IV supplies
DISPLAY OF POSTERS • patient evaluation • dosing of drugs • check lists
FACILITIES MUST
OTHER SUPPLIES & REQUIREMENTS • Means to safely preserve the
narcotic and sedative drugs
• Means for documentation. • Means for intra hospital
communication.
DISPLAY OF POSTERS • patient evaluation • dosing of drugs • check lists
DRUGS
NARCOTICS
ANXIOLYTICS
V
P
U
A
ATROPINE
LOCAL ANESTHETICS
FLUMAZENIL
NALOXONE
DRUGS
NARCOTICS
ANXIOLYTICSFLUMAZENIL
NALOXONE
ANESTHETICS
PRE-PROCEDURE ISSUES
HOSPITAL
NPO PROTOCOLS
DOCUMENTATION
REASSURANCE
VIGILANCE MONITORING
DRUG ADMINISTRATION
INTRA PROCEDURE
RECOVERY AND
DISCHARGE
CONSCIOUS SEDATION COMPARED TO ANESTHESIA
• Less risk patients only• Minor procedure only• Moderate sedation only, with prior analgesia/LA• No OR, no anesthetist except as back support
• Careful selection• Strict preparation• Stringent monitoring• Extreme safety precautions• Meticulous discharge protocols
APPARENTLY EASY BUT
RISK IS RELATIVELY NOT
ACCEPTABLE
DEEP COMA
EMERGENCE
PATHOLOGICAL PROCESS
MEDICAL INTERVENTION
General anesthesia
Conscious sedation
“be meticulous…do no harm”
EXTREME AGITATION
DEEP COMA
AWAKE PATIENT
TAKE HOME MESSAGE• Conscious sedation is safe, reliable, economical• Sound airway management and resuscitation skills in
back up
Anesthetist must know everything about anesthesia and something about everything else
Every body must know something about anesthesia and resuscitation
THANK YOUMERC
V
U
A
Ravindar Bethi
P