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Procedural sedation
From WikEM
Contents
Background
- ACEP Definition: Procedural sdeation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. [1]
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 |
| Deep Sedation | React purposefully to painful stimuli | use in: Reduction |
| General Anesthesia | Unarousable, requires intubation/advanced airway |
Procedural Checklist[2]
- Consent in chart
- PIV with fluids attached
- ETCO2 and NC
- Airway preparation
- Suction with yankaeur attached
- BVM attached to wall oxygen
- Oral/nasal airway
- Mac/miller blade
- ETT with stylet placed and 10 cc syringe
- Meds at bedside
- Sedation Meds
- Narcan 0.4mg if opioid being used, not drawn up
- Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle
- Glycopyrollate, 1 vial; not drawn up
Fasting
- No need to delay procedure based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia (ACEP Level B) [1]
- Some specialty societies recommend:
- 2-hour fasting time for clear liquids
- 4-hour fasting time for breast milk
- 6-hour fasting time for solids
Airway Monitoring
- Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. However, there is a lack of evidence that capnography reduces the incidence of serious adverse events (neurologic injury caused by hypoxia, aspiration, death) (ACEP Level B). [1]
- Placing the patient on ETCO2 + SpO2 is ideal[3]
- Position the patient in a position you would intubate if neeeded (ear at level of sternal notch)
- Consider nasal airway in patients with likely OSA
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
Fentanyl/Midazolam
- Dose fentanyl first: 0.5-1mcg/kg
- Follow with 1-2 mg of midazolam
- Designed for moderate sedation
- Too deep when painful stimulus stops the patient may become apneic
- Combination of other opioids with benzodiazepines such as Lorazepam is possible
- Duration 30min
Fentanyl/Etomidate
- Similar to versed/fentanyl but better because of 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
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)[5]
- 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/Ketamine (Ketofol)
- 1:1 mixture of ketamine and propofol[6]
- 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[7]
- 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
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
See Also
References
- ↑ 1.0 1.1 1.2 1.3 1.4 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
- ↑ ../docss/Sedation_Checklist-8-1-10.pdf
- ↑ Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.
- ↑ Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
- ↑ 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
- ↑ 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
- ↑ 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.
