Template:Sedative agents

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 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)
• 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)
  • 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
• Safe in children and adults undergoing procedural sedation and anesthesia (Level B Reccomendation)
• 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
• 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