Nurse Led Sedation for TAVR Bria Kneller, RN BSN CCRN Emory - - PowerPoint PPT Presentation

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Nurse Led Sedation for TAVR

Bria Kneller, RN BSN CCRN Emory University Hospital Midtown

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• I, Bria Kneller, DO NOT have a financial interest,

arrangement, or affiliation with one or more

• rganizations that could be perceived as a

real or apparent conflict of interest in the context of the subject of this presentation.

Disclosures

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Minimalist Approach

• Use of procedural sedation/moderate anesthesia care is gaining

popularity over General Anesthesia

• Potential benefits:
• No intubation; less respiratory compromise
• Decreased vasopressor use
• Shortened procedure time
• Shorter hospital stay
• Potential disadvantages
• Use of TEE is challenging; may miss PVL
• Patient discomfort

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What is Minimalist sedation?

• No clear definition is listed
• TVT registry lumps all non-GA

cases together

• MAC (Monitored Anesthesia

Care)

• NLS (Nurse Led Sedation)

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Emory Protocols for Sedation

• Determine which patients are

appropriate candidates for Minimalist

• Perform Conscious Sedation

algorithm

• ASA Score
• Mallampati score
• H&P
• Appropriate consents
• Conscious sedation ‘powerplan’

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Emory Protocols for Sedation

• Heart Team decides if patient is

scheduled for NLS, MAC or General Anesthesia based on protocol

• Anesthesia Pre-operative Clinic performs

consultation with patient the day before their procedure

• RN meets patient in the pre-op area on

the day of their procedure

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What does NLS look like?

• RN assessment in the pre-op area
• Allergies
• Age
• Hemodynamics
• Baseline respiratory status, blood pressure and HR
• Body habitus; frailty or obesity
• hx of COPD/OSA/respiratory conditions
• hx of HF (what is EF)
• hx of stroke/dementia/neuro conditions
• Home narcotic or benzo use
• Patient comfort preference

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What does NLS look like?

• 2 RNs circulate every TAVR
• One of the RNs is primarily responsible for medication

administration

• Ensure patient’s position is comfortable before sedating
• Protect elbows, heels and sacrum, arm position in radial access,

lumbar support if needed, use of home CPAP, bair hugger

• RN operates under “Moderate Sedation” protocol using

narcotics and benzodiazepines primarily

• RN assesses patient’s response to the medication throughout

the procedure and communicates with Physicians about patient status

• LOC, hemodynamics, breathing pattern, pain/anxiety

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What happens when things don’t go as planned?

• Defibrillator pads placed prior to starting procedure
• Venous sheath used as a central line
• Vasopressors primed and are on “hold”
• Anesthesia team is present in the department
• An overhead page for “all available help” called
• Airway and other emergency equipment in the room

for every case

• Crash cart, ambu bag, intubation box, IABP,

pericardiocentesis tray

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Evaluation of MAC vs NLS

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Evaluation of our outcomes

• Reviewed Emory Healthcare Database
• 2012-2017
• Only included balloon expandable valves
• Procedures performed under the “minimalist protocol”
• Two groups
• NLS- Conscious sedation delivered by RN (807 patients)
• MAC- Moderate sedation delivered by Anesthesia (MD +/-

CRNA)- (285 patients)

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Results

NLS n=807 MAC n=285 p-value Clinical Results Procedure Room TIme 147 minutes 164 minutes 0.001 Conversion to general anesthesia 2.1% 1.1% 0.22 Conversion to open surgery 0.74% 1.1% 0.63 Survival to discharge 98.6% 99.7% 0.12

* No statistical difference in major/minor vascular complications, major/minor bleeds, CVA, new-onset AFIB, new pacemaker placement, or need for second valve

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Discharge Echo Outcomes

Echocardiogram metrics NLS MAC P-value

Ejection Fraction 54.5% 56.9% 0.029 Aortic Valve Area 1.91cm2 1.79cm2 0.01 Mean Gradient 11.5mmHg 11.8mmHg 0.47

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Summary of Emory findings

• Nurse-Led Sedation can be performed safely and

effectively

• Procedural outcomes with nurse-led sedation are similar

to those with anesthesiologist-led moderate sedation

• No clinically significant differences in post-deployment

hemodynamics, vascular complications, or valve area

• Nurse-led sedation is associated with significantly less

procedure room time than anesthesia-led moderate sedation

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Thank you!

• Bria.kneller@emoryhealthcare.org
• Patricia.keegan@emoryhealthcare.org

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References

• https://www.sciencedirect.com/science/article/pii/S19368

7981832524X

• https://www.acc.org/latest-in-

cardiology/articles/2017/07/19/15/42/the-evolution-of- transcatheter-aortic-valve-replacement

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6242923/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4004491/