We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Sedation (main)
From WikEM
(Redirected from Sedation (Main))
Contents
Specific Types of Sedation and Sedation Protocols
- Trauma sedation
- Combative patient
- Procedural sedation
- Procedural Sedation (Peds)
- Intranasal sedation
- ICU sedation
Sedative agents
Background
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 |
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[1] 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)[2]
- 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)[3]
- 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[4]
- Safe in children and adults undergoing procedural sedation and anesthesia (Level B Reccomendation)[2]
- 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[5]
- 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
See Also
References
- ↑ Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
- ↑ 2.0 2.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
- ↑ 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.
