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Kevin

Drew

Team

Profile

Birth

Dates

December

age

Kevin

April

age

Drew

Hometown

Bayonne

New

Jersey

Kevin

Staten

Island

New

York

Drew

Relation

Fraternity

brothers

The

Amazing

Race

Legs

Competed

Legs

Won

Placement

Average

Position

Roadblock

Count

Kevin

Drew

Countries

Raced

The

Amazing

Race

AllStars

Legs

Competed

Legs

Won

Placement

Average

Position

Roadblock

Count

Kevin

Drew

Countries

Raced

Gallery

Link

Kevin

OConnor

and

Drew

Feinberg

are

a

team

of

Fraternity

Brothers

on

The

Amazing

Race

and

a

team

of

Lifelong

Friends

on

The

Amazing

Race

AllStars

Friends

from

New

York

and

the

first

fan

favorites

due

to

their

constant

joking

around

and

goodnatured

bickering

with

each

other

They

would

prove

to

be

deceptively

good

racers

winning

three

legs

on

their

way

to

finishing

They

were

officially

eliminated

in

leg

after

their

cab

driver

took

them

to

the

wrong

entrance

of

Tiantan

Park

but

their

real

elimination

came

like

Bill

Joe

when

the

badly

placed

equalizers

distanced

them

from

the

front

two

teams

during

leg

Their

status

as

the

first

fan

favorites

would

get

them

invited

back

for

AllStars

Unfortunately

Drew

was

ill

fit

to

run

the

race

due

to

his

various

ailments

and

injuries

and

they

were

further

hindered

by

their

complete

unpreparedness

having

done

nothing

to

get

ready

for

the

season

They

grumped

their

way

through

two

legs

finishing

when

Drew

failed

to

notice

that

the

speed

limit

had

raised

from

to

and

they

were

repeatedly

passed

by

other

teams

on

their

way

to

the

Pit

Stop

Contents

show

Profile

Retrieved

from

CBScom

The

Amazing

Race

The

Amazing

Race

AllStars

Kevin

and

Drew

met

in

when

they

became

fraternity

brothers

in

New

York

When

they

heard

about

THE

AMAZING

RACE

they

knew

that

it

was

an

unbelievable

opportunity

for

two

guys

who

had

never

been

anywhere

where

you

need

a

passport

They

make

a

strong

Team

because

theyre

both

very

competitive

and

both

feel

that

it

would

sure

be

nice

to

win

a

million

dollars

The

Amazing

Race

Kevin

Drews

Race

History

Episode

Leg

Destinations

Detour

Choice

underlined

Roadblock

Performer

Placement

Notes

United

States

South

Africa

Zambia

Air

Land

Drew

of

Zambia

France

Far

Near

Kevin

of

France

Used

Fast

Forward

of

France

Tunisia

Full

Body

Brew

Full

Body

Massage

Drew

of

Tunisia

Listening

Puzzling

Kevin

of

Tunisia

Italy

Foot

Hoof

Drew

of

Italy

India

Glide

Ride

Kevin

of

India

Elephant

Row

Boat

Kevin

of

India

Thailand

Public

Private

Drew

of

Thailand

Hike

Climb

Kevin

of

Thailand

China

Volley

Rally

Drew

of

Average

Legend

The

team

finished

in

first

place

The

team

finished

in

last

place

and

was

eliminated

from

the

race

The

team

finished

in

last

place

in

a

nonelimination

leg

The

team

that

won

The

Amazing

Race

The

team

that

crossed

the

Finish

Line

second

The

team

that

crossed

the

Finish

Line

third

The

team

used

the

Fast

Forward

pass

Notes

Leg

had

an

unaired

Roadblock

where

one

teammate

had

to

cook

a

whole

ostrich

egg

for

the

whole

team

to

eat

Drew

was

shown

to

have

completed

the

task

in

the

DVD

release

Kevin

Drew

chose

Private

initially

for

the

Detour

before

switching

to

Public

The

Amazing

Race

AllStars

Kevin

Drews

Race

History

Episode

Leg

Destinations

Detour

Choice

underlined

Roadblock

Performer

Placement

Notes

United

States

Ecuador

Wrangle

It

Recover

It

No

Roadblock

of

Ecuador

Chile

By

Hand

By

Machine

Kevin

of

Average

Legend

The

team

finished

in

first

place

The

team

finished

in

last

place

and

was

eliminated

from

the

race

The

team

finished

in

last

place

in

a

nonelimination

leg

The

team

that

won

The

Amazing

Race

The

team

that

crossed

the

Finish

Line

second

The

team

that

crossed

the

Finish

Line

third

The

team

used

the

Fast

Forward

pass

The

team

used

the

Yield

Recipient

of

the

Yield

PostRace

Kevin

and

Drew

made

a

cameo

in

the

first

leg

of

The

Amazing

Race

Family

Edition

where

they

dressed

as

hotdog

vendors

and

handed

clues

for

the

teams

Trivia

Franchise

Records

Kevin

and

Drew

are

the

first

team

to

win

multiple

legs

in

a

single

season

First

team

to

be

eliminated

in

China

First

allmale

team

to

be

eliminated

from

the

competition

Became

the

first

team

to

appear

on

three

seasons

The

Amazing

Race

The

Amazing

Race

Family

Edition

and

The

Amazing

Race

AllStars

External

links

Interviews

Season

Susan

L

Harper

at

New

York

Lawyer

Court

Officer

Consultant

Race

for

Jane

Clayson

on

The

Early

Show

Sadly

Time

Was

Up

For

The

Shows

Abbott

Costello

TV

Guide

Online

Chatting

with

Kevin

Drew

TARflies

QA

with

Kevin

Tatiana

Morales

on

Early

Show

Kevin

and

Drew

Unleashed

TARflies

A

Friendly

and

Affable

Fellow

Drew

David

W

Taylor

at

Reality

Reel

Media

PeekABoo

Kevin

Drew

II

The

Interview

AllStars

Hannah

Storm

on

Early

Show

Road

Ends

for

Racing

Brothers

Oscar

Dahl

at

BuddyTV

Exclusive

Interview

Kevin

Drew

Team

Eliminated

on

The

Amazing

Race

AllStars

Christopher

Rocchio

at

Reality

TV

World

Kevin

and

Drew

talk

about

their

AllStars

experience

Eric

Goldman

at

IGN

AllStars

Interview

Kevin

Drew

Teeuwynn

Woodruff

on

RealityNewsOnline

Dont

Ever

Go

To

Ecuador

At

Least

Dont

Go

High

Up

TARflies

The

Second

Time

Around

Social

Media

Profiles

Kevins

Facebook

irishkevo

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References

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O O O O B B O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O B O O O O O B O O O O B O O O O B O B I O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O B O B O O O O O B O O B O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O B O O O O O O O O O B O O O O O O O O O B O O O O O O O O O B O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B B O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B B O O O O B O O O O O O B O B O O O O O O O O B O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O B B O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O B B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


Amish Tours of Harmony Southeast Minnesotas Premier Amish Tour Company Tour through Minnesotas largest Old Order Amish community with the regions premier Amish Tour Company Amish Tours of Harmony has been offering quality tours for over thirty years of the HarmonyCanton Amish community Let our experienced guides tell you about Amish culture history and customs as you stop at shops that offer Amish furniture baked goods baskets quilts and much more Our knowledgeable tour guides can answer all of your questions about the Amish way of life Travel with us through pastoral settings in the comfort of your own vehicle or on one of our air conditioned mini busses Or contact us about booking a tour guide for your bus group An Amish tour is a great day trip destination for a school group senior group or community education trip We had a very informative tour guide who knew some of the Amish personally We were able to interact with Amish families and purchase handmade items onsite Furniture is gorgeous and baskets lovely prices unbelievable We plan to make another trip to purchase more items Dont forget to check out the baked goods too Fell in love with cashew crunch candy This tour was the highlight of our mini vacation to Minnesota Susan S If you are in the area its a must see and do Jill M We look forward to sharing this unique culture with you Other points of interest in the Harmony area include Niagara Cave one of the Driftless Areas most unique geological attractions Visitors to Niagara Cave will take a one hour guided tour where they will witness an underground waterfall discover fossils and view cave formations both delicate and massive The cave also offers an 18 hole mini golf course and gemstone mining Harmony is located on the Root River and Harmony Preston State Valley bike trail This DNR maintained paved trail offers over 60 miles of cycling for bike enthusiasts of all skill levels Harmony is also home to award winning restaurants New Generations of Harmony antique mall unique gift shops and more Visit the Harmony Area Chamber of Commerce for more information on local events services and attractions

B I I I O O O O O O O O O O O O O O O O O O O O O B I I I O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O

amish tours of harmony
amish culture
community education trip


Definitions Focus Purpose Application Task Force Members and Consultants Availability and Strength of Evidence Guidelines References Free Practice Parameter April 2002 Practice Guidelines for Sedation and Analgesia by NonAnesthesiologists Author Notes Anesthesiology 4 2002 Vol96 10041017 doi Tables PDF Tools Get Permissions Get Citation Alerts ANESTHESIOLOGISTS possess specific expertise in the pharmacology physiology and clinical management of patients receiving sedation and analgesia For this reason they are frequently called on to participate in the development of institutional policies and procedures for sedation and analgesia for diagnostic and therapeutic procedures To assist in this process the American Society of Anesthesiologists ASA has developed these Guidelines for Sedation and Analgesia by NonAnesthesiologists Practice guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care These recommendations may be adopted modified or rejected according to clinical needs and constraints Practice guidelines are not intended as standards or absolute requirements The use of practice guidelines can not guarantee any specific outcome Practice guidelines are subject to revision as warranted by the evolution of medical knowledge technology and practice The guidelines provide basic recommendations that are supported by analysis of the current literature and by a synthesis of expert opinion open forum commentary and clinical feasibility data This revision includes data published since the Guidelines for Sedation and Analgesia by NonAnesthesiologists were adopted by the ASA in 1995 it also includes data and recommendations for a wider range of sedation levels than was previously addressed Definitions Sedation and analgesia comprise a continuum of states ranging from minimal sedation anxiolysis through general anesthesia Definitions of levels of sedationanalgesia as developed and adopted by the ASA are given in table 1 These Guidelines specifically apply to levels of sedation corresponding to moderate sedation frequently called conscious sedation and deep sedation as defined in table 1 Table 1 Continuum of Depth of Sedation Definition of General Anesthesia and Levels of SedationAnalgesia Full Size Slide ppt Focus These Guidelines are designed to be applicable to procedures performed in a variety of settings eg hospitals freestanding clinics physician dental and other offices by practitioners who are not specialists in anesthesiology Because minimal sedation anxiolysis entails minimal risk the Guidelines specifically exclude it Examples of minimal sedation include peripheral nerve blocks local or topical anesthesia and either 1 less than 50 nitrous oxide N 2 O in oxygen with no other sedative or analgesic medications by any route or 2 a single oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of insomnia anxiety or pain The Guidelines also exclude patients who are not undergoing a diagnostic or therapeutic procedure eg postoperative analgesia sedation for treatment of insomnia Finally the Guidelines do not apply to patients receiving general or major conduction anesthesia eg spinal or epiduralcaudal block whose care should be provided medically directed or supervised by an anesthesiologist the operating practitioner or another licensed physician with specific training in sedation anesthesia and rescue techniques appropriate to the type of sedation or anesthesia being provided Purpose The purpose of these Guidelines is to allow clinicians to provide their patients with the benefits of sedationanalgesia while minimizing the associated risks Sedationanalgesia provides two general types of benefit 1 sedationanalgesia allows patients to tolerate unpleasant procedures by relieving anxiety discomfort or pain and 2 in children and uncooperative adults sedationanalgesia may expedite the conduct of procedures that are not particularly uncomfortable but that require that the patient not move At times these sedation practices may result in cardiac or respiratory depression which must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage cardiac Application These Guidelines are intended to be general in their application and broad in scope The appropriate choice of agents and techniques for sedationanalgesia is dependent on the experience and preference of the individual practitioner requirements or constraints imposed by the patient or procedure and the likelihood of producing a deeper level of sedation than anticipated Because it is not always possible to predict how a specific patient will respond to sedative and analgesic medications practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended For moderate responds purposefully after repeated or painful stimulation whereas for deep sedation this implies the ability to manage respiratory or cardiovascular instability in a patient who does not respond purposefully to painful or repeated stimulation Levels of sedation referred to in the recommendations relate to the level of sedation intended by the practitioner Examples are provided to illustrate airway assessment preoperative fasting emergency equipment and recovery procedures however clinicians and their institutions have ultimate responsibility for selecting patients procedures medications and equipment Task Force Members and Consultants The ASA appointed a Task Force of 10 members to 1 review the published evidence 2 obtain the opinion of a panel of consultants including nonanesthesiologist physicians and dentists who routinely administer sedationanalgesia as well as of anesthesiologists with a special interest in sedationanalgesia see 1 and 3 build consensus within the community of practitioners likely to be affected by the Guidelines The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States a gastroenterologist and methodologists from the ASA Committee on Practice Parameters This Practice Guideline is an update and revision of the ASA Guidelines for Sedation and Analgesia by NonAnesthesiologists 1 The Task Force revised and updated the Guidelines by means of a fivestep process First original published research studies relevant to the revision and update were reviewed and analyzed only articles relevant to the administration of sedation by nonanesthesiologists were evaluated Second the panel of expert consultants was asked to 1 participate in a survey related to the effectiveness and safety of various methods and interventions that might be used during sedationanalgesia and 2 review and comment on the initial draft report of the Task Force Third the Task Force held open forums at two major national meetings to solicit Availability and Strength of Evidence Evidencebased Guidelines are developed by a rigorous analytic process To assist the reader the Guidelines make use of several descriptive terms that are easier to understand than the technical terms and data that are used in the actual analyses These descriptive terms are defined below The following terms describe the strength of scientific data obtained from the scientific literature Supportive There is sufficient quantitative information from adequately designed studies to describe a statistically significant relationship P 001 between a clinical intervention and a clinical outcome using metaanalysis Suggestive There is enough information from case reports and descriptive studies to provide a directional assessment of the relationship between a clinical intervention and a clinical outcome This type of qualitative information does not permit a statistical assessment of significance Equivocal Qualitative data have not provided a clear direction for clinical outcomes related to a clinical intervention and 1 there is insufficient quantitative information or 2 aggregated comparative studies have found no quantitatively significant differences among groups or conditions The following terms describe the lack of available scientific evidence in the literature Inconclusive Published studies are available but they can not be used to assess the relation between a clinical intervention and a clinical outcome because the studies either do not meet predefined criteria for content as defined in the Focus of these Guidelines or do not provide a clear causal interpretation of findings because of research design or analytic concerns Insufficient There are too few published studies to investigate a relationship between a clinical intervention and clinical outcome Silent No studies that address a relationship of interest were found in the available published literature The following terms describe survey responses from the consultants for any specified issue Responses were solicited on a fivepoint scale ranging from 1 strongly disagree to 5 strongly agree with a score of 3 being neutral Strongly Agree median score of 5 Agree median score of 4 Equivocal median score of 3 Disagree median score of 2 Strongly Disagree median score of 1 Guidelines Patient Evaluation There is insufficient published evidence to evaluate the relationship between sedationanalgesia outcomes and the performance of a preprocedure patient evaluation There is suggestive evidence that some preexisting medical conditions may be related to adverse outcomes in patients receiving either moderate or deep sedationanalgesia The consultants strongly agree that appropriate preprocedure evaluation history physical examination increases the likelihood of satisfactory sedation and decreases the likelihood of adverse outcomes for both moderate and deep sedation Recommendations Clinicians administering sedationanalgesia should be familiar with sedationoriented aspects of the patients medical history and how these might alter the patients response to sedationanalgesia These include 1 abnormalities of the major organ systems 2 previous adverse experience with sedationanalgesia as well as regional and general anesthesia 3 drug allergies current medications and potential drug interactions 4 time and nature of last oral intake and 5 history of tobacco alcohol or substance use or abuse Patients presenting for sedationanalgesia should undergo a focused physical examination including vital signs auscultation of the heart and lungs and evaluation of the airway Example I Preprocedure Preparation The literature is insufficient regarding the benefits of providing the patient or legal guardian in the case of a child or impaired adult with preprocedure information about sedation and analgesia For moderate sedation the consultants agree and for deep sedation the consultants strongly agree that appropriate preprocedure counseling of patients regarding risks benefits and alternatives to sedation and analgesia increases patient satisfaction TABLE Table Example IAirway Assessment Procedures for Sedation and Analgesia Full Size Slide ppt Sedatives and analgesics tend to impair airway reflexes in proportion to the degree of sedationanalgesia achieved This dependence on level of sedation is reflected in the consultants opinion They agree that preprocedure fasting decreases risks during moderate sedation while strongly agreeing that it decreases risks during deep sedation In emergency situations when preprocedure fasting is not practical the consultants agree that the target level of sedation should be modified ie less sedation should be administered for moderate sedation while strongly agreeing that it should be modified for deep sedation The literature does not provide sufficient evidence to test the hypothesis that preprocedure fasting results in a decreased incidence of adverse outcomes in patients undergoing either moderate or deep sedation Recommendations Patients or their legal guardians in the case of minors or legally incompetent adults should be informed of and agree to the administration of sedationanalgesia including its benefits risks and limitations associated with this therapy as well as possible alternatives Patients undergoing sedationanalgesia for elective procedures should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying before their procedure as recommended by the ASA Guidelines for Preoperative Fasting 2 Example II In urgent emergent or other situations in which gastric emptying is impaired the potential for pulmonary aspiration of gastric contents must be considered in determining 1 the target level of sedation 2 whether the procedure should be delayedor 3 whether the trachea should be protected by intubation TABLE Table Example IISummary of American Society of Anesthesiologists Preprocedure Fasting Guidelines 2 Full Size Slide ppt Monitoring Level of Consciousness The response of patients to commands during procedures performed with sedationanalgesia serves as a guide to their level of consciousness Spoken responses also provide an indication that the patients are breathing Patients whose only response is reflex withdrawal from painful stimuli are deeply sedated approaching a state of general anesthesia and should be treated accordingly The literature is silent regarding whether monitoring patients level of consciousness improves patient outcomes or decreases risks The consultants strongly agree that monitoring level of consciousness reduces risks for both moderate and deep sedation The members of the Task Force believe that many of the ie before the development of cardiovascular decompensation or cerebral hypoxia Patients given sedatives or analgesics in unmonitored settings in anticipation of a subsequent procedure may be at increased risk of these complications Pulmonary Ventilation It is the opinion of the Task Force that the primary causes of morbidity associated with sedationanalgesia are druginduced respiratory depression and airway obstruction For both moderate and deep sedation the literature is insufficient to evaluate the benefit of monitoring ventilatory function by observation or auscultation However the consultants strongly agree that monitoring of ventilatory function by observation or auscultation reduces the risk of adverse outcomes associated with sedationanalgesia The consultants were equivocal regarding the ability of capnography to decrease risks during moderate sedation while agreeing that it may decrease risks during deep sedation In circumstances in which patients are Oxygenation Published data suggest that oximetry effectively detects oxygen desaturation and hypoxemia in patients who are administered sedativesanalgesics The consultants strongly agree that early detection of hypoxemia through the use of oximetry during sedationanalgesia decreases the likelihood of adverse outcomes such as cardiac arrest and death The Task Force agrees that hypoxemia during sedation and analgesia is more likely to be detected by oximetry than by clinical assessment alone Hemodynamics Although there are insufficient published data to reach a conclusion it is the opinion of the Task Force that sedative and analgesic agents may blunt the appropriate autonomic compensation for hypovolemia and procedurerelated stresses On the other hand if sedation and analgesia are inadequate patients may develop potentially harmful autonomic stress responses eg hypertension tachycardia Early detection of changes in patients heart rate and blood pressure may enable practitioners to detect problems and intervene in a timely fashion reducing the risk of these complications The consultants strongly agree that regular monitoring of vital signs reduces the likelihood of adverse outcomes during both moderate and deep sedation For both moderate and deep sedation a majority of the consultants indicated that vital signs should be monitored at 5min intervals once a stable level of sedation is established The consultants strongly agree that continuous electrocardiography reduces risks during deep sedation while they were equivocal regarding its eg with significant cardiovascular disease or dysrhythmias may decrease risks during moderate sedation Recommendations Monitoring of patient response to verbal commands should be routine during moderate sedation except in patients who are unable to respond appropriately eg young children mentally impaired or uncooperative patients or during procedures where movement could be detrimental During deep sedation patient responsiveness to a more profound stimulus should be sought unless contraindicated to ensure that the patient has not drifted into a state of general anesthesia During procedures where a verbal response is not possible eg oral surgery upper endoscopy the ability to give a thumbs up or other indication of consciousness in response to verbal or tactile light tap stimulation suggests that the patient will be able to control his airway and take deep breaths if necessary corresponding to a state of moderate sedation Note that a response limited to reflex withdrawal from a painful stimulus is not considered a purposeful response and thus represents a state of general anesthesia All patients undergoing sedationanalgesia should be monitored by pulse oximetry with appropriate alarms If available the variable pitch beep which gives a continuous audible indication of the oxygen saturation reading may be helpful In addition ventilatory function should be continually monitored by observation or auscultation Monitoring of exhaled carbon dioxide should be considered for all patients receiving deep sedation and for patients whose ventilation can not be directly observed during moderate sedation When possible blood pressure should be determined before sedationanalgesia is initiated Once sedationanalgesia is established blood pressure should be measured at 5min intervals during the procedure unless such eg pediatric magnetic resonance imaging where stimulation from the blood pressure cuff could arouse an appropriately sedated patient Electrocardiographic monitoring should be used in all patients undergoing deep sedation It should also be used during moderate sedation in patients with significant cardiovascular disease or those who are undergoing procedures where dysrhythmias are anticipated Recording of Monitored Parameters The literature is silent regarding the benefits of contemporaneous recording of patients level of consciousness respiratory function or hemodynamics Consultant opinion agrees with the use of contemporaneous recording for moderate sedation and strongly agrees with its use for patients undergoing deep sedation It is the consensus of the Task Force that unless technically precluded eg uncooperative or combative patient vital signs and respiratory variables should be recorded before initiating sedationanalgesia after administration of sedativeanalgesic medications at regular intervals during the procedure on initiation of recovery and immediately before discharge It is the opinion of the Task Force that contemporaneous recording either automatic or manual of patient data may disclose trends that could prove critical in determining the development or cause of adverse events In addition manual recording ensures that an individual caring for the patient is aware of changes in patient status in a timely fashion Recommendations For both moderate and deep sedation patients level of consciousness ventilatory and oxygenation status and hemodynamic variables should be assessed and recorded at a frequency that depends on the type and amount of medication administered the length of the procedure and the general condition of the patient At a minimum this should be 1 before the beginning of the procedure 2 after administration of sedativeanalgesic agents 3 at regular intervals during the procedure 4 during initial recovery and 5 just before discharge If recording is performed automatically device alarms should be set to alert the care team to critical changes Availability of an Individual Responsible for Patient Monitoring Although the literature is silent on this issue the Task Force recognizes that it may not be possible for the individual performing a procedure to be fully cognizant of the patients condition during sedationanalgesia For moderate sedation the consultants agree that the availability of an individual other than the person performing the procedure to monitor the patients status improves patient comfort and satisfaction and that risks are reduced For deep sedation the consultants strongly agree with these contentions During moderate sedation the consultants strongly agree that the individual monitoring the patient may assist the practitioner with interruptible ancillary tasks of Recommendation A designated individual other than the practitioner performing the procedure should be present to monitor the patient throughout procedures performed with sedationanalgesia During deep sedation this individual should have no other responsibilities However during moderate sedation this individual may assist with minor interruptible tasks once the patients level of sedationanalgesia and vital signs have stabilized provided that adequate monitoring for the patients level of sedation is maintained Training of Personnel Although the literature is silent regarding the effectiveness of training on patient outcomes the consultants strongly agree that education and training in the pharmacology of agents commonly used during sedationanalgesia improves the likelihood of satisfactory sedation and reduces the risk of adverse outcomes from either moderate or deep sedation Specific concerns may include 1 potentiation of sedativeinduced respiratory depression by concomitantly administered opioids 2 inadequate time intervals between doses of sedative or analgesic agents resulting in a cumulative overdose and 3 inadequate familiarity with the role of pharmacologic antagonists for sedative and analgesic agents Because the primary complications of sedationanalgesia are related to respiratory or cardiovascular depression it is the consensus of the Task Force that the individual responsible for monitoring the patient should be trained in the recognition of complications associated with sedationanalgesia Because sedationanalgesia constitutes a continuum practitioners administering moderate sedation should be able to rescue patients who enter a state of deep sedation whereas those intending to administer deep sedation should be able to rescue patients who enter a state of general anesthesia Therefore the consultants strongly agree that at least one qualified individual trained in basic life support skills cardiopulmonary eg tracheal intubation defibrillation use of resuscitation medications for moderate sedation and in the procedure room itself for deep sedation Recommendations Individuals responsible for patients receiving sedationanalgesia should understand the pharmacology of the agents that are administered as well as the role of pharmacologic antagonists for opioids and benzodiazepines Individuals monitoring patients receiving sedationanalgesia should be able to recognize the associated complications At least one individual capable of establishing a patent airway and positive pressure ventilation as well as a means for summoning additional assistance should be present whenever sedationanalgesia is administered It is recommended that an individual with advanced life support skills be immediately available within 5 min for moderate sedation and within the procedure room for deep sedation Availability of Emergency Equipment Although the literature is silent the consultants strongly agree that the ready availability of appropriately sized emergency equipment reduces risks associated with both moderate and deep sedation The literature is also silent regarding the need for cardiac defibrillators during sedationanalgesia During moderate sedation the consultants agree that a defibrillator should be immediately available for patients with both mild eg hypertension and severe eg ischemia congestive failure cardiovascular disease During deep sedation the consultants agree that a defibrillator should be immediately available for all patients Recommendations Pharmacologic antagonists as well as appropriately sized equipment for establishing a patent airway and providing positive pressure ventilation with supplemental oxygen should be present whenever sedationanalgesiais administered Suction advanced airway equipment and resuscitation medications should be immediately available and in good working order Example III A functional defibrillator should be immediately available whenever deep sedation is administered and when moderate sedation is administered to patients with mild or severe cardiovascular disease TABLE Table Example IIIEmergency Equipment for Sedation and Analgesia Full Size Slide ppt Use of Supplemental Oxygen The literature supports the use of supplemental oxygen during moderate sedation and suggests that supplemental oxygen be used during deep sedation to reduce the frequency of hypoxemia The consultants agree that supplemental oxygen decreases patient risk during moderate sedation while strongly agreeing with this view for deep sedation Recommendations Equipment to administer supplemental oxygen should be present when sedationanalgesia is administered Supplemental oxygen should be considered for moderate sedation and should be administered during deep sedation unless specifically contraindicated for a particular patient or procedure If hypoxemia is anticipated or develops during sedationanalgesia supplemental oxygen should be administered Combinations of SedativeAnalgesic Agents The literature suggests that combining a sedative with an opioid provides effective moderate sedation it is equivocal regarding whether the combination of a sedative and an opioid may be more effective than a sedative or an opioid alone in providing adequate moderate sedation For deep sedation the literature is insufficient to compare the efficacy of sedativeopioid combinations with that of a sedative alone The consultants agree that combinations of sedatives and opioids provide satisfactory moderate and deep sedation However the published data also suggest that combinations of sedatives and opioids may increase the likelihood of adverse outcomes including ventilatory depression Recommendations Combinations of sedative and analgesic agents may be administered as appropriate for the procedure being performed and the condition of the patient Ideally each component should be administered individually to achieve the desired effect eg additional analgesic medication to relieve pain additional sedative medication to decrease awareness or anxiety The propensity for combinations of sedative and analgesic agents to cause respiratory depression and airway obstruction emphasizes the need to appropriately reduce the dose of each component as well as the need to continually monitor respiratory function Titration of Intravenous SedativeAnalgesic Medications The literature is insufficient to determine whether administration of small incremental doses of intravenous sedativeanalgesic drugs until the desired level of sedation or analgesia is achieved is preferable to a single dose based on patient size weight or age The consultants strongly agree that incremental drug administration improves patient comfort and decreases risks for both moderate and deep sedation Recommendations Intravenous sedativeanalgesic drugs should be given in small incremental doses that are titrated to the desired end points of analgesia and sedation Sufficient time must elapse between doses to allow the effect of each dose to be assessed before subsequent drug administration When drugs are administered by nonintravenous routes eg oral rectal intramuscular transmucosal allowance should be made for the time required for drug absorption before supplementation is considered Because absorption may be unpredictable administration of repeat doses of oral medications to supplement sedationanalgesia is not recommended Anesthetic Induction Agents Used for SedationAnalgesia Propofol Methohexital Ketamine The literature suggests that when administered by nonanesthesiologists propofol and ketamine can provide satisfactory moderate sedation and suggests that methohexital can provide satisfactory deep sedation The literature is insufficient to evaluate the efficacy of propofol or ketamine administered by nonanesthesiologists for deep sedation There is insufficient literature to determine whether moderate or deep sedation with propofol is associated with a different incidence of adverse outcomes than similar levels of sedation with midazolam The consultants are equivocal regarding whether use of these medications affects the likelihood of producing satisfactory moderate sedation while agreeing that using them increases the likelihood of satisfactory The Task Force cautions practitioners that methohexital and propofol can produce rapid profound decreases in level of consciousness and cardiorespiratory function potentially culminating in a state of general anesthesia The Task Force notes that ketamine also produces doserelated decreases in level of consciousness culminating in general anesthesia Although it may be associated with less cardiorespiratory depression than other sedatives airway obstruction laryngospasm and pulmonary aspiration may still occur with ketamine Furthermore because of its dissociative properties some of the usual signs of depth of sedation may not apply eg the patients eyes may be open while in a state of deep sedation or general anesthesia The Task Force also notes that there are no specific pharmacologic antagonists for any of these medications Recommendations Even if moderate sedation is intended patients receiving propofol or methohexital by any route should receive care consistent with that required for deep sedation Accordingly practitioners administering these drugs should be qualified to rescue patients from any level of sedation including general anesthesia Patients receiving ketamine should be cared for in a manner consistent with the level of sedation that is achieved Intravenous Access Published literature is equivocal regarding the relative efficacy of sedativeanalgesic agents administered intravenously as compared with those administered by nonintravenous routes to achieve moderate sedation the literature is insufficient on this issue for deep sedation The literature is equivocal regarding the comparative safety of these routes of administration for moderate sedation and is insufficient for deep sedation The consultants strongly agree that intravenous administration of sedative and analgesic medications increases the likelihood of satisfactory sedation for both moderate and deep sedation They also agree that it decreases the likelihood of adverse outcomes For both moderate and deep sedation when sedativeanalgesic eg oral rectal intramuscular the need for intravenous access is not sufficiently addressed in the literature However initiation of intravenous access after the initial sedation takes effect allows additional sedativeanalgesic and resuscitation drugs to be administered if necessary Recommendations In patients receiving intravenous medications for sedationanalgesia vascular access should be maintained throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression In patients who have received sedationanalgesia by nonintravenous routes or whose intravenous line has become dislodged or blocked practitioners should determine the advisability of establishing or reestablishing intravenous access on a casebycase basis In all instances an individual with the skills to establish intravenous access should be immediately available Reversal Agents Specific antagonist agents are available for the opioids eg naloxone and benzodiazepines eg flumazenil The literature supports the ability of naloxone to reverse opioidinduced sedation and respiratory depression Practitioners are cautioned that acute reversal of opioidinduced analgesia may result in pain hypertension tachycardia or pulmonary edema The literature supports the ability of flumazenil to antagonize benzodiazepineinduced sedation and ventilatory depression in patients who have received benzodiazepines alone or in combination with an opioid The consultants strongly agree that the immediate availability of reversal agents during both moderate and deep sedation is associated with decreased risk of adverse outcomes It is the consensus of the Task Force that respiratory depression should be initially treated Recommendations Specific antagonists should be available whenever opioid analgesics or benzodiazepines are administered for sedationanalgesia Naloxone or flumazenil may be administered to improve spontaneous ventilatory efforts in patients who have received opioids or benzodiazepines respectively This may be especially helpful in cases where airway control and positive pressure ventilation are difficult Before or concomitantly with pharmacologic reversal patients who become hypoxemic or apneic during sedationanalgesia should 1 be encouraged or stimulated to breathe deeply 2 receive supplemental oxygen and 3 receive positive pressure ventilation if spontaneous ventilation is inadequate After pharmacologic reversal patients should be observed long enough to ensure that Recovery Care Patients may continue to be at significant risk for developing complications after their procedure is completed Decreased procedural stimulation delayed drug absorption following nonintravenous administration and slow drug elimination may contribute to residual sedation and cardiorespiratory depression during the recovery period Examples include intramuscular meperidinepromethazinechlorpromazine mixtures and oral or rectal chloral hydrate When sedationanalgesia is administered to outpatients it is likely that there will be no medical supervision once the patient leaves the medical facility Although there is not sufficient literature to examine the effects of postprocedure monitoring on patient outcomes the consultants strongly agree that continued observation monitoring and Recommendations Following sedationanalgesia patients should be observed in an appropriately staffed and equipped area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression Oxygenation should be monitored periodically until patients are no longer at risk for hypoxemia Ventilation and circulation should be monitored at regular intervals until patients are suitable for discharge Discharge criteria should be designed to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel Example IV TABLE Table Example IVRecovery and Discharge Criteria after Sedation and Analgesia Full Size Slide ppt Special Situations The literature suggests and the Task Force members concur that certain types of patients are at increased risk for developing complications related to sedationanalgesia unless special precautions are taken In patients with significant underlying medical conditions eg extremes of age severe cardiac pulmonary hepatic or renal disease pregnancy drug or alcohol abuse the consultants agree that preprocedure consultation with an appropriate medical specialist eg cardiologist pulmonologist decreases the risks associated with moderate sedation and strongly agree that it decreases the risks associated with deep sedation In patients with significant sedationrelated risk factors eg uncooperative patients morbid obesity potentially difficult airway sleep apnea the consultants are equivocal regarding whether preprocedure consultation with an anesthesiologist increases the likelihood of satisfactory moderate sedation while agreeing that it decreases adverse outcomes The consultants strongly agree that preprocedure consultation increases the likelihood of satisfactory outcomes while decreasing risks associated with deep sedation The Task Force notes that in emergency situations the benefits of awaiting preprocedure consultations must be weighed against the risk of delaying the procedure For moderate sedation the consultants are equivocal regarding whether the immediate availability of an individual with postgraduate training in anesthesiology increases the likelihood of a satisfactory outcome or decreases the associated risks For deep sedation the consultants agree that the immediate availability of such an individual improves the likelihood of satisfactory sedation and that it will decrease the likelihood of adverse outcomes Recommendations Whenever possible appropriate medical specialists should be consulted before administration of sedation to patients with significant underlying conditions The choice of specialists depends on the nature of the underlying condition and the urgency of the situation For severely compromised or medically unstable patients eg anticipated difficult airway severe obstructive pulmonary disease coronary artery disease or congestive heart failure or if it is likely that sedation to the point of unresponsiveness will be necessary to obtain adequate conditions practitioners who are not trained in the administration of general anesthesia should consult an anesthesiologist Appendix I Methods and Analyses 1 The scientific assessment of these Guidelines was based on the following statements or evidence linkages These linkages represent directional statements about relationships between sedationanalgesia interventions by nonanesthesiologists and clinical outcomes A preprocedure patient evaluation ie history physical examination laboratory evaluation consultation a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Preprocedure preparation of the patient eg counseling fasting a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Patient monitoring ie level of consciousness pulmonary ventilation observation auscultation oxygenation pulse oximetry automated apnea monitoring capnography hemodynamics electrocardiogram blood pressure heart rate a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Contemporaneous recording of monitored parameters eg level of consciousness respiratory function hemodynamics at regular intervals in patients receiving sedation or analgesia a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Availability of an individual who is dedicated solely to patient monitoring and safety a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Education and training of sedation and analgesia providers in the pharmacology of sedationanalgesia agents a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes The presence of an individuals capable of establishing a patent airway positive pressure ventilation and resuscitation ie advanced lifesupport skills during a procedure a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Availability of appropriately sized emergency and airway equipment eg laryngeal mask airway defibrillators a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes The use of supplemental oxygen during procedures performed with sedation or analgesia a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Use of sedative agents combined with analgesic agents eg sedativeanalgesic cocktails fixed combinations of sedatives and analgesics titrated combinations of sedatives and analgesics a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Titration of intravenous sedativeanalgesic medications to achieve the desired effect a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Intravenous sedationanalgesic medications specifically designed to be used for general anesthesia ie methohexital propofol and ketamine a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Administration of sedativeanalgesic agents by the intravenous route a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Maintaining or establishing intravenous access during sedation or analgesia until the patient is no longer at risk for cardiorespiratory depression a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Availability of reversal agents naloxone and flumazenil only for the sedative or analgesic agents being administered a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Postprocedural recovery observation monitoring and predetermined discharge criteria reduce adverse outcomes Special regimens eg preprocedure consultation specialized monitoring special sedativestechniques for patients with special problems eg uncooperative patients extremes of age severe cardiac pulmonary hepatic renal or central nervous system disease morbid obesity sleep apnea pregnancy drug or alcohol abuse emergencyunprepared patients metabolic and airway difficulties a Improves clinical efficacy ie satisfactory sedation and analgesia b Reduces adverse outcomes Scientific evidence was derived from aggregated research literature and from surveys open presentations and other consensusoriented activities For purposes of literature aggregation potentially relevant clinical studies were identified via electronic and manual searches of the literature The electronic search covered a 36yr period from 1966 through 2001 The manual search covered a 44yr period from 1958 through 2001 More than 3000 citations were initially identified yielding a total of 1876 nonoverlapping articles that addressed topics related to the 15 evidence linkages After review of the articles 1519 studies did not provide direct evidence and were subsequently eliminated A total of 357 articles contained direct linkagerelated evidence A directional result for each study was initially determined by a literature count classifying each outcome as either supporting a linkage refuting a linkage or neutral The results were then summarized to obtain a directional assessment of support for each linkage Literature pertaining to three evidence linkages contained enough studies with welldefined experimental designs and statistical information to conduct formal metaanalyses These three linkages were linkage 8 supplemental oxygen linkage 9 benzodiazepines combined with opioids vs benzodiazepines alone and linkage 13 naloxone for antagonism of opioids flumazenil for antagonism of benzodiazepines and flumazenil for antagonism of benzodiazepineopioid combinations Combined probability tests were applied to continuous data and an oddsratio procedure was applied to dichotomous study results Two combined probability tests were employed as follows 1 the Fisher combined test producing chisquare values based on logarithmic transformations of the reported P values from the independent studies and 2 the Stouffer combined test providing weighted representation of the studies by weighting each of the standard normal deviates by the size of the sample An oddsratio procedure based on the MantelHaenszel method for combining study results using 2 2 tables was used with outcome frequency information An acceptable significance level was set at P 001 onetailed and effect size estimates were calculated Tests for heterogeneity of the independent studies were conducted to assure consistency among the study results Der SimonianLaird randomeffects odds ratios were calculated when significant heterogeniety was found To assess potential publishing bias a failsafe N value was calculated for each combined probability test No search for unpublished studies was conducted and no reliability tests for locating research results were performed Metaanalytic results are reported in table 2 The following outcomes were found to be significant for combined probability tests 1 oxygen saturation linkage 8 supplemental oxygen 2 sedation recovery linkage 13 naloxone for antagonism of opioids and flumazenil for antagonism of benzodiazepineopioid combinations 3 psychomotor recovery linkage 13 flumazenil for antagonism of benzodiazepines and 4 respiratoryventilatory recovery linkage 13 naloxone for antagonism of opioids flumazenil for antagonism of benzodiazepines and flumazenil for antagonism of benzodiazepineopioid combinations To be considered acceptable findings of significance both the Fisher and weighted Stouffer combined test results must agree Weighted effect size values for these linkages ranged from r 019 to 080 representing moderate to high effect size estimates Table 2 Metaanalysis Summary Full Size Slide ppt MantelHaenszel odds ratios were significant for the following outcomes 1 hypoxemia linkage 8 supplemental oxygen and linkage 9 benzodiazepineopioid combinations vs benzodiazepines alone 2 sedation recovery linkage 13 flumazenil for antagonism of benzodiazepines and 3 recall of procedure linkage 9 benzodiazepineopioid combinations To be considered acceptable findings of significance MantelHaenszel odds ratios must agree with combined test results when both types of data are assessed Interobserver agreement among Task Force members and two methodologists was established by interrater reliability testing Agreement levels using a Kappa κ statistic for tworater agreement pairs were as follows 1 type of study design κ 025064 2 type of analysis κ 036083 3 evidence linkage assignment κ 078089 and 4 literature inclusion for database κ 071100 Threerater chancecorrected agreement values were 1 study design Sav 045 Var Sav 0012 2 type of analysis Sav 051 Var Sav 0015 3 linkage assignment Sav 081 Var Sav 0006 4 literature database inclusion Sav 084 Var Sav 0046 These values represent moderate to The findings of the literature analyses were supplemented by the opinions of Task Force members as well as by surveys of the opinions of a panel of consultants drawn from the following specialties where sedation and analgesia are commonly administered Anesthesiology 8 Cardiology 2 Dental Anesthesiology 3 Dermatology 2 Emergency Medicine 5 Gastroenterology 9 Intensive Care 1 Oral and Maxillofacial Surgery 5 Pediatrics 1 Pediatric Dentistry 3 Pharmacology 1 Pulmonary Medicine 3 Radiology 3 Surgery 3 and Urology 2 The rate of return for this Consultant survey was 78 n 5165 Median agreement scores from the Consultants regarding each linkage table 3 Table 3 Consultant Survey Summary Full Size Slide ppt For moderate sedation Consultants were supportive of all of the linkages with the following exceptions linkage 3 electrocardiogram monitoring and capnography linkage 9 sedatives combined with analgesics for reducing adverse outcomes linkage 11 avoiding general anesthesia sedatives for improving satisfactory sedation linkage 13b routine administration of naloxone linkage 13c routine administration of flumazenil and linkage 15b anesthesiologist consultation for patients with medical conditions to provide satisfactory moderate sedation In addition Consultants were equivocal regarding whether postgraduate training in anesthesiology improves moderate sedation or reduces adverse outcomes For deep sedation Consultants were supportive of all of the linkages with the following exceptions linkage 9 sedatives combined with analgesics for reducing adverse outcomes linkage 11 avoiding general anesthesia sedatives linkage 13b routine administration of naloxone and linkage 13c routine administration of flumazenil The Consultants were asked to indicate which if any of the evidence linkages would change their clinical practices if the updated Guidelines were instituted The rate of return was 57 n 3765 The percent of responding Consultants expecting no change associated with each linkage were as follows preprocedure patient evaluation 94 preprocedure patient preparation 91 patient monitoring 80 contemporaneous recording of monitored parameters 91 availability of individual dedicated solely to patient monitoring and safety 91 education and training of sedationanalgesia providers in pharmacology 89 presence of an individuals capable of establishing a patent airway 91 availability of appropriately sized emergency Appendix II Summary of Guidelines 2 Except as noted recommendations apply to both moderate and deep sedation Preprocedure evaluation Relevant history major organ systems sedationanesthesia history medications allergies last oral intake Focused physical examination to include heart lungs airway Laboratory testing guided by underlying conditions and possible effect on patient management Findings confirmed immediately before sedation Patient counseling Risks benefits limitations and alternatives Preprocedure fasting Elective proceduressufficient time for gastric emptying Urgent or emergent situationspotential for pulmonary aspiration considered in determining target level of sedation delay of procedure protection of trachea by intubation See ASA Guidelines for Preoperative Fasting 2 Monitoring Data to be recorded at appropriate intervals before during and after procedure Pulse oximetry Response to verbal commands when practical Pulmonary ventilation observation auscultation Exhaled carbon dioxide monitoring considered when patients separated from caregiver Blood pressure and heart rate at 5min intervals unless contraindicated Electrocardiograph for patients with significant cardiovascular disease For deep sedation Response to verbal commands or more profound stimuli unless contraindicated Exhaled CO 2 monitoring considered for all patients Electrocardiograph for all patients Personnel Designated individual other than the practitioner performing the procedure present to monitor the patient throughout the procedure This individual may assist with minor interruptible tasks once patient is stable For deep sedation The monitoring individual may not assist with other tasks Training Pharmacology of sedative and analgesic agents Pharmacology of available antagonists Basic life support skillspresent Advanced life support skillswithin 5 min For deep sedation Advanced life support skills in the procedure room Emergency Equipment Suction appropriately sized airway equipment means of positivepressure ventilation Intravenous equipment pharmacologic antagonists and basic resuscitative medications Defibrillator immediately available for patients with cardiovascular disease For deep sedation Defibrillator immediately available for all patients Supplemental Oxygen Oxygen delivery equipment available Oxygen administered if hypoxemia occurs For deep sedation Oxygen administered to all patients unless contraindicated Choice of Agents Sedatives to decrease anxiety promote somnolence Analgesics to relieve pain Dose Titration Medications given incrementally with sufficient time between doses to assess effects Appropriate dose reduction if both sedatives and analgesics used Repeat doses of oral medications not recommended Use of anesthetic induction agents methohexital propofol Regardless of route of administration and intended level of sedation patients should receive care consistent with deep sedation including ability to rescue from unintended general anesthesia Intravenous Access Sedatives administered intravenouslymaintain intravenous access Sedatives administered by other routescasebycase decision Individual with intravenous skills immediately available Reversal Agents Naloxone and flumazenil available whenever opioids or benzodiazepines administered Recovery Observation until patients no longer at risk for cardiorespiratory depression Appropriate discharge criteria to minimize risk of respiratory or cardiovascular depression after discharge Special Situations Severe underlying medical problemsconsult with appropriate specialist if possible Risk of severe cardiovascular or respiratory compromise or need for complete unresponsiveness to obtain adequate operating conditionsconsult anesthesiologist References Practice Guidelines for sedation and analgesia by nonanesthesiologists A report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by NonAnesthesiologists A nesthesiology 1996 84 45971NA Practice Guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration application to healthy patients undergoing elective procedures A report by the American Society of Anesthesiologist Task Force on Preoperative Fasting A nesthesiology 1999 90 896905NA Web of Science Times Cited 844

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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O B O O O O O O B O O O O O O O O O O O O O O O O B O B O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O O B O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O B O B O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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How can I download pics from Fetlife Last edited by 8016311166 That trick doesnt work anymore You cant open in new tab it will say hotlinking is not allowed Using Google Chrome right click on the page and select Inspect Element A new box will appear on the bottom half of the browser window At the top of this new window is a series of clickable tabs youll be on Elements Just to the right of this click on tab called Resources Along the left side will now be a list of tabs with arrows next to their namesleft side You want to expand Frames Then expand the tab with numbers in paranthesis 000000 Then click on the word images this will expand it to show a list of files with little tiny pictures next to their names The files will be named things like 0004a9f1000fhjg etc Clicking on the first one will most likely display a users profile pic in the center of the frame If youre lucky itll be the full size image Using the arrow keys keep pushing down until the photo you want is displayed in full size Right click on the picture and tell it to open the picture in a new tab Switch to the new tab and right click on the picture to save it Give it a nice new name while youre doing this so you know what it is I personally use an image browserpreviewer on my computer so I use Fetlife_user name_image numberjpg This works great on the KP page there are few user profile pics most are fullsized images Remember to never repost content you do not have rights to or present it as your own work I have long periods of no internet and use it as viewing material Categories

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Call 8128822065 HOME HVAC INSTALLATIONS HVAC SERVICING CONTRACTS SHEET METAL Serving Knox County and Daviess County IN as well as Lawrence County of Illinois including Bridgeport and St Francisville Doing whatever it takes for 50 years Your onestop HVAC and sheet metal shop HVAC work includes Local business Trust Anthis Heating Air Conditioning Inc for residential or commercial HVAC service and custom sheet metal work We are a family business serving the local community for more than 50 years Start today with a FREE estimate Convenient contracts Keeping your HVAC units in like new condition is easy with our convenient service contracts Designed to fit any budget or service you just prepay for the year and let our experts take care of the rest Roundtheclock service If your heater or air conditioner is busted dont wait for normal business hours to get it fixed Take advantage of our afterhours emergency service to get the problem solved immediately New installations Maintenance

O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O


About Us Welcome to the best salon in this area Anthony Vince Spa located at 1441 Merchant Ln Hampton Virginia Anthony Vince Spa has become a preferential destination of local and tourists due to our best technicians together with products Coming to our salon you can easily choose the colors that suit you most among a wide variety of nail lacquers Staff here is trained well to work professionally and creatively to ensure to bring you healthy and beautiful nails Photo Gallery Our Services MANICURE PEDICURE PINK WHITE ACRYLIC OVERLAY LIP or CHIN WHOLE FACE

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Business Organization Detail Back to Corporations Search NOTICE The West Virginia Secretary of States Office makes every reasonable effort to ensure the accuracy of information However we make no representation or warranty as to the correctness or completeness of the information If information is missing from this page it is not in the The West Virginia Secretary of States database MIKE ROSS INC Organization Information Org Type Effective Date Established Date Filing Date Charter Class Sec Type Termination Date Termination Reason C Corporation 6291982 6291982 Domestic Profit Organization Information Business Purpose 2111 Mining Quarrying Oil Gas Extraction Oil and Gas Extraction Crude Oil and Natural Gas Extraction Capital Stock 100000000 Charter County Randolph Control Number 0 Charter State WV Excess Acres 6000 At Will Term Member Managed At Will Term Years Par Value 100000000 Authorized Shares 100 Addresses Type Address Mailing Address PO BOX 219 COALTON WV 26257 USA Notice of Process Address MICHAEL ROSS PO BOX 219 COALTON WV 26257 Principal Office Address CENTER STREET PO BOX 219 COALTON WV 26257 USA Type Address Officers Type NameAddress Director JOANN ROSS MICHAEL ROSS PO BOX 219 COALTON WV 26257 Director JAMES V ROSS PO BOX 219 COALTON WV 26257 Incorporator MICHAEL ROSS BOX 173 COALTON WV 26257 President JAMES V ROSS PO BOX 136 COALTON WV 26257 Secretary JOANN ROSS PO BOX 219 COALTON WV 26257 Treasurer JOANN ROSS PO BOX 219 COALTON WV 26257 Type NameAddress Date Amendment 11172010 AMENDMENT FILED AMENDING ARTICLES Date Amendment Annual Reports Filed For 2018 2017x 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 Date filed For more information please contact the Secretary of States Office at 3045588000

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211 Advantages and Disadvantages of Qualitative Data Analysis Qualitative data provides a rich detailed picture to be built up about why people act in certain ways and their feelings about these actions However it is important to be aware of the advantages and disadvantages of qualitative data analysis as this may influence your choice of data collection Advantages of qualitative data analysis Provides depth and detail looks deeper than analysing ranks and counts by recording attitudes feelings and behaviours Creates openness encouraging people to expand on their responses can open up new topic areas not initially considered Simulates peoples individual experiences a detailed picture can be built up about why people act in certain ways and their feelings about these actions Attempts to avoid prejudgements if used alongside quantitative data collection it can explain why a particular response was given Disadvantages of qualitative data analysis Usually fewer people studied collection of qualitative data is generally more time consuming that quantitative data collection and therefore unless time staff and budget allows it is generally necessary to include a smaller sample size Less easy to generalise because fewer people are generally studied it is not possible to generalise results to that of the population Usually exact numbers are reported rather than percentages Difficult to make systematic comparisons for example if people give widely differing responses that are highly subjective Dependent on skills of the researcher particularly in the case of conducting interviews focus groups and observation

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Entertainment Arts Movies Movie Genres What is the main characteristic of a narrative film What is the main characteristic of a narrative film begins with expository material adds levels of complication builds to a climax and ends with a resolution of all the plot elements 1 person found this useful What are the characteristics of narrative poetry Narrative poetry tells a story usually a farfetched one or a story that has been passed down through generations and is an oral tradition An example is the Cremation of Sa What are the characteristics of a historical narrative 1 Based on real events 2 Told in chronological order sequential order 3 Narrator is involved with the story 4 Told in the first person usually point of view 5 Na What was the first narrative film Nanook Of The North Nanook was released in 1922 well past the point of narrative film development It is more accurate to call Nanook the first attempt at a documentary What are the characteristics of a narrative essay A narrative essay is an essay that tells a story usually aboutones life or part of ones life Many times narrative essays areanecdotal or personal The writer may use a na What are some characteristics of a fantasy narrative animals or things talk setting in a magical world magical things happen What are the narrative codes and conventions in film There are different narrative codes for different films What are the characteristics of a narrative characters plot setting problem solution and if you wanna gettechnical good balanced introduction good and clear bodymain idea of storyand a interesting solution What is the exact definition of film narrative nThe exact definition of film narrative is this Film narrative is the depiction in the medium of film of a series of events in cause and effect relationship occurring in tim What are some characteristics about a historical narrative some characteristics would be that you would have to have something that happened in history or some kind of historical thing also it would be told like a story maybe with fa What was the first narrative film in 1903 The first narrative film was The Cabbage Fairy in 1896 by Alice Guy httpenwikipediaorgwikiAlice_GuyBlachÃ What is the main purpose of a narrative poem to tell a story Were there narratives in the film The Wizard of Oz A narrative is a story whose events are described in detail Very little in the form of narrative is found in the beloved 1939 film version of The Wizard of Oz But yes t Answered In Essays What are three characteristics of narrative writing first I Second you third he she it Answered In Biology What is the Function of a narrative in the adaptation of a film well I have to research first I dont have idea to answer it help me and follow me on twitter bieber_ninja thanks LOL Answered In Writing Narrative Viewpoint What are the main purposes of narratives Narratives are stories so the main purposes are to entertain toeducate and perhaps to cause you to think Answered In Uncategorized What the main part of folk narrative fables Answered In Essays What are the characteristics of etiological narratives the characteri

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