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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 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 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 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 At total dose 0.1 mg/kg = 60 mins Adult Sedation and Analgesia Drugs And Reversal Agents 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 Propofol: Dose: 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 Flumazenil: Precautions/ Contraindications Monitoring must be performed for an appropriate period after initial reversal Contraindicated in 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 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 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 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: 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 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 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 PROCEDURAL SEDATION 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