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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 • • • • • 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 • • • • • • LP 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 – 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.