Template:Sedative agents: Difference between revisions
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==[[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 | |||
*[[Etomidate]] used less frequently than other agents; causes myoclonus that is undesirable for orthopedic reduction | |||
===[[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)<ref name="ACEP">ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department [http://www.acep.org/workarea/DownloadAsset.aspx?id=93816 full text]</ref> | ||
* | *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)<ref>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</ref> | ||
**Versed can be used subsequently if emergence reaction occurs | |||
===Fentanyl/ | *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]]=== | |||
*Potentiates GABA receptors, sedative hypnotic agent without analgesic properties | |||
*Rapid onset <1 min, short duration <10 min, predictable dose dependent potency | |||
*0.5-1mg/kg IV over 3-5 mins, repeat 0.5 mg/kg q3-5 min PRN | |||
*Can cause dose-related respiratory depression, hypotension, and decreased cardiac output, however, rarely leads to unplanned intubation, prolonged observation, or complications requiring admission <ref> Blackburn 2000, Burnton JH, Miner JR, et al. Propofol for emergency department procedural sedation and analgesia: a tale of three centers. Acad Emerg Med. 2006;13(1):24-30 </ref> | |||
*Can cause sympathomimetic effects, such as tachycardia, hypertension, and increased cardiac output, and caution should be used in patients with known or suspected coronary artery disease | |||
===[[Fentanyl]]/[[Midazolam]]=== | |||
*Dose fentanyl first: 0.5-1mcg/kg | |||
*Follow with 1-2 mg of [[midazolam]] | |||
*Designed for moderate sedation | *Designed for moderate sedation | ||
** | **Too deep when painful stimulus stops the patient may become apneic | ||
*Duration | **Combination of other [[opioids]] with [[benzodiazepines]] such as [[lorazepam]] is possible | ||
*Duration 30min | |||
===Etomidate | ===[[Fentanyl]]/[[Etomidate]]=== | ||
*Similar to | *Similar to fentnayl/midazolam, but better because shorter duration of action | ||
* | *An alternative to propofol for brief sedation | ||
**E.g. shoulder/hip reduction, cardioversion | **E.g. shoulder/hip reduction, cardioversion | ||
*Can cause myoclonus<ref> Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.</ref> and occaisonly adrenal supression. | |||
*Dose fentanyl first: 0.5-1mcg/kg | *Dose fentanyl first: 0.5-1mcg/kg | ||
*Etomidate 0.15mg/kg (8-10mg avg) | *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 | |||
===Propofol/Ketamine (Ketofol)=== | ===[[Propofol]]/[[Ketamine]] ([[Ketofol]])=== | ||
*1:1 mixture of ketamine and propofol<ref>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</ref> | *1:1 mixture of ketamine and propofol<ref>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</ref> | ||
*Safe in children and adults undergoing procedural sedation and anesthesia (Level B Reccomendation)<ref name="ACEP">ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department [http://www.acep.org/workarea/DownloadAsset.aspx?id=93816 full text]</ref> | |||
*Theorized that side-effect profiles counter one another | *Theorized that side-effect profiles counter one another | ||
*Dose: 0.5mg/kg propofol with 0.5mg/kg ketamine (may be mixed in same syringe) | **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<ref>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.</ref> | |||
*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]] | |||
===[[Etomidate]]=== | |||
{{Procedure sedation etomidate}} | |||
Latest revision as of 17:43, 17 April 2024
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
- Etomidate used less frequently than other agents; causes myoclonus that is undesirable for orthopedic reduction
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)[2]
- 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
- Potentiates GABA receptors, sedative hypnotic agent without analgesic properties
- Rapid onset <1 min, short duration <10 min, predictable dose dependent potency
- 0.5-1mg/kg IV over 3-5 mins, repeat 0.5 mg/kg q3-5 min PRN
- Can cause dose-related respiratory depression, hypotension, and decreased cardiac output, however, rarely leads to unplanned intubation, prolonged observation, or complications requiring admission [3]
- Can cause sympathomimetic effects, such as tachycardia, hypertension, and increased cardiac output, and caution should be used in patients with known or suspected coronary artery disease
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 fentnayl/midazolam, but better because 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
Propofol/Ketamine (Ketofol)
- 1:1 mixture of ketamine and propofol[5]
- 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[6]
- 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
Etomidate
- 0.1mg/kg one time dosing
- Max: 10mg
- Minimal respiratory depression but decrease blood pressure and heart rate (alpha2 agonism)
- ↑ 1.0 1.1 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
- ↑ Blackburn 2000, Burnton JH, Miner JR, et al. Propofol for emergency department procedural sedation and analgesia: a tale of three centers. Acad Emerg Med. 2006;13(1):24-30
- ↑ Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
- ↑ 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.