Transcript Sedation in a Nutshell ()

Procedural Sedation:
Deb Updegraff, R.N., M.S.N. P.N.P.
Clinical Nurse Specialist
Pediatric Intensive Care
3S Intermediate Intensive Care
LPCH
The Players
• MD
• RN
• Patient
Sedation VS Analgesia
Levels of Sedation
• Minimal Sedation (anxiolysis)
• Moderate Sedation/Analgesia (formerly
called conscious sedation)
• Deep Sedation
American Association of
Anesthesiologists: ASA Risk
Classification
ASA I ASA II ASA III -
A healthy patient
A patient with mild systemic disease
A patient with severe systemic disease
(limits activity but not
incapacitating)
ASA IV- A patient with an incapacitating systemic
disease that is a
constant threat to life
ASA V- A moribund patient not expected to survive
24 hours with or without surgery
Pre-sedation Risk Assessment
Ampule
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Allergies
Medications
Past Medical History
Last Meal
Events leading up to the need for sedation
Other Risks
• Previous problems with anesthesia or
sedation
• Known difficult intubation
• Cranial facial syndromes
• Decreased airway protective reflexes
• Obesity
• GERD or problems with gastric motility
Equipment (SOAP)
• Suction
• Oxygen
• Airway
• Pharmacy
Monitoring
Continuous:
• ECG
• O2 Sat
Blood Pressure
• Q 5 min for moderate to deep sedation
• Q 15 min for others
Pharmacology: Selecting the Meds
Depends on the Procedure and
Patient History
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MRI
PICC placement
Central Line Placement
Bronchoscopy
Chest tube placement
Choice of Drugs
• Analgesics
– Narcotics
• Fentanyl
• Morphine
– Ketamine
• Sedation
– Benzodiazepines
• Midazolam
• Lorazepam
– Barbiturates
• -Propofol
Narcotics
• Fentanyl
– Bolus= 0.5-1.0
mcg/kg (MAY
REPEAT Qq5-10MIN)
– Rigid Chest
Syndrome
• Morphine
- Bolus=0.050.1mg/kg (may repeat
q5-10min)
– Histamine
Release
– + Sedative and
Hypnotic properties
Narcotics have both sedative and analgesic qualities
Benzodiazepines
• Midazolam
–Bolus=0.050.2 mg/kg
• Lorazepam
–Bolus=0.050.2 mg/kg
Benzodiazepines have both sedative and Amnesic
qualities
NO Analgesic Properties
Ketamine
Dissociative anesthetic: phencyclidine
derivative (PCP)
• IV - 0.5 to 2mg/kg
• IM -3-4 mg/kg
• + Analgesia/Sedation
• Contraindicated
Increased Intracranial Pressure
Increased Intraoccular Pressure
• Onset of action IV 1-2 minute
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IM
3-10 minutes
Can cause larygospasms and hallucinogenic
emergent reactions.
Propofol
• General Anesthetic Agent
• NO Analgesic Properties
• Advantages:
– Rapid Onset and Emergence
– Profound Sedation
• Disadvantages:
– Metabolic Acidosis
– Severe  SVR
Propofol - dosing
Induction
Continuous Infusion
2.5 – 3.5 mg/kg
Over 20-30 seconds
Repeat as child emerges
5-50 mcg/kg/hr
Reversal Agents
Narcan: For Narcotic Reversal
dose: 1-10mcg/kg IV push (1/10th of dose recommended for full
reversal of narcotic poisoning)
May need to repeat. OK: IV, IM, endotracheal
Flumazenil: For Benzodiazepine Reversal- Can reverse benzo-induced
respiratory depression and paradoxical excitatory reactions.
dose: 0.01-0.02 mg/kg. May be repeated.