Procedural sedation: Difference between revisions
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==Agents==
==Agents==
===Fentanyl/Versed===
{{Sedative agents}}
*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
<br>
*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''<ref>http://www.precedex.com/wp-content/uploads/2010/02/Procedural-Sedation-dosing-Card.pdf</ref>
*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==
==Side Effects==

Revision as of 18:11, 18 June 2015

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

Sedative agents

  • The ideal agent is short-acting with minimal respiratory or hemodynamic depression
  • Ketamine offers the greatest safety profile overall but caution in the elderly or patients with known cardiovascular disease due to sympathetic surge
  • Propofol is often used for orthopedic procedures due to muscle relaxation, but can cause respiratory depression and hypotension
  • Etomidate used less frequently than other agents; causes myoclonus that is undesirable for orthopedic reduction

Ketamine

  • Noncompetitive NMDA receptor antagonist that produced dissociative state
  • Sedation, analgesia, and amnesia
  • Safe to use in children undergoing procedural sedation and analgesia (Level A recommendation)[1]
  • Maintains upper airway tone, protective reflexes, and spontaneous breathing
  • Little evidence to advocate for prevention of emergence phenomenon, may pretreat with midazolam 0.05 mg/kg (2-4 mg for most adults)[2]
    • Versed can be used subsequently if emergence reaction occurs
  • 1-2 mg/kg IV, followed by 0.5-1 mg/kg IV PRN
  • 4-5 mg/kg IM → repeat 2-4 mg/kg IM after 10 min if first dose unsuccessful
  • Duration 10 to 20 minutes

Propofol

  • Potentiates GABA receptors, sedative hypnotic agent without analgesic properties
  • Rapid onset <1 min, short duration <10 min, predictable dose dependent potency
  • 0.5-1mg/kg IV over 3-5 mins, repeat 0.5 mg/kg q3-5 min PRN
  • Can cause dose-related respiratory depression, hypotension, and decreased cardiac output, however, rarely leads to unplanned intubation, prolonged observation, or complications requiring admission [3]
  • Can cause sympathomimetic effects, such as tachycardia, hypertension, and increased cardiac output, and caution should be used in patients with known or suspected coronary artery disease

Fentanyl/Midazolam

  • Dose fentanyl first: 0.5-1mcg/kg
  • Follow with 1-2 mg of midazolam
  • Designed for moderate sedation
  • Duration 30min

Fentanyl/Etomidate

  • Similar to fentnayl/midazolam, but better because shorter duration of action
  • An alternative to propofol for brief sedation
    • E.g. shoulder/hip reduction, cardioversion
  • Can cause myoclonus[4] and occaisonly adrenal supression.
  • Dose fentanyl first: 0.5-1mcg/kg
  • Etomidate 0.15mg/kg (8-10mg avg)
  • Duration: 6min

Brevital (Methohexital)/Fentanyl

  • Suppresses the reticular activating center in the brainstem and cerebral cortex, thereby causing sedation
  • Sedation and amnesia, no analgesia
  • Dose fentanyl first: 0.5-1mcg/kg
  • Initial dose 0.75 to 1mg/kg IV
  • Repeat doses of 0.5mg/kg IV can be given every two minutes.
  • Immediate onset, duration <10 minutes

Propofol/Ketamine (Ketofol)

  • 1:1 mixture of ketamine and propofol[5]
  • Safe in children and adults undergoing procedural sedation and anesthesia (Level B Reccomendation)[1]
  • Theorized that side-effect profiles counter one another
    • Propofol-associated hypotension and respiratory depression can theoretically be reduced with increases in circulatory norepinephrine induced by ketamine
    • Ketamine associated nausea and emergence reactions are theoretically reduced by the antiemetic and anxiolytic properties of propofol
  • A study of pediatric patients found the total patient sedation times to be shorter (3 minutes) with the combined ketamine and propofol regimen compared with ketamine alone[6]
  • Dose: 0.5mg/kg propofol with 0.5mg/kg ketamine (may be mixed in same syringe or given separately)

Dexmedetomidine

  • 1 mcg/kg loading dose followed by 0.2-1 mcg/kg/hr maintenance dose
  • Side effects include bradycardia and hypotension.
  • Avoid in patients with heart blocks
  • May need to supplement with 1-2 mg of midazolam

Etomidate

  • 0.1mg/kg one time dosing
  • Max: 10mg
  • Minimal respiratory depression but decrease blood pressure and heart rate (alpha2 agonism)

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

References

  1. ↑ 1.0 1.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
  2. ↑ Sener S, Eken C, Schultz CH, Serinken M, Ozsarac M. Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial. Ann Emerg Med. 2011 Feb;57(2):109-114.e2
  3. ↑ Blackburn 2000, Burnton JH, Miner JR, et al. Propofol for emergency department procedural sedation and analgesia: a tale of three centers. Acad Emerg Med. 2006;13(1):24-30
  4. ↑ Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
  5. ↑ Andolfatto G, Abu-Laban RB, Zed PJ, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012; 59(6): 504-12.e1-2. PMID: 22401952
  6. ↑ Shah A, Mosdossy G, McLeod S, et al. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011;57:425-433.

See Also

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