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

• 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

• 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

1. Desaturation
   1. Stimulate
      1. Try pressure behind ear
   2. Jaw thrust
   3. Nasal airway
   4. BVM (just 10 breaths/min) count to 5 between breaths
   5. NIV
   6. LMA
   7. Intubation

Source

• EMCrit Podcast 29

See Also

• Sedation (Main)
• Intranasal Sedation