Procedural sedation

Background

• Placing pt on ETCO2 + SpO2 is best
  • If do not have ETCO2 consider placing pt on room air alone
    • Works as indirect measure of ventilation (as CO2 incr, SpO2 decr)
• Position pt in position you would intubate them (ear at level of sternal notch)
• Consider nasal airway in pt with likely OSA

Sedation Levels

Sedation levels

Level	Definition	Comments
Minimal Sedation	Standard pain medications
Moderate Sedation	Awake and able to respond to questions	use in: LP, I+D
Dissociative Sedation	Trance-like state, airway reflexes preserved
Deep Sedation	React purposefully to painful stimuli	use in: Reduction
General Anesthesia	Unarousable, requires intubation/advanced airway

Agents

Fentanyl/Versed

• Designed for moderate sedation
  • If titrate to deep sedation, when painful stimulus stops may become apneic
• Duration = 30min

Etomidate/Fentanyl

• Similar to versed/fentanyl but better b/c of shorter duration of action
• Good for brief sedation if don't have access to propofol
  • E.g. shoulder/hip reduction, cardioversion
• Dose fentanyl first: 0.5-1mcg/kg
• Etomidate 0.15mg/kg (8-10mg avg)
  • Wears off in 6min

Propofol

• Similar to etomidate/fentanyl
• Give fentanyl 1-1.5mcg/kg first
• Give initial 0.5mg/kg dose
  • Give another 0.5mg/kg as needed
• Works w/in 60s
• Duration only few minutes
• See Propofol

Ketamine

• Ideal for extended procedural time, complete analegesia, muscle relaxation
• See Ketamine

Ketofol

• 2 definitions
  • 1. 50% ketamine mixed with 50% propofol in same syringe
  • 2. Pretreatment with 1/2 dose ketamine, followed by propofol
• Ketamine comes in a 50 mg/mL concentration
• take a 10 mL saline flush and empty 2 mL and draw up 2 mL of ketamine
  • 100 mg of ketamine in flush

• Propofol comes in a standard 10 mg/mL concentration.
• fill a different 10 mL syringe with this you have 100 mg of propofol

• If you mix the two in a new 20 or 30 mL syringe you get 100 mg ketamine + 100 mg propofol = 200 mg total.
• Every one mL has 10 mg of ketofol.
• Your starting dose of this will be 0.5 mg/kg followed by another 0.5 mg/kg after about 30-60 sec.
• From then on for maintenance you can use 0.25 mg/kg as needed.

Brevital

• Dose 1-1.5 mg/kg
• Onset < 1 minute; Duration 10 minutes
• No analgesic effect
• Beware of laryngospasm (3 syringe method)

Dexmedetomidine

Brand Name: Precedex

• Dose 0.5 - 1 mcg/kg initial bolus
• Infusion 0.2mcg - 0.6mcg/kg for procedure
• Provides analgesia and anesthesia
• Hemodynamically neutral medication
• Apnea risk as with propofol

Side Effects

• Desaturation
  • Stimulate
    • Try pressure behind ear
  • Jaw thrust
  • Nasal airway
  • BVM (just 10 breaths/min) count to 5 between breaths
  • NIV
  • LMA
  • Intubation

See Also

• Sedation (Main)
• Intranasal Sedation