Procedural sedation
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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)
- If do not have ETCO2 consider placing pt on room air alone
- Position pt in position you would intubate them (ear at level of sternal notch)
- Consider nasal airway in pt with likely OSA
Sedation Levels
- Minimal Sedation
- Pain meds
- Moderate Sedation
- Pt awake, pt able to respond to questions
- use in: LP, I+D
- Deep Sedation
- If give pt painful stimuli they will react purposefully
- use in: Reduction
- General Anesthesia
- Unarousable, requires intubation
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[1]
- 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
- Stimulate
Source
- EMCrit Podcast 29