Transcript Slide 1
Procedural Sedation Pharmacology
Deb Updegraff R.N., P.N.P, C.N.S.
Clinical Nurse Specialist
LPCH Pediatric Intensive Care Unit
Procedural Sedation
The phrase “procedural sedation”
refers to techniques of managing a
patient’s pain and anxiety to
facilitate appropriate medical care
in a safe, effective and humane
fashion.
Sedation Pharmacolgy
Individual responses are dependant on:
Age
Concurrent disease states
Concurrent drug therapy
Chloral Hydrate
Hypnotic“Short term sedative and hypnotic given prior
to nonpainful procedures
Chloral Hydrate
Usually given to Outpatients due to
relative low risk profile. For nonpainful procedures only.
EEGs
MRI/CT Scans
Echocardiograms
Chloral Hydrate
PO/Rectal
Dose: 50mg/kg give 30-60
minutes prior to procedure.
Can repeat x1
25mg/kg
Not to exceed 100mg/kg in a 24 hour
period
Chloral Hydrate
Expect a moderate decrease in
heart rate and blood pressure in
patients ASA I-II
For infants < 6 months there is ↑
risk for apnea and hypoxia.
Age a limiting factor. High failure
rate in children > 4 years.
Pentobarbital : Nembutal®
Barbituate- Non elective central nervous system depressants
primarily used as Hypnotic sedative for non painful procedures.
Nembutal
PO/Rectal/IM/IV
Dose for procedural sedation:
4mg/kg , may repeat 2mg/kg, max
100mg
Nembutal: precautions
Rapid IV injection ie, can cause
respiratory depression, apnea,
laryngospasm, bronchospasm and
hypotension
Recommended to infuse IV dose
over 10-30 minutes.
Can significantly decrease cardiac
output and should be avoided with
CHF
Benzodiazepines
Midazolam- Versed®
Lorazepam - Ativan®
Induce anterograde amnesia (not
retrograde)
May have some opioid sparing
effect by ↓ anticipatory pain
response
Midazolam -® Versed
Most commonly used Benzo for
preoperative and pre-procedural sedation.
Undergoes hepatic metabolism and renal
excretion and prolonged effects seen with
dysfunction of either system
Sedative, amnestic and anxiolytic with no
analgesic properties
Commonly used with an opioid analgesic
such as Fentanly®
Versed®
Onset in 1 to 2 minutes
Duration 30 min
Caution for respiratory depression
and hypotension
Dosage for children
having procedures:
PO; 0.5 mg/kg/dose may
repeat once with
0.25mg/kg/dose. Max dose:
20mg.
IV: 0.05-0.1 mg/kg dose.
May repeat over several minutes
to a max dose of 0.1-0.2 mg/kg.
Intranasal: 0.2-0.3
mg/kg. May repeat in 15 min
Adults: 0.5 mg to 2mg slow push
over at least 2 min. Usual dose
needed is 2.5 – 5 mg . > 5mg
generally not needed.
Fentanyl- Sublimaze®
Used in combination with Versed for
many years due to rapid onset and
effectiveness
Synthetic opioid
Metabolized by the liver
Short duration of effect
Pure analgesic (should not be
used alone)
Least histamine release of opiates
Caution:
Chest rigidity with rapid infusion and
hypotension
Fentanyl
Dosage for Pediatrics:
-IM or IV 0.5-1.0 mcg/kg/dose
-onset 1-2 min
-lasts 30 minutes
Etomidate
Classified as a General Anesthetic
Ultra short acting nonbarbiturate
hypnotic used for the induction of Anesthesia
Used for Sedation in Adults
0.2mg/kg IV given over 30-60 seconds
Onset <1minutes Duration 3-5 minutes
Limited data, Action too short for some procedures
Ketamine-Ketalar®
Classified as a general anesthetic
Rapid acting dissociative anesthetic
that produces a profound analgesic
effect
Gaining favor in children due to
reliable effects and strong safety
profile
Ketamine
When patients are on ketamine they
may appear awake. Eyes may remain
open, they may have nystagmus.
Ketamine is a potent phencyclidine
deriviative
Produces potent analgesia and rapid
sedation while it preserves
respiratory drive and airway protective
reflexes
Ketamine
IV 1-2 mg/kg/dose
-Onset is 1 minute
-Duration 10-20 minutes
IM 2-4 mg
-onset 5 minutes
-duration 15-45 minutes
Ketamine Caution:
Nystagmus can occur along
with hypersecretions, agitation
Delirium, vomiting , myoclonus
and laryngospasm
PropofolClassified as a general anesthetic
-Lower doses
sedation
hypnosis
Anmestic, anxiolytic, antiemetic, and
antiepileptic properties
No Analgesic effects
Propofol
Dosing 2.5 -3.5 mg/kg/ dose over 2030 seconds
Onset 10-30 seconds
Duration 10-20 minutes
For prolonged procedures may
require continuous infusion 125300mcg/kg/minute. (smaller children
may require smaller infusion rates.
Propofol Caution
Profound Respiratory Depression
Profound Irreversible bradycardia
Profound Hypotension
Avoid with Soy or Egg allergies