Sedation (main)

From WikEM
(Redirected from Sedation (Main))
Jump to: navigation, search

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
  • 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

  1. Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
  2. 2.0 2.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
  3. 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
  4. 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
  5. 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.