One EP Lab`s Solution to the Administration of Deep Sedation

In the EP lab setting, the most common procedure that conflicts with the new guidelines is defibrillation threshold (DFT) testing after implantable cardioverter-defibrillator (ICD) implants. To perform DFT testing, deep sedation must be administered at the end of the procedure to ensure the patient does not feel the 10-24 joule shock initiated by the ICD. The EP lab physicians at Riverside Methodist Hospital are all credentialed to administer deep sedation. It has been a challenge to initiate a process in which the EP physician, not the EP nurse, administers the sedative while assuring patient safety, good patient outcomes and preserving physician satisfaction. Due to an increased risk of infection, it was not an option for physicians to break sterile technique by coming around the table to push the medication, or to close the incision, complete the procedure and then sedate the patient. If DFT testing failed, the physician would then have to scrub again and re-open the incision. This is not optimal for the patient. Therefore, through creative thinking and ingenuity, the EP lab staff developed a process to facilitate the administration of deep sedation by the physician without breaking scrub, while meeting regulatory guidelines in a safe and effective way. James Ferguson, RN, who has been a member of our EP lab staff for five years, created the following injection system for administering deep sedation. The process involves assembling a manifold, which includes the following items: a 10 cc luer-lock syringe, a 30 cc luer-lock syringe, a three-way stop-cock, and a sterile 49 cm extension tubing set (Figure 1). All of these items are handed off, in sterile fashion, to the scrub nurse. The specific deep sedation medication (propofol, Brevital, etomidate) is obtained by the circulating nurse after it is ordered by the physician, and poured into an appropriately labeled container on the sterile field. The 30 cc syringe is filled with 0.9% normal saline from a labeled bowl already on the sterile field, and is connected to one end of the three-way stop-cock. The sterile extension tubing is then placed onto another end of the three-way stop-cock, and flushed with the 0.9% normal saline. The last port of the three-way stop-cock will house the syringe with the sedative. When it is time to perform DFT testing, the scrub nurse attaches the apparatus to the sterile field and places the open end of the sterile tubing across the patient s sterile drape, to the circulating nurse. The circulating nurse then fastens an alligator clip to the end of the tubing, while the scrub nurse flushes the line again with 0.9% normal saline to validate that there is no air in the tubing. The alligator clip is then attached to the patient s direct IV port. The physician draws up the correct amount of the sedative, based on the patient s weight, into the 10 cc syringe and fastens it to the stop-cock. The doctor gives the medication and follows this administration with a flush of 0.9% normal saline from the 30 cc syringe. Once deep sedation has been established by the physician, DFT testing can be performed. At Riverside Methodist Hospital, this technique has been successful in a variety of ways. It allows physicians to effectively administer deep sedation while maintaining a safe environment for the patient. The physicians are satisfied with this method of administration as it allows them to maintain sterile technique, decreasing any risk of infection. The nurses are pleased with this process as it allows them to continue to provide high quality and efficient care of the patient during the deep sedation process, while staying in the scope of practice for registered nurses as established by the Ohio Board of Nursing. Riverside Methodist Hospital is consistently named as one of America s Best Hospitals by U.S. News and World Report, and a Top 100 Cardiovascular Hospital by Solucient. The staff at Riverside s EP lab takes pride in high patient satisfaction and good outcomes of procedures. Recent Press-Ganey scores have been in the 99th percentile. The lab also well exceeds national standards in benchmarking patient outcomes with our infection rate being less than 1%. It is a goal to maintain this highly reputable standard of practice and continue to perform high quality and safe patient care with each procedure. Editor s Note: This article was peer reviewed by one or more members of EP Lab Digest s editorial board.