Ppg-gdch-Anesot-03.09 Moderate and Deep Sedation

GULF DIAGNOSTIC CENTER
HOSPITAL
ANESTHESIA POLICY
TITLE: MODERATE & DEEP SEDATION

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide
Policy No: MED-ANS-P003/09

Issue Date : March 2009
Revision No.: 02
Revision Date : July 2012
Next Revision : July 2014
Page 1 of 18
MODERATE & DEEP SEDATION

APPROVAL SHEET
Prepared by:
Name
Signature
Date
Signature
Date
Signature
Date
Dr. Thomas Patrick Long

Head Anesthesia & Operating Theater
Reviewed by:
Name
Dr. Hassan Al Mahdi
Head of Surgery Department
Mr. Zuher Arawi
Quality Manager
Approved by:
Name
Dr Emad Yassin Al Rahmani
Medical Director
Mrs. Jamal Kaddoura
Co-Founder & Hospital Director
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 2 of 18
DOCUMENT AMENDMENT RECORD SHEET

Date
Description of Change
Page Effected
8/1/2013
Improved criteria for delineation of

4.1.7.14
Privileges re administration Propofol &
other anesthetic agents.
Revision
Number
03
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 3 of 18
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 4 of 18
1. DEFINITIONS
1.1. Sedation results from the administration of a medication that produces a depressed
level of consciousness. Sedation may result in the loss of protective reflexes. There
are four specifically defined levels of sedation. Levels of sedation: see Appendix :
Sedation levels.
2. POLICY
2.1. It is the policy of the hospital that these guidelines apply to all locations within the
hospital where moderate and deep sedation is administered.
2.2. This policy includes the practice guidelines for sedation by non-anesthesiologists.
2.3. Individuals administering sedation must be credentialed and privileged by the GDCHospital.
2.3.1. Personnel
2.3.1.1. The use of moderate and deep sedation shall include an individual
privileged to direct sedation and a credentialed monitoring assistant.
2.3.1.2. The physician administering moderate and deep sedation must have the
appropriate privileges and be qualified to rescue patients from deep
sedation or even anesthesia and must be competent to manage an
unstable cardiovascular system as well as a compromised airway and
inadequate oxygenation and ventilation including ACLS certification for
adult patients or PALS certification for pediatric patients.
2.3.1.3. The physician prescribing drugs for moderate and deep sedation should
have an understanding of their pharmacology as well as the
pharmacology of antagonist medications.
2.3.1.4. The credentialed monitoring assistant (RN) must be trained in basic
EKG/Arrhythmia, have current BLS certification, and have satisfactorily
completed the sedation medication education program.
3. SCOPE / RESPONSIBILITIES
3.1. This policy applies to the use of conscious sedation for operative, diagnostic,
therapeutic or other invasive procedures at the hospital and is designed for nonanesthesiology providers.
3.2. The policy does not apply to the following patients:
3.2.1. Patients having an anesthesiologist providing sedation. Anesthesiologists are
governed by the standards of care established by the department of
anesthesiology.
3.2.2. Patients receiving anxiolytic or analgesic agents, which are administered
routinely to alleviate pain and agitation (e.g. preoperative sedation or
postoperative analgesia).
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 5 of 18
3.2.3. Patients who receive any local anesthesia, and 50% or less nitrous oxide in
oxygen with no other sedatives or analgesics by any route.
3.3. The physician privileged to direct sedation is responsible for the safety and well
being of the patient and shall ensure that this policy is observed. In either elective or
emergency procedures, if circumstances warrant deviation from this policy, the
reason will be documented in the patient's medical record.
3.4. Additional responsibilities include
3.4.1. Completion of history and physical status
3.4.2. Completion of informed consent
3.4.3. Ordering of the medications, dosage and route of administration
3.4.4. Emergency interventions as needed
3.5. The credentialed monitoring assistant's responsibility is to monitor physiologic
parameters and assist in any supportive or resuscitative measures as required.
3.5.1. The monitoring assistant shall also:
3.5.1.1. Be familiar with the effects of the drugs used.
3.5.1.2. Know how to recognize airway obstruction and correct it.
3.5.1.3. Know how to monitor required parameters, how to recognize
abnormalities in the required parameters and how to deal with it.
3.5.1.4. Be able to manage ventilation with a self-inflating bag valve mask.
3.5.1.5. Be familiar with this policy.
4. PROCEDURE
4.1. Pre-procedure Evaluation: A pre-sedation assessment must be performed by a
qualified individual and documented in the medical record for each patient before
administering sedation. This includes:
4.1.1. Relevant history (major organ systems, sedation and anesthesia history,
medications, allergies, last oral intake).
4.1.2. Laboratory testing guided by underlying conditions and possible effect on
patients management.
4.1.3. Reevaluation immediately before sedation is administered.
4.1.4. At this time he/she will determine if the patient is an adequate candidate to
undergo the sedation. This immediate pre-sedation assessment will be
documented on the appropriate form.
4.1.4.1. Patient Counseling:
4.1.4.1.1. Each patient's sedation is planned and documented prior to
procedure
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 6 of 18
4.1.4.1.2. The risks, benefits, limitations, alternatives, potential complications

and options are discussed with the patient, his or her family or those
who make decisions for the patient.
4.1.4.1.3. The informed consent is documented in the medical record.
4.1.4.1.4. The nurse must verify the presence of this documentation before
administration of sedation.
4.1.4.2. Pre-Procedure Fasting
4.1.4.2.1. The ASA Guidelines for Pre Operative fasting are mandatory. (see
Appendix II)
4.1.4.3. Patient selection:
4.1.4.3.1. Patients must be screened for potential risk factors with respect to
any pharmacological agents selected.
4.1.4.3.2. Patients will be screened for risk factors utilizing the ASA Physical
Status Classification (See Appendix III)
4.1.4.3.3. This decision on which agent to use must be based on the goals of
sedation, type of procedure and condition and age of patient.
4.1.4.3.4.
Patients considered appropriate for conscious sedation are ASA I
and ASA II.
4.1.4.3.5. Patients in ASA class III or IV present special problems which may
necessitate a consultation by a member of the anesthesia department.
4.1.4.4. Equipments needed (The following minimum equipment must be
present and in working order and be ready for use in the room where
sedation is being administered)
4.1.4.4.1. An operating table, trolley or chair that can be easily tilted.
4.1.4.4.2. Non-invasive RR monitor
4.1.4.4.3. Pulse oximeter
4.1.4.4.4. Continuous ECG shall be used for patient requiring continuous
ECG monitoring
4.1.4.4.5. A source and means for providing supplemental oxygen (nasal
cannula, mask etc.)
4.1.4.4.6. A source of suction (wall or portable).
4.1.4.4.7. Emergency airway equipment (masks, ambu-bag, airways, etc.)
4.1.4.4.8. Emergency Crash Cart with defibrillator must be in close
proximity.
4.1.4.4.9.
Emergency drugs including IV fluids and reversal drugs
4.1.5. Staffing (A minimum of two personnel must be involved in the care of patient
undergoing sedation during the entire procedure)
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 7 of 18
4.1.5.1. the physician who performs the procedure and

4.1.5.2. the individual whose responsibility is directed only to the patient: to
administer medication, to monitor the patient, and to observe the
patient's response to both the sedation and the procedure.
4.1.6. Patient preparation/ pre- procedure management:
4.1.6.1. An assessment of the patient's pre-procedure Aldrete score will be
performed by a RN. For the patient who is scheduled for an elective
procedure, the availability and appropriateness of transportation
following the procedure must be verified prior to the administration of
sedation.
4.1.6.2. Informed consent for procedure and sedation is confirmed.
4.1.6.3. Pre-procedure patient/family education is completed if needed.
4.1.6.4. Immediate pre-sedation assessment is completed.
4.1.6.5. A venous access site is established as required.
4.1.6.6. Cardiac monitor and pulse oxymeter are applied.
4.1.6.7. Baseline BP, RR, PR, Sao2, sedation/ pain score and cardiac
monitoring are obtained and recorded.
4.1.6.8. Verify patient has responsible adult providing transportation post
procedure.
4.1.7. Intra-Procedure
4.1.7.1. A monitoring RN shall be present to continuously assess patients
condition and facilitate patient safety and comfort.
4.1.7.2. The monitoring RN shall have no responsibility other than direct care of
the patient in question.
4.1.7.3. A venous access site will be maintained throughout the procedure and
recovery period as indicated by physician.
4.1.7.4. Medications shall be administered only under the direction of the
responsible physician.
4.1.7.5. All medications administered must be recorded (drug, dose, time and
route).
4.1.7.6. The amount and means of oxygen supply shall be documented.
4.1.7.7. Vital signs (ECG, SaO2, HR and RR) are recorded every 5-10 minutes.
Level of consciousness (sedation scale) is recorded every 15 minutes.
4.1.7.8. Verbal reassurance to patient frequently throughout the procedure. The
patients head position, airway and chest excursion must be
continuously monitored. The patient is repositioned as necessary to
ensure adequate spontaneous tidal volume.
4.1.7.9. Untoward reactions or sudden/significant changes in monitored
parameters should be immediately reported to the responsible physician.
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 8 of 18
4.1.7.10. In case of any emergency call help from Anesthesia Department or

alarm Code Blue
4.1.7.11. Total fluid shall be recorded.
4.1.7.12. Unusual, unanticipated or adverse events shall be described and
recorded.
4.1.7.13. The patient's condition at the conclusion of the procedure shall be
assessed and documented.
4.1.7.14. Use of Propofol for sedative purposes in the institution is limited to the
following persons
Anesthesiologists. [MD]
Anesthesia Technicians under the direct supervision of the
Anesthesiologist.
Non Anesthesiologist physicians who can demonstrate either formal
training in its administration or clinical experience[with written
references attesting to such] & a proven track record in administration
thereof.[The Anesthesiologist shall directly observe clinical
practice/Propofol administration by the physician,prior to granting
such privileges] Use of Propofol in this situation,is limited to
procedures specific to the physicians specialty & scope of practice &
to patients of ASA CLASS 1-2.All such privileges are contingent upon
maintenance of current ACLS/airway management skills &
certification.The use of all other anesthetic agents,induction &
vaporous is solely restricted to anesthesiology personnel..
4.1.8. Post-Procedure
4.1.8.1. Patient will recover in the unit where the procedure occurred or in the
Recovery Room if the procedure was performed in the OR for at least 30
minutes after the last medication dose.
4.1.8.2. Qualified competent personnel shall monitor patients.
4.1.8.3. A venous access site will be maintained throughout the recovery period.
4.1.8.4. Monitoring of the patient is to be continuous with documentation of vital
signs every 5 minutes, for 30 minutes after the last iv medication dose.
Monitoring and documentation will include BP, HR, SaO2, RR, level of
consciousness/ pain
4.1.8.5. Sedation and pain scores shall be recorded every 15 minutes until
discharge criteria are met. (see Appendix IV, V, VI, VII).
4.1.8.6. If a reversal agent is given, the patient will be monitored in the recovery
area every 5 minutes for a minimum of 30 minutes after the last iv
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide
4.1.8.7.
4.1.8.8.
4.1.8.9.
4.1.8.10.

Revision No.: 02
Page 9 of 18
medication dose and every 15 minutes for 60 minutes thereafter to

ensure re-sedation will not occur.
The patient may be discharged from the recovery area with a written
order from the physician providing sedation. The RN, under the
direction of the physician, may discharge patients when they have met
discharge criteria.
The modified Aldretes' scoring system (see Appendix IV) shall be used
for those patients discharged to the patient care unit (e.g. inpatients).
Patients must have a score of 8 or greater to be discharged.
The Modified Post Anesthesia Discharge Scoring System (see Appendix
V) shall be used for those patients discharged home. Patients must have
a score of greater or equal to 9 for discharge home.
The physician providing sedation will be consulted regarding
reassessment of patient not meeting the above criteria. S/he must
reassess the patient and determine appropriate action.
4.1.9. Discharge The patient will be discharge home if:

4.1.9.1. He met the required score on the modified post anesthesia discharge
scoring system (9 )
4.1.9.2. A responsible adult is available to escort the patient home
4.1.9.3. Written instruction are given including : the name of individuals to
contact in the event of emergencies, instruction to avoid driving a motor
vehicle or operating heavy equipment for 24 hours after sedation, and
any additional instructions as per physician (like dietary and medication
instructions, post discharge activity instructions etc.)
4.1.9.4. To Patient Care Unit. The patient met the required score on Modified
Aldretes scoring system. Patients monitoring must be continued as per
that units nursing standard.
4.1.9.5. Performance monitoring
4.1.9.5.1. Care providers monitor key aspects of moderate and deep sedation
as outlined in this policy in order to ensure that patients receiving
sedation are provided the same level of safe and effective care
throughout the hospital. Unusual, unanticipated, or adverse events
shall be reported to the quality improvement department. These
include but are not limited to the following indicators:
4.1.9.5.1.1.
Manual intervention to support airway/breathing
4.1.9.5.1.2.
Unplanned admission to a higher level of care,
including unplanned admission of out patients.
4.1.9.5.1.3. Cancellation of a procedure due to unsuccessful sedation
attempt.
4.1.9.5.1.4. Cardiopulmonary resuscitation.
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 10 of 18
4.1.9.5.1.5. Administration of any reversal agents, Epinephrine etc.

5. REFERENCES
5.1. Practice Guidelines for sedation and Analgesia By non-Anesthesiologist, ASA ,Inc.,
1998, 231-232
5.2. Anesthesia and Sedation Standards and Regulations, California Medical Association.
6. RELATED DOCUMENTS
6.1. Policy of conscious sedation
6.2. Code Blue Policy
6.3. Practice guidelines for preoperative fasting, Anesthesiology (1999), 90, 896-905
7. APPENDICES
7.1. Appendix I
LEVEL OF SEDATION
7.1.1. Minimal sedation (anxiolysis): A drug-induced state during which patients
respond normally to verbal commands. Although cognitive function and
coordination may be impaired, ventilatory and cardiovascular functions are
unaffected.
7.1.2. Moderate sedation/analgesia (conscious sedation): A drug-induced depression
of consciousness during which patients respond purposefully to verbal
commands, either alone or accompanied by light tactile stimulation. No
interventions are required to maintain a patent airway, and spontaneous
ventilation is adequate. Cardiovascular function is usually maintained.
7.1.3. Deep sedation/analgesia: A drug-induced depression of consciousness during
which patients cannot be easily aroused but respond following repeated or
painful stimulation. The ability to independently maintain ventilatory function
may be impaired. Patients may require assistance in maintaining a patent airway
and spontaneous ventilation may be inadequate. Cardiovascular function is
usually maintained.
7.1.4. Anesthesia: Consists of general anesthesia and spinal or major regional
anesthesia. It does not include local anesthesia. General anesthesia is a druginduced loss of consciousness during which patients are not arousable, even by
painful stimulation. The ability to independently maintain ventilatory function is
often impaired. Patients often require assistance in maintaining a patent airway,
and positive pressure ventilation may be required because of depressed
spontaneous ventilation or drug-induced depression of neuromuscular function.
Cardiovascular function may be impaired.
7.2. Appendix II
NPO Guidelines For Sedation
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 11 of 18
Recommendations on preoperative fasting in elective, healthy patients were issued by the

American Society of Anesthesiology (ASA) in 1999.
Ingested material
Minimum fasting time
Clear liquids
2 hrs
Breast milk
4 hrs
Light meal, infant formula and other milk
6 hrs
Heavy meal
8 hrs
7.3. Appendix III ASA (American Society of Anesthesiology)

PHYSICAL STATUS CLASSIFICATION:
7.3.1. Class I
No organic, physiologic, biochemical or psychiatric
disturbance. Normal, healthy patient.
7.3.2. Class II
Mid-moderate systemic disturbance; may or may not be related
to reason for surgery. (Examples: hypertension, diabetes mellitus)
7.3.3. Class III
Severe systemic disturbance. (Examples: significant coronary
artery disease, poorly controlled hypertension, diabetes)
7.3.4. Class IV
Life threatening systemic disturbance. (Examples: congestive
heart
failure, persistent angina pectoris)
7.3.5. Class V
Moribund patient. Little chance for survival in next 24 hours.
Surgery is last resort. (Example: ruptured abdominal aortic aneurysm,
catastrophic intracerebral bleeding0
7.3.6. Class E
Patient
requires
emergency
procedure.
(Example:
appendectomy, D&C for uncontrolled bleeding)
7.4. Appendix IV
MODIFIED ALDRETE'S SCORE
7.4.1. Activity:
Muscle activity is assessed by observing the ability of the patient to move his/her
extremities spontaneously or on command.
Score:
2 - Able to move 4 extremities
1 - Able to move 2 extremities
0 - Not able to control any extremity
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 12 of 18
7.4.2. Respiration:
Respiratory efficiency evaluated in a form that permits accurate and objective
assessment without complicated physical tests.
Score:
2 - Able to breathe deeply and cough
1 - Limited respiratory effort (dyspnea or splinting)
0 - No spontaneous respiratory effort
7.4.3. Circulation:
Use changes of arterial blood pressure from pre-anesthetic level.
Score:
2 - Systolic arterial pressure between plus or minus 20% of preanesthetic level (Riva-Rocci method)
1 - Systolic arterial pressure between plus or minus 20% to 50% of
pre-anesthetic level
0 - Systolic arterial pressure between plus or minus 51% or more of
pre-anesthetic level
7.4.4. Consciousness
Determination of the patient's level of consciousness
Score:
2 - Full alertness seen in patient's ability to answer questions and
acknowledge his/her location
1 - Aroused when called by name
0 - Failure to elicit a response upon auditory stimulation
Physical stimulation should not be considered reliable as even a decerebrated
patient might react to it.
7.4.5. Color:
This is a sign that is sometimes difficult to recognize.Correlate with
Sao2,clinical state: patient confusion or agitation etc.
Score:
2 - Normal skin color and appearance
1 - Any alteration in skin color; pale, dusky, blotch, jaundiced, etc.
0 - Frank cyanosis
All outpatients who receive sedation for any procedure must be observed and
monitored for a minimum of 1 hour prior to being discharged home. Vital
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 13 of 18
signs (heart rate, respiratory rate and blood pressure) are recorded at 15 - 30
minute intervals.
7.5. Appendix V
DISCHARGE SCORING SYSTEM
Medical staff approved discharge criteria includes:
7.5.1. Completion of Aldrete score.
7.5.2. Ability to ambulate consistent with baseline assessment.
7.5.3. Ability to demonstrate a gag reflex.
7.5.4. Ability to retain oral fluid, as appropriate to LIP orders
7.5.5. Pain minimal.
7.5.6. Ability of patient and home care provider to understand all home care
instructions.
7.5.7. Written discharge instructions given to patient/family.
7.5.8. Concurrence with prearrangements for safe transportation,including discharge
to the care of a responsible adult. The patient may not drive self home.
7.6. Appendix VI SEDATION SCALES
7.6.1. 1 - Alert
7.6.2. 2 - Occasionally drowsy; easy to arouse
7.6.3. 3 - Frequently drowsy; easy to arouse
7.6.4. 4 - Asleep; easy to arouse
7.6.5. 5 - Somnolent; difficult to arouse.
7.7. SEDATION AGITATION SCALE
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 14 of 18
7 Dangerous Agitation
Pulling at ET tube, trying to remove catheters, climbing over bed rails,

striking at staff,
thrashing side to side
6 Very Agitated
Does not calm, despite frequent verbal reminding of limits, requires

physical restraints,
biting ET tube
5 Agitated
Anxious or mildly agitated, attempting to sit up, calms down to verbal

instructions
4 Calm & Cooperative
Calm, awakens
commands
easily,
follows
3 Sedated
Difficult to arouse, awakens to verbal stimuli gentle shaking but drifts

off again,
follows simple commands
2 Very sedated
Arouses to physical stimuli but does not communicate or follow

commands,
may move spontaneously
1 Unarousable
Minimal or no response to noxious stimuli, does not communicate

or follow
commands
The target is 3-4.

below three (3) need intervention ( reduction of sedation/analgesia).
Above (4) need intervention( Increase the sedation/analgesia).
7.8. Appendix VII
PAIN ASSESSMENT SCALES:
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Revision No.: 02
Page 15 of 18

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide
Wong Baker Faces pain scale
6
Faces scale & numerical scale:
1-3 non- pharmacological treatment and possible mild analgesic.
>=4 inform physician and pharmacological intervention.
Numeric pain scale

0
0:
10:
no pain
worst possible pain
10
- Visual Analogue Scale, VAS

0---------------------------------------------10 cm line-----------------------------------------10
0: no pain
10: worst possible pain
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 16 of 18
Pain relief scale

0---------------------------------------------10 cm line-----------------------------------------10
0: no relief
10: complete relief
- NEONATAL PAIN ASSESSMENT SCALE (NIPS): (For Neonates up to 1 year)

BEHAVIORA
L CUES
Facial
Expression
Relaxed musclesRestful face, neutral

Expression
Grimace-tight facial
muscles,
furrowed
brow,
chin,
jaw
(negative
facial
expression-nose,
mouth and brow)
------
Vigorous cry Loud scream,

rising, shrill. Continuous.
Whimper Mild
Moaning, intermittent
(Note: Silent cry may be scored if
crying
baby is intubated, as evidence by
obvious mouth, facial movement.)
Cry
Quiet Not crying
Breathing
Patterns
Relaxed Usual pattern

For this baby
Arms
Relaxed No muscular Tense, straight arms,

rigidity,
occasional rigid and/or rapid
random arm movement
extension, flexion
------
Legs
Relaxed No muscular Tense , straight legs,

rigidity , occasional leg rigid and/or rapid
movement
extension, flexion
------
Tense,
irregular,
faster than usual,
gagging,
breath
holding
-----
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
State of Arousal
Pain Level
0-2= mild to no pain
3-4=mild to moderate
pain
>4=sever pain
: Medical
: Anesthesia
: Hospital Wide
Sleeping/awake Quiet, Fussy
peaceful, sleeping or alert restless,

and settled.
thrashing

Revision No.: 02
Page 17 of 18
Alert,
and
------
Intervention
None
None Pharmacological intervention with a reassessment in less than 30 minutes
Pharmacological intervention with a reassessment in less than 30 minutes
Appendix: Yes [ ]
No [ ]

HOSPITAL
NEONATAL PAIN ASSESSMENT SCALE NIPS pain Scale
Pain Level
Intervention
0-2= mild to ANESTHESIA
no pain
None
POLICY
3-4=mild
to
moderate
Pharmacological
intervention
in less than
Issuewith
Datea reassessment
: March 2009
pain
30 minutes
Revision No.: 02
>4=sever pain : Medical
Pharmacological intervention
withDate
a reassessment
Department
Revision
: July 2012in less than
30 minutes
Section
: Anesthesia
Faces
scale
&
numerical
scale:
Distribution
: Hospital Wide
Page 18 of 18
1-3 ( face No:2)
non- pharmacological treatment and possible mild analgesic.
>=4 (face No:3)
inform physician and pharmacological intervention
Pain Scale For Comatose Patients

Score 0
Patients scoring 0 are identified as those who do not have pain. No
further management.
Score +
Patients scoring + requiring minimal pain management but shall be

reassessed at least once every shift. These patients may require non
Pharmacological interventions.
Score ++
Patients scoring ++ require pain management. They shall be

reassessed using the above guidelines as per the Pain Assessment
and Management Policy and Procedure Guideline.
FLACC Pain Scale REPORTABLE CONDITIONS

FLACC pain score > 5.
Unrelieved pain or worsening pain.
Abnormal vital signs
When to Assess/ Reassess for pain:
Assess pain at each visit and /or admission to the hospital /unit
As part of initial admission assessment.
Nurses should routinely; every shift while the patient is awake, assess patients for pain and/or
evaluate them for pain management.
30 minutes prior to invasive procedure /post surgical mobilization /potentially painful activity of
daily living.
Hourly for 4 hours following an invasive procedure, surgery or child birth.
Upon request for analgesia
Acute / Chronic Pain:
Always assess within 30 minutes of giving analgesia or any pain relief measure example position
changes, heat packs, cold packs etc.
The following standards should be flexible according to individual patient responses to medication
and/or treatment.
Yes [
Cardiac pain should be reassessed every five (5) minutes until the painAppendix:
is relieved.
No [ ]
The physician should be notified when any type of prescribed pain management regimen is not
effective in relieving patients pain.

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 19 of 18
FACE LEGS ACTIVITY CRY CONSOLABILITY (FLACC) Pain Scale (For Children 1
up to 7 years)
CATEGORIES
FACE
SCORING
0
1
No particular expression or Occasional grimace or
smile
frown,
withdrawn,
disinterested.
LEGS
Normal position or relaxed. Uneasy, restless, tense.
ACTIVITY
Lying quietly, normal Squirming, shifting back

position moves easily.
and forth, tense.
No cry, (awake or asleep)
Moans or whimpers;
occasional complaint
CRY
CONSOLABILITY
Content, relaxed.
Reassured by occasional
touching hugging or being
talked to, distractible.
2
Frequent
to
constant
quivering chin,
Clenched jaw.
Kicking or legs
drawn up.
Arched, rigid or
jerking.
Crying steadily,
screams or sobs,
frequent
complaints.
Difficulty
to
console
or
comfort
REPORTABLE CONDITIONS
FLACC pain score > 5.
Unrelieved pain or worsening pain.
Abnormal vital sign(s)
BEHAVIORAL-PHYSIOLOGICAL PAIN SCALE FOR
NON-VERBAL OR PRE-VERBAL PATIENTS
Score Assessment Guideline
0
No Signs of Irritability or Pain Exhibited
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
+
++
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 20 of 18
Signs of Irritability
Intermittent vocalizations, soft or brief cry but able to suck or feed
Increased activity of extremities, restless, purposeless movements but trunk is relaxed
Frowning, furrowed brow, eyes open
Mildly increased tone of extremities
Increased arousal, more awake than usual
Unexplained mild changes in respiratory pattern, HR and BP

Signs of Pain
Loud cry, sustained attempts to cry
Refuses to feed, eat and/or pacifier does not relieve crying
Thrashing of limbs of infants
Marked brow bulge in infants, grimace, eyes closed tightly
Decreased activity, fatigue, social withdrawal
Tense muscles, guarding, posturing
Flushed face, diaphoresis
Change in sleep wake pattern
Attempts to withdraw limb from pain or tries to touch painful area
Unexplained duskiness/decreased oxygen saturations
Unexplained changes in RR, HR and BP

This tool should be used as a guideline for healthcare providers attempting to assess
irritability and pain in non-verbal or pre-verbal patients.
Instructions for use of Assessment Guideline: Evaluate all patients at regular intervals.
Score 0
Patients are identified as those who do not exhibit one or more of the behaviors
listed in the (+) or (++) boxes.
Score +
Patients demonstrate one or more of the behaviors listed in the (+) box. Use ageappropriate comforting measures. Re-evaluate.
Score ++ Patients demonstrate one or more of the behaviors listed in the (++) box.
Consider trial of pain medication. Re-evaluate.
There is no reliable tool yet developed that accurately measures pain in patients that are
unable to verbalize their pain. It is possible that the patient may be experiencing pain and not
show any of the behaviors listed above. Whenever pain is suspect, pain medication may be
indicated.
Appendix: Yes [ ]
No [ ]

HOSPITAL
ANESTHESIA POLICY

Department
Section
Distribution
: Medical
: Anesthesia
: Hospital Wide

Revision No.: 02
Page 21 of 18
REFERENCE:American Society of Anesthesiologists;Advisories on granting privileges

to non-anesthesiologist sedation practitioners.October 2005 & 2011
Appendix: Yes [ ]
No [ ]

Ppg-gdch-Anesot-03.09 Moderate and Deep Sedation

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GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

MODERATE & DEEP SEDATION

Dr. Thomas Patrick Long

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

DOCUMENT AMENDMENT RECORD SHEET

Improved criteria for delineation of

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

4.1.4.1.2. The risks, benefits, limitations, alternatives, potential complications

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

4.1.5.1. the physician who performs the procedure and

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

4.1.7.10. In case of any emergency call help from Anesthesia Department or

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

medication dose and every 15 minutes for 60 minutes thereafter to

4.1.9. Discharge The patient will be discharge home if:

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

4.1.9.5.1.5. Administration of any reversal agents, Epinephrine etc.

NPO Guidelines For Sedation

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

Recommendations on preoperative fasting in elective, healthy patients were issued by the

Minimum fasting time

Light meal, infant formula and other milk

7.3. Appendix III ASA (American Society of Anesthesiology)

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

GULF DIAGNOSTIC CENTER

TITLE: MODERATE & DEEP SEDATION

Policy No: MED-ANS-P003/09

Pulling at ET tube, trying to remove catheters, climbing over bed rails,

Does not calm, despite frequent verbal reminding of limits, requires

Anxious or mildly agitated, attempting to sit up, calms down to verbal

4 Calm & Cooperative

Difficult to arouse, awakens to verbal stimuli gentle shaking but drifts

Arouses to physical stimuli but does not communicate or follow

Minimal or no response to noxious stimuli, does not communicate