Transcript Stages and Techniques

Enteral Sedation
Review Course
Stages of Anesthesia
A Continuum…
Stage I Analgesia/sedation
– 3 planes of CNS depression—initial CNS effects of
agent to the clinical endpoint of light to mild
sedation and/or relaxation in the conscious patient.
Altered perception in time
Diminished perception of pain
Reduction in anxiety
Continually retaining the ability to respond appro. to
physical stimulation/verbal commands
Any enteral sedation technique must not
exceed Stage I of anesthesia
Stages of Anesthesia
A Continuum…
Stage II Delirium/Excitement
– Much deeper level of CNS depression
– Patient is clinically unconscious
– May be combative or exhibit hyper-active
or unusual jerky movements
Stages of Anesthesia
A Continuum…
Stage III Surgical Anesthesia
– Most surgical procedures are performed in
Stage III
– Subdivided into 4 planes resulting in:
Deepening CNS depression
Diminished or loss of protective reflexes
Skeletal muscle relaxation
Will not respond to physical stimulation or
verbal commands
May loose ability to maintain airway
Stages of Anesthesia
A Continuum…
Stage IV Medullary Paralysis/Death
– Unconscious patient experiences the
deepest level of CNS depression
Respiratory paralysis
Cardiac arrest
Clinical death
Conscious Sedation
Objectives and Techniques
Enteral vs. Parenteral
Enteral
Mildly anxious pt
Convenient route of
administration
Pharmacokinetics
– ADME
Level of training
Office requirements
and staff training
Parenteral
Greater anxiety
levels
Requires injection
(IM or IV)
Pharmacokinetics
– ADME
Level of training
Office requirements
and staff training
Single Drug Technique…
Advantages
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Effective at appropriate level of anxiety
One drug to be knowledgeable about
Decreased incidence of drug interactions
Overdose– one drug to consider/reverse
Disadvantages
– Not for the severely anxious patient
– Less timing flexibility and specificity
Combination Drug Techniques…
More than one drug used to match the
anticipated pain and anxiety levels of
the patient
The simpler the combinations the safer
the technique
What are the intent and the
contributions of the various drugs
employed?
Intent and Contributions of
Agents…
Two basic components—sedation/hypnosis and
analgesia
Sedation/hypnotic agent
– Sedation vs hypnosis
– Sedative agent should be regarded as the
titratable agent
Analgesia
– Not regarded as titratable
– Administered in a low fixed dose to enhance
analgesia and sedation
In a conscious sedation technique analgesia is
achieved with effective local anesthesia
Selection of Agents…
Should be reversible
Relatively short acting
Provide minimal respiratory depression
– Insidious at onset and not easily
recognizable without PETCO2
Pulse oximetry is a crude monitor of respiration
if patient breathing room air
– Supplemental O2 obscures the early
detection of respiratory depression
Role of pulse oximetry with supplemental O2?
Selection of Agents…
Goal
– Find a predictable and beneficial
combination of drugs that:
Maximize the desirable features of the drugs
Minimize the undesirable side effects of the
drugs
Oral Techniques…
Indications
– Mildly apprehensive patient prior to appt
– Pt unable to sleep evening prior to appt.
Bolus dose of drug with variable
degrees of achieving desired sedation
– May require additional sedative agents
– N2O/O2
Intravenous Techniques…
Indications
– Extremely apprehensive
– Other lesser forms of sedation have failed
– Perception by patient that the procedure is
undesirable, painful or prolonged
Advantages
– Can produce significant levels of amnesia,
analgesia and control of secretions
– Titratable rather than bolus administration
Intramuscular Techniques…
Indications: administration of:
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Sedative agents
Analgesics
Antiinfectives
Emergency drugs
Disadvantages
– Bolus administration based on patients size and
weight
– Variable sedative effects
Not recommended for the very young due to
small muscle mass
Sites of IM Injections
Mid-deltoid
Vastus lateralis
Gluteal area
IM Technique…
20-22 gauge 1-1½ inch length needle
Cleans the skin thoroughly with
antiseptic
Hold tissue taut and insert needle
Aspirate
Inject slowly
Hold pressure on site to control
bleeding and swelling
Injection Site
Vastus Lateralis
Superior: a hands breadth below the
greater trochanter
Inferior: a hands breadth above the
knee
Mid-anterior thigh on the front
Mid-lateral thigh on the side
Injections Site
Mid-Deltoid
Boundaries for injection
– Superior: acromion
– Inferior: point that corresponds with the
axilla
– Side: 1/3 of the way around the lateral
aspect of the arm
Deltoid Technique
Deltoid Technique
Deltoid Technique
Injection Site
Gluteal Region
Divide into quadrants
– Use the upper-outer quadrant
– Superior border is the posterior superior
iliac spine
Other Techniques…
Rectal
Intra-buccal
Sublingual
Transmucosal
Transdermal
Nasal
Inhalation Techniques…
Any of the previously mentioned
methods can be used with inhalational
sedation (N2O/O2)
Allows titration of effect without using
inappropriate dosages of a single agent