Procedural Sedation

Procedural sedation is used to for analgesia and amnesia during short procedures, such as reductions, I&Ds in sensitive areas, and various pediatric cases.  Normally the treating physician carries out the procedure while a colleague takes care of the procedural sedation.  Rarely are there any complications, but consent must always be sought for both the procedure and the sedation.  Obviously the patient should be in an appropriate room containing monitors and emergency equipment should complications be met.

Approach

  • Consent
  • Brief history and PMHx (specifically for any cardiovascular or respiratory problems; pregnancy)
  • Assessment of patient’s airway
  • Allergies (i.e. drugs, egg…)
  • Time of last meal
  • Selection of drugs
  • Monitors



 

Drug selection

Propofol

  • Anesthetic-hypnotic
  • Supplied in 20mL ampules (concentration:10mg/mL)
  • T1/2 = 2-8 minutes
  • Recovery via redistribution and elimination (metabolized in liver, renal excretion)
  • Effects: decrease RR, decrease BP
  • 1-2mg/kg IV

Etomidate

  • Hypnotic
  • Onset within 1minutes, duration 3-5minutes
  • Metabolized in the liver
  • Effects: may cause respiratory depression, muscle twitching, emergence N/V, adrenocorticoid suppression, no hemodynamic effects!
  • 0.3mg/kg IV

Ketamine

  • Dissociative anesthetic
  • Concentration 10mg/mL or 50mg/mL
  • IV onset 1-2 minutes, duration 10-20 minutes
  • Metabolized in the liver
  • Effects: nystagmus (eyes open), hypersecretions, delirium/agitation/hallucinations, increased tone, vocalizations, mild respiratory depression, sympathetic stimulation (increased in HR, BP, SVR – beware if sympathetics blocked – may cause myocardial depression)
  • 1-2mg/kg IV

Midazolam (Versed)

  • Benzodiazepine: sedation, amnesia and anxiolytic *no analgesia
  • Concentration 1-5mg/mL
  • Onset in 1-2 minutes, duration 30 minutes
  • Metabolized in the liver, excreted by the kidney
  • Effects: cardiorespiratory depression
  • 0.5-3mg IV or 0.02mg/kg IV (pediatrics 0.1mg/kg)

Fentanyl

  • Opioid: analgesia
  • Onset in 1-2 minutes, duration 30 minutes
  • Metabolized by the liver
  • Effects: cardiorespiratory depression
  • 0.5-3mcg/kg

Naloxone

  • Opioid reversal
  • 0.1-2mg IV

Flumazenil

  • Benzodiazepine reversal
  • 0.2mg IV over 15 seconds, if after 1 minutes LOC not improved repeat doses of 0.1mg q1minute (up to 2mg)

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