Transcript PROCEDURAL SEDATION

PROCEDURAL SEDATION
INTERN LECTURE SERIES
JULY 2003
PROCEDURAL SEDATION

Procedural sedation and analgesia is a
complex interaction between the physician
nurse, and patient which allows proper
administration of drugs to obtund, dull or
reduce the intensity of pain or awareness.
PROCEDURAL SEDATION

The administration of drugs by any route is
intended to allow the patient to maintain
airway control independently and
continously, but carries the risk of loss of
protective reflexed.
anxiolysis
conscious sedation
deep sedation
general anesthesia
PROCEDURAL SEDATION
PROCEDURAL SEDATION
Relevant History and Physical Exam:
 1. Pt age
 2. H/o abnormalities of major organ
systems, including heart, lung, kidneys or
airway ( sleep apnea, snoring, stridor)
 3. Pregnancy test as needed
 4. Current medications

PROCEDURAL SEDATION
Relevant History and Physical Exam:
 5. H/o any adverse or allergic drug
reactions with anesthesia or
sedation/analgesia
 6. H/o prior sedation/ analgesia, including
adequacy of pain control for those
procedures
 7. H/o tobacco, alcohol, or substance
abuse or use

PROCEDURAL SEDATION
Relevant History and Physical Exam:
 8. Vital signs (wt, HR, BP, RR, pulse ox)
 9. Cardiopulmonary exam
 10. Airway exam
 11. Labs and/or relevant findings that may
effect plan for sedation/analgesia

PROCEDURAL SEDATION

Indicators of Potential Problematic Airway
Decreased mouth opening
 Micrognathia
 Retrognathia
 Significant malocclusion
 Dentures
 Macroglossia
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PROCEDURAL SEDATION

Indicators of Potential Problematic Airway
Nonvisible uvula
 Decreased neck flexibility
 Advanced rheumatoid arthritis
 Dysmorphic facial features

 Pierre
Robin syndrome
 Trisomy 21
 < 3cm hyoid-mental distance (adult)

Tracheal deviation
PROCEDURAL SEDATION
Equipment:
 2 physicians
 Pulse oximetry, continuous
 Cardiac monitoring, continuous
 Sedation agents
 Reversal agents
 Procedural consent forms

PROCEDURAL SEDATION
Equipment:
 Intubation materials
 Oxygen delivery equipment
 Nurse, continuous monitoring
 Age-appropriate resusciation equipment
 Pre-measured doses for pediatric patients

PROCEDURAL SEDATION
Adult Sedation and Analgesia
Drugs
And
Reversal Agents
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Etomidate
Adult Sedation and Analgesia Drugs
And
Reversal Agents

Etomidate:
Recommended dosage: 0.1-0.3 mg/kg
 Route: IV over 30-60 secs
 Onset: ultra rapid 2-3 min
 Duration: 1 hour

Adult Sedation and Analgesia Drugs
And
Reversal Agents

Etomidate:
Considered a general anesthetic; also
sedation and amnestic
 Cardiac, respiratory and BP monitoring
required

Adult Sedation and Analgesia Drugs
And
Reversal Agents

Etomidate:

Contraindications/ Precautions
Not approved for kids < 12 yo
 Avoid if seizure d/o, N/V
 May cause myoclonic jerks
 Pain at injection site

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Fentanyl Citrate (Sublimaze)
Adult Sedation and Analgesia Drugs
And
Reversal Agents

Fentanyl Citrate:

Dosage: 1-5 mcg/kg induction

(50-100 mcg = 1-2 cc)
Route: IV
 Onset: 1.7 min
 Duration: 30-60 mins

Adult Sedation and Analgesia Drugs
And
Reversal Agents


Fentanyl Citrate:
Potent narcotic analgesic
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100 mcg (2cc)=10 mg MSO4 or 75 mg Demerol
Acts as respiratory depressant (5-15 mins after
injection)
Reduce dose in elderly and debilitiated pts
CNS depressant drugs have additive or
potentiating effects with fentanyl
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Fentanyl Citrate:
 Contraindications/Precautions
 Large doses produce apnea
 Chest wall rigidity may occur if pushed too
quickly
 Duration of respiratory depressant may be
longer than the analgesic effect

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Fentanyl Citrate:
 Contraindications/Precautions
 May produce bradycardia and
bronchoconstriction
 Use with caution in pts with COPD, liver
disease, kidney dysfunction
 Adverse reactions: hypotension, HTN,
emesis, laryngospasm

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Lorazepam (Ativan)
Adult Sedation and Analgesia Drugs
And
Reversal Agents

Lorazepam:
Dose: 0.02-0.05 mg/kg
 Route: IV
 Onset: 15 mins
 Duration: 2 hours
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Adult Sedation and Analgesia Drugs
And
Reversal Agents

Lorazepam:

Useful as anxiolytic, sedation for
radiographic procedures, some minor
surgical procedures (burns, FB removal,
laceration repair)
Adult Sedation and Analgesia Drugs
And
Reversal Agents

Lorazepam:

Precautions/ Contraindications
Severe liver disease
 Severe respiratory disease

Adult Sedation and Analgesia Drugs
and Reveral Agents
Meperidine (Demerol)
Adult Sedation and Analgesia Drugs
And
Reversal Agents

Meperidine:
Dose: 0.3-1.5 mg/kg
 Route: IV
 Onset: 10-15 min
 Duration: 1 ½- 2 hour half-life, effective
duration 2-3 hours

Adult Sedation and Analgesia Drugs
and Reveral Agents

Meperidine:

Precautions/ Contraindications
Metabolite normeperidine may cause CNS
toxicity, seizures in sickle cell pts or renalimpaired pts
 Contraindicated if pt on MAOI

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Methohexital (Brevital)
Adult Sedation and Analgesia Drugs
and Reveral Agents

Brevital:
Dose: 1-3 mg/kg
 Route: IV
 Onset: 1 min
 Duration: 10 mins

Adult Sedation and Analgesia Drugs
And
Reversal Agents

Brevital:
Discontinue immediately if extravasation
occurs since tissue necrosis can occur
 May cause hemodynamic instability and
bronchospasm

Adult Sedation and Analgesia Drugs
and Reveral Agents
Brevital:
 Precautions/ Contraindications
 If given intraarterially, thrombosis and
gangrene can occur
 Contraindicated in severe hepatic
dysfunction or porphyria
 May cause respiratory depression,
hypotension

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Midazolam (Versed)
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Versed:
 Dose: 0.05-0.1 mg/kg (1-2 mg)


(total dose 0.1 mg/kg)
Route: IV
 Onset: 3-5 mins
 Duration: 2 hr half-life
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At total dose 0.1 mg/kg = 60 mins
Adult Sedation and Analgesia Drugs
And
Reversal Agents

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Versed:
Short-acting benzodiazepine CNS depressant
Do not give as a bolus dose; administer over at
least 2 mins and allow an additional 2 mis to
evaluate sedative effect
Reduce dosage in older (>60 yrs) or debilitated
pts.
Causes impairment in memory and recall
Adult Sedation and Analgesia Drugs
and Reveral Agents
Versed:
 Precautions/ Contraindications
 Associated with respiratory depression
and respiratory arrest
 May cause hypotension from venous
pooling
 Contraindicated in pts with acute narrow
angle glaucoma

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Versed:
 Precautions/ Contraindications
 Pts with chronic RF and CHF eliminate
versed slowly
 Potentiates respiratory depression in acute
ETOH intoxication
 Reduce dose by 30% in pts > 60 yo or
chronic illness

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Morphine Sulfate
Adult Sedation and Analgesia Drugs
And
Reversal Agents

Morphine Sulfate:
Dose: 0.03-0.15 mg/kg (2-10mg)
 Route: IV
 Onset: 1-3 min; peak effect = 15 min
 Duration: 3-5 hr half-life/ effective duration

Adult Sedation and Analgesia Drugs
And
Reversal Agents

Morphine Sulfate:

Can be given with hydroxyzine 0.5 mg/kg
IM or PO in children
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Morphine Sulfate:
 Precautions/ Contraindications
 Bronchospasm,
 respiratory depression,
 histamine release
 Hypotension
 bradycardia

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Morphine Sulfate:
 Precautions/ Contraindications

Prolonged sedation
 GI dysmotility
 Chest wall rigidity

Adult Sedation and Analgesia Drugs
and Reveral Agents
Propofol (Diprivan)
Adult Sedation and Analgesia Drugs
And
Reversal Agents

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Propofol:
Dose:
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50-200 mcg/kg/min sedation
(2-3 mg/kg induction)
1-2 mg/kg for orthopedic procedures, joint reduction,
burns requiring sedation
(10 mg/cc concentration)
May be used as an infusion 100-200 mcg/kg/min
(10-20mg/min in a typical adult, titrated for
effect)
Adult Sedation and Analgesia Drugs
And
Reversal Agents

Propofol:
Route: IV
 Onset: 1-2 min
 Duration: 5-10 min
 Titrate to effect

Adult Sedation and Analgesia Drugs
And
Reversal Agents

Propofol:

Use with caution in volume-depleted pts (may
need fluid bolus prior to giving propofol)
Causes pain on injection so use larger
antecubital vein and/or add lidocaine 0.5-1.0
mg/kg
Lidocaine may be given w/ propofol drip or as
bolus alone


Adult Sedation and Analgesia Drugs
And
Reversal Agents
Propofol:
 Precautions/ Contraindications
 Side effects: hypotension, bradycardia,
apnea, N/V
 Transient apnea in up to 40%
 As propofol as no analgesic properties,
may need to add 0.1 mcg/kg fentanyl
 Anaphylaxis with soy and egg allergy

Adult Sedation and Analgesia Drugs
and Reveral Agents
Reversal Agents
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Reversal Agents
Naloxone
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Naloxone (Narcan)
 Dose: 5-10 mcg/kg titrated to desired
effect


0.4 mg-2 mg standard historical dose for OD
Route: IV, IM, ET
 Onset: 1-2 min
 Duration: dependent upon the dose and
route of administration, 30-60 min typical

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Naloxone (Narcan):
 A narcotic antagonist, preventing or
reversing the effects of opoids, including
respiratory depression, sedation, and
hypotension
 Titration is preferred to rapid bolus
 Maximum dose = 10 mg
 Only applies to suspected unknown OD

Adult Sedation and Analgesia Drugs
and Reveral Agents
Naloxone (Narcan):
 Precautions/ Contraindications
 The pt who has responded satisfactorily to
narcan should be kept under continued
surveillance; repeated doses may be
required as necessary since the duration
of action of some narcotics may exceed
that of naloxone.

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Reversal Agent
Flumazenil (Mazicon)
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Flumazenil:
 Dose: 0.01 mg/kg

May repeat 60 secs x 3 (0.2 mg)
 Max dose = 1 mg

Route: IV
 Onset: 1-2 min
 Duration: 20 mins

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Flumazenil:
 Use for reversal of benzodiazepineinduced sedation
 Administer slowly to avoid the adverse
consequences of abrupt awakening such
as dysphoria and agitation
 Repeated doses may be given at 20-min
intervals as needed to reverse resedation

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Flumazenil:
 Maximum dose of 1 mg at any one time;
no more than 3 mg in 1 hour.
 A 1 mg dose sustains antagonism for 48
mins

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Flumazenil:
 Precautions/ Contraindications
 Seizures may occur as reversal of
sedative effects performed
 Duration of action of flumazenil is shorter
than versed and other benzos
 Resedation may occur following initial
reversal

Adult Sedation and Analgesia Drugs
And
Reversal Agents

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Flumazenil:
Precautions/ Contraindications
Monitoring must be performed for an appropriate
period after initial reversal
Contraindicated in
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Status epilepticus
Increased intracranial pressure
TCA od
Chronic benzodiazepine use (> 2 weeks)
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Dissociative Agents
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Ketamine (Ketalar):
 Dosage and Route:

1 mg/kg sedation (2 mg/kg induction) IV
 2-5 mg/kg IM
 6 mg/kg intra-nasal
 6-10 mg/kg PO
 10-15 mg/kg PR

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Ketamine:
 Onset:

IV 1-3 mins with 10-20 mins duration
 IM 5-20 mins
 Intra-nasal 15-30 mins
 PO 15-30 mins
 PR 15-30 mins

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Ketamine:
 Duration:

IV 10-20 mins
 IM, PO, PR and intra-nasal 30-60 mins
 Analgesic duration = 45 mins
 Anesthesia duration = 15-20 mins

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Ketamine:
 Pre-treatment with glycopyrrolate at 0.01
mg/kg (or atropine 0.01 mg/kg) to
decrease secretions should be given
 Combine glycopyrrolate with IV, IM or PO
dose to give all at once; I.e., ,may combine
in syringe for one injection

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Ketamine:
 Precautions/ Contraindications
 Increases intracranial pressure
 Positive side effect = bronchodilation (can
be used in asthmatics)
 Hallucinatory emergence reactions are
common in adults but uncommon in kids

Adult Sedation and Analgesia Drugs
and Reveral Agents

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Ketamine:
Can treat with versed 0.2 mg/kg concurrently
Potential for laryngospasm so avoid if active
pulmonary or upper respiratory infection or
excessive salivation or bleeding
Avoid if coronary artery disease or if pt has
elevated intraocular pressure
Possible HTN
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Adult Drugs For Agitation
Adult Sedation and Analgesia Drugs
And
Reversal Agents
Adult Drugs for Agitation
Droperidol (Inapsine)
Adult Sedation and Analgesia Drugs
And
Reversal Agents

Droperidol (Inapsine):
Dose: 1-10 mg
 Route: IV or IM
 Onset: 10 mins
 Duration: 2 hours

Adult Sedation and Analgesia Drugs
and Reveral Agents

Droperidol:

Agitated pts, CT scan or procedures on an
uncooperative patient
Adult Sedation and Analgesia Drugs
and Reveral Agents
Droperidol:
 Precautions/ Contraindications
 Contraindicated if cardiac condution
abnormality

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QT prolongation with torsade de pointes
Rare hypotension
 Rare neuroleptic malignant syndrome

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Adult Drugs for Agitation
Haloperidol (Haldol)
Adult Sedation and Analgesia Drugs
and Reveral Agents
Haloperidol (Haldol):
 Dose: 1-10 mg
 Route: IV or IM
 Onset:

IV 10 mins
 IM 20 mins


Duration: 2 hours
Adult Sedation and Analgesia Drugs
and Reveral Agents

Haldol:
Agitated, combative patients
 Pts requiring rapid sedation

Adult Sedation and Analgesia Drugs
And
Reversal Agents
Haldol:
 Precautions/ Contraindications
 Contraindicated if:

Cardiac conduction abnormality
 History of dystonic reactions

Conscious Sedation
Pediatric Sedation and Analgesia
Drugs and
Reversal Agents
Pediatric Sedation and Analgesia
Drugs and
Reversal Agents
Methohexital (Brevital)
Pediatric Sedation and Analgesia Drugs and
Reversal Agents
Brevital:
 Dose and Route:

1 mg/kg IV
 25 mg/kg PR

Onset: IV within 1 min; PR within 2-5 mins
 Duration:

IV lasts 10 mins
 PR lasts 45 mins

Pediatric Sedation and Analgesia Drugs and
Reversal Agents

Brevital:
Discontinue immediately if extravasation
occurs, since tissue necrosis can occur
 May cause hemodynamic instability and
bronchospasm

Pediatric Sedation and Analgesia Drugs and
Reversal Agents
Brevital:
 Precautions/ Contraindications
 If given intraarterially, thrombosis and
gangrene can occur
 Contraindicated:

Severe hepatic dysfunction
 porphyria

Pediatric Sedation and Analgesia
Drugs and
Reversal Agents
Midazolam (Versed)
Pediatric Sedation and Analgesia Drugs and
Reversal Agents


Versed:
Dose and Route:




0.05-0.1 mg/kg IV
0.1 mg/kg IM
0.2-0.5 mg/kg intranasal
0.5-1.0 mg/kg PO/PR


Versed:
Onset and Duration:

1-3 min for 1 hour
15-30 mins for 1-2 hrs
2-5 mins for 1-2 hrs

10-30 mins for 1-2 hrs
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
Pediatric Sedation and Analgesia Drugs and
Reversal Agents
Versed:
 Suggested Pedi combo: Versed 0.02
mg/kg + 1 mcg/kg fentanyl when used IV
 IV : may repeat 0.1 mg/kg by giving
increments of 0.05 mg/kg until adequate
sedation to a maximum total of 2 mg
 IM: use 5 mg/cc concentration to reduce
volume. Max total= 2 mg

Pediatric Sedation and Analgesia Drugs and
Reversal Agents
Versed:
 PO: max total = 15-20 mg

Mix w/ small amt juice or w/ tylenol (15mg/kg)
 Po or intra-nasal, use 5 mg/cc concentration
 Syrup (cherry flavored): 0.25-1.0 mg/kg, most
effective dose 0.5 mg/kg (up to 20 mg) onset
20 mins; duration 1 hr


Excellent amnestic, anxiolytic
Pediatric Sedation and Analgesia
Drugs and
Reversal Agents
Fentanyl (Sublimaze)
Pediatric Sedation and Analgesia Drugs and
Reversal Agents


Fentanyl:
Dose and Route:

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


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1-3 mcg/kg IV
1-2 mcg/kg IM
5-10 mcg/kg Oralet
1-2 mcg/kg Nasal
Dose can be titrated
Oralet: 100, 200, 300,
400 mcg


Fentanyl:
Onset and Duration:




1-2 mins ; peak 10 min
7-15 mins; variable
15 mins; 1 ½-2 hrs
10 mins; 1 hr
Pediatric Sedation and Analgesia Drugs and
Reversal Agents


Fentanyl:
Max dose: 5 mcg/kg

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PO: for wt < 40 kg, dose 5-10 mcg/kg up to max of
400 mcg
PO: for wt > 40 kg, give adult dose of 400 mcg
Can cause respiratory depression
Oralet may cause N/V
Can cause bradycardia, hypotension, chest wall
rigidity
Pediatric Sedation and Analgesia
Drugs and
Reversal Agents
Reversal Agents
Pediatric Sedation and Analgesia Drugs and
Reversal Agents





Naloxone (Narcan):
5-10 mcg/kg titrated
to desired effect
IV/IM/ET
Onset: 1-2 mins
Duration: 30-60 mins



Flumazenil (Mazicon):
0.2 mg/kg IV with
onset of 1-2 mins;
duration of 20 mins
Smaller kids= 0.01
mg/kg IV
PROCEDURAL SEDATION


Topical Agents:
EMLA Cream (lidocaine 2.5%, prilocaine, 2.5%)




2.5 gm
Venipuncture and venous cannulation, lumbar
puncture, arterial puncture)
Onset ½-1hr
Duration 1 hr after removal of occlusive dressing
PROCEDURAL SEDATION


Topical Agents:
EMLA Cream


Apply at least ½ hr
prior to procedure
After 1-1 ½ hr, wipe off
cream, clean the area
with antiseptic and do
procedure


Topical Agents:
EMLA Cream



Contraindication: kids
< 1 month of age
Do not apply to broken
skin
Conditions associated
w/
methemoglobinemia
(prilocaine)
PROCEDURAL SEDATION
Topical Agents:
 TAC (tetracaine 0.5%/ adrenaline 0.05%
/cocaine 4-11%)

Max dose = 1.5cc/10 kg
 Suture of lacerations
 Onset 10-20 mins
 Duration 45-60 mins

PROCEDURAL SEDATION

TAC


Soak gauze pad in
soln and place directly
over wound for 5-10
mins
Anesthesia =
blanching appearance
of wound

TAC

Contraindications


Mucus membranes
Areas w/ end-organ
circulation ( ears,
fingers, toes, nose,
penis)
PROCEDURAL SEDATION
Topical Agents:
 Tetracaine (amethocaine) Cream

4% cream
 suturing, venipuncture
 Onset 40 mins
 Duration 4 hrs

PROCEDURAL SEDATION
Topical Agents:
 Tetracaine Cream


Apply under occlusion for 40 mins in kids
undergoing IV placement
PROCEDURAL SEDATION
Topical Agents:
 Iontophoresis

2% lidocaine with epi, 0.6-1 cc
 Place electrode well over intact skin
 Onset 10 mins
 Duration 10 min without epi, 60 mins w/
epinephrine

PROCEDURAL SEDATION


Topical Agents:
Iontophoresis


Tingling, burning,
itching of skin over
both electrodes may
occur
Do not use in pts with
pacemakers or over
metal indwelling
catheter ports or endorgans
PROCEDURAL SEDATION
Topical Agents:
 LET ( lidocaine 5%, epinephrine 0.1%,
tetracaine 0.5%)

Recommended dose = 1-3 cc
 Effective 75-98% of facial & scalp lacerations
 Onset 20-30 mins
 Duration 45-60 mins

PROCEDURAL SEDATION
Topical Agents:
 LET

May need to supplement with injected
buffered lidocaine before suturing
 Only 40-60% effective in extremity wounds

PROCEDURAL SEDATION
Ramsey Sedation Scale
 Awake
 Level 1: anxious and agitated
 Level 2: cooperative, oriented, tranquil
 Level 3: responds to command
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PROCEDURAL SEDATION
Ramsey Sedation Scale
 Asleep
 Level 4: brisk response to light glabellar
tap or loud auditory stimulus
 Level 5: sluggish response to light
glabellar tap or loud auditory stimulus
 Level 6: no response to light glabellar tap
or loud auditory stimulus
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PROCEDURAL SEDATION
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Recommended Fasting Time to Reduce
Aspiration Risk:
Clear liquids
2 hrs
Breast milk
4 hrs
Infant formula
6 hrs
Non-human milk
6 hrs
Light meal
6 hrs
Regular meal
8 hrs
PROCEDURAL SEDATION
PROCEDURAL SEDATION