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)
- 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
- LP, I+D
- Deep Sedation
- If give pt painful stimuli they will react purposefully
- Reduction,
- General Anesthesia
- Unarousable
Agents
Fentanyl/Versed
- Designed for moderate sedation
- If titrate to deep sedation, when painful stimulus stops may become apneic
- Duration = 30min
Ketamine
- Ideal for extended procedural time, complete analegesia, muscle relaxation
- Avoid in elderly, hypertensive, baseline psych
Ketamine
Sympathomimetic - avoid in old, hypertensive, baseline crazy/psych
Etomidate + fentanyl
Good for brief sedation if don't have propofol shoulder/hip reduction, cardioversion for short lived but painful procedure Dose fentanyl first: 0.5-1mcg/kg analgesia Etomidate 0.15mg/kg (8-10 on avg.. if not enough then give additional 4mg boluses) by 6 min wears off sedation of profound sedative agent matches the length of time of the stimulus Hemodynamically stable for pt
just like versed/fentanyl but better b/c it disappears faster what about myoclonus? - usually mild either let it wear off or can try to give versed to stop it
Propofol
Side Effects
Dropping sats 1. Stimulate 2. Jaw thrust 3. Nasal airway 4. BVM (just 10 breaths/min) count to 5 between breaths 5. NIV 6. LMA 7. Intubation