Procedural Sedation Record

Procedural Sedation Record Patient Identification: Sarah Jane Smith, Hospital Folder Number: 1234567, Date of Birth: 15/03/1988, Gender: Female Procedure Details: Gastroscopy performed in the Endoscopy Suite. Estimated duration was 45 minutes. Responsible proceduralist was Dr. Emily White, Gastroenterologist. Sedation Indication: Patient undergoing diagnostic gastroscopy for persistent dyspepsia and reflux symptoms. Sedation indicated for patient comfort, anxiety relief, and to ensure procedural cooperation. No absolute contraindications identified. Pre-Sedation Assessment: Fasting status confirmed: NPO for 8 hours prior to procedure. Baseline vital signs: HR 72 bpm, BP 128/78 mmHg, SpO₂ 98% on room air, RR 16 breaths/min. Airway assessment: Mallampati Class II, no loose teeth, no signs of obesity impacting airway. Known comorbidities: Well-controlled asthma. Relevant examination findings: Clear lung sounds bilaterally, patent airway. Sedation Plan: Conscious sedation strategy planned using Midazolam and Fentanyl. Selected agents: Midazolam 0.05 mg/kg IV titrated to effect, Fentanyl 1-2 mcg/kg IV titrated to effect for analgesia. Administration routes: Intravenous (IV) via peripheral cannula. Titration method: Incremental dosing until desired sedation depth achieved (Ramsay Sedation Score 2-3). Monitoring: Parameters monitored: Heart Rate (HR), Blood Pressure (BP), Oxygen Saturation (SpO₂), Respiratory Rate (RR), and Level of Consciousness (LOC). Equipment used: Electronic vital signs monitor with continuous SpO₂ and ECG. Frequency of observations: Every 5 minutes during sedation, then every 15 minutes during recovery. Administration Log: 10:00 - Midazolam 2mg IV, Administered by Dr. Thomas Kelly 10:05 - Fentanyl 50mcg IV, Administered by Nurse Jane Doe 10:15 - Midazolam 1mg IV, Administered by Dr. Thomas Kelly Sedation Depth and Responsiveness: Sedation depth maintained at Ramsay Sedation Score 3 (responsive to verbal commands). Patient remained verbally responsive throughout the procedure, occasionally drowsy but easily aroused. Intra-Procedure Course: Procedure lasted 30 minutes. Patient tolerated the procedure well with no significant distress. Haemodynamic status remained stable (BP 120-135/70-85 mmHg, HR 68-75 bpm). Respiratory rate maintained between 14-18 breaths/min, SpO₂ maintained at 97-99% on 2L O₂ via nasal cannula. No airway support required. No sedation-related or procedural complications observed. Fluids and Adjuncts: IV fluids administered: 250ml of 0.9% Normal Saline. No local anaesthetics, antiemetics, or other supportive medications administered. Complications and Adverse Events: No sedation-related adverse events (e.g., desaturation, hypotension, agitation, vomiting, laryngospasm) occurred. No interventions were required. Recovery Assessment: Recovery vital signs: HR 70 bpm, BP 125/75 mmHg, SpO₂ 99% on room air, RR 16 breaths/min. Level of consciousness: Alert and oriented x3. Ability to maintain airway: Fully patent and self-maintained. Readiness for discharge from recovery area confirmed based on Aldrete score of 9. Post-Sedation Instructions: Patient instructed to have an adult escort home. Activity restrictions: No driving, operating machinery, or making important decisions for 24 hours. Dietary advice: Start with light, clear fluids, then progress to soft foods as tolerated. Medication guidance: Resume usual medications unless otherwise advised. Red flags to watch for: Persistent nausea, vomiting, severe abdominal pain, difficulty breathing – instructed to seek immediate medical attention if any occur. Follow-up arrangements: Scheduled for outpatient gastroenterology clinic in 2 weeks. Clinician Signature: Dr. Thomas Kelly, Anaesthetist, 1 November 2024, 11:30