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==[[Sedative agents]]==
==[[Sedative agents]]==
*[[Propofol]]
*The ideal agent is short-acting with minimal respiratory or hemodynamic depression
*[[Opioids]]
*[[Ketamine]] offers the greatest safety profile overall but caution in the elderly or patients with known cardiovascular disease due to sympathetic surge
**[[Fentanyl]]
*[[Propofol]] is often used for orthopedic procedures due to muscle relaxation, but can cause respiratory depression and hypotension
**[[Morphine]]
*[[Etomidate]] used less frequently than other agents; causes myoclonus that is undesirable for orthopedic reduction
*[[Benzodiazepines]]
**[[Midazolam]]
**[[Lorazepam]]
*[[Dexmedetomidine]]
*[[Ketamine]]
*[[Haloperidol]] and other tranquilizers


===Fentanyl/Versed===
===[[Ketamine]]===
*Designed for moderate sedation
*Noncompetitive NMDA receptor antagonist that produced dissociative state
**If titrate to deep sedation, when painful stimulus stops may become apneic
*Sedation, analgesia, and amnesia
*Duration = 30min
*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
*{{MedicationDose|drug=Ketamine|dose=1-2 mg/kg|route=IV|context=Procedural sedation|indication=Procedural sedation|population=Adult|duration=10-20 min|notes=Followed by 0.5-1 mg/kg IV PRN}}
*{{MedicationDose|drug=Ketamine|dose=4-5 mg/kg|route=IM|context=Procedural sedation (IM)|indication=Procedural sedation|population=Adult|duration=10-20 min|notes=Repeat 2-4 mg/kg IM after 10 min if unsuccessful}}
*{{MedicationDose|drug=Ketamine|dose=1.5-2 mg/kg|route=IV|context=Procedural sedation|indication=Procedural sedation|population=Pediatric|notes=Safe for children (Level A)}}
*{{MedicationDose|drug=Ketamine|dose=4-5 mg/kg|route=IM|context=Procedural sedation (IM)|indication=Procedural sedation|population=Pediatric}}
*{{MedicationDose|drug=Ketamine|dose=3-6 mg/kg|route=IN|context=Procedural sedation (IN)|indication=Procedural sedation|population=Pediatric}}<ref>Hall, D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014; 31:789-90.</ref>


===Etomidate/Fentanyl===
===[[Propofol]]===
*Similar to versed/fentanyl but better b/c of shorter duration of action
*Potentiates GABA receptors, sedative hypnotic agent without analgesic properties
*Good for brief sedation if don't have access to propofol
*Rapid onset <1 min, short duration <10 min, predictable dose dependent potency
**E.g. shoulder/hip reduction, cardioversion
*{{MedicationDose|drug=Propofol|dose=0.5-1 mg/kg IV over 3-5 min|route=IV|context=Procedural sedation|indication=Procedural sedation|population=Adult|onset=<1 min|duration=<10 min|notes=Repeat 0.5 mg/kg q3-5 min PRN}}
*Dose fentanyl first: 0.5-1mcg/kg
*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>
*Etomidate 0.15mg/kg (8-10mg avg)
**Wears off in 6min


===Brevital (Methohexital)/Fentanyl===
===[[Fentanyl]]/[[Midazolam]]===
*{{MedicationDose|drug=Fentanyl|dose=0.5-1 mcg/kg|route=IV|context=Procedural sedation (with midazolam)|indication=Procedural sedation|population=Adult|notes=Dose fentanyl first}}
*{{MedicationDose|drug=Midazolam|dose=1-2 mg|route=IV|context=Procedural sedation (with fentanyl)|indication=Procedural sedation|population=Adult|duration=30 min|notes=Follow fentanyl; designed for moderate sedation}}
*Combination of other [[opioids]] with [[benzodiazepines]] such as [[lorazepam]] is possible
 
===[[Fentanyl]]/[[Etomidate]]===
*Similar to fentanyl/midazolam, but better because shorter duration of action
*An alternative to propofol for brief sedation (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>
*{{MedicationDose|drug=Fentanyl|dose=0.5-1 mcg/kg|route=IV|context=Procedural sedation (with etomidate)|indication=Procedural sedation|population=Adult|notes=Dose fentanyl first}}
*{{MedicationDose|drug=Etomidate|dose=0.15 mg/kg|route=IV|context=Procedural sedation|indication=Procedural sedation|population=Adult|duration=6 min|notes=Average 8-10 mg}}
 
===Brevital (Methohexital)/[[Fentanyl]]===
*Suppresses the reticular activating center in the brainstem and cerebral cortex, thereby causing sedation
*Suppresses the reticular activating center in the brainstem and cerebral cortex, thereby causing sedation
*Sedation and amnesia, no analgesia
*Sedation and amnesia, no analgesia
*Dose fentanyl first: 0.5-1mcg/kg
*{{MedicationDose|drug=Fentanyl|dose=0.5-1 mcg/kg|route=IV|context=Procedural sedation (with brevital)|indication=Procedural sedation|population=Adult|notes=Dose fentanyl first}}
*Initial dose 0.75 to 1mg/kg IV
*{{MedicationDose|drug=Methohexital|dose=0.75-1 mg/kg|route=IV|context=Procedural sedation|indication=Procedural sedation|population=Adult|onset=immediate|duration=<10 min|display=Brevital|notes=Repeat 0.5 mg/kg IV q2 min PRN}}
*Repeat doses of 0.5mg/kg IV can be given every two minutes.
*Immediate onset, duration <10 minutes


===Ketamine===
===[[Propofol]]/[[Ketamine]] ([[Ketofol]])===
*Noncompetitive NMDA receptor antagonist that produced dissociative state
*Sedation, analgesia, and amnesia
*Maintain upper airway tone, protective reflexes, spontaneous breathing
*To prevent 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>
**Sebsequently, if having bad trip after, can always give midazolam then
*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<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 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>
*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>
*{{MedicationDose|drug=Ketofol|dose=0.5 mg/kg propofol + 0.5 mg/kg ketamine|route=IV|context=Procedural sedation|indication=Procedural sedation|population=Adult|notes=May be mixed in same syringe or given separately}}
 
===[[Dexmedetomidine]]===
*{{MedicationDose|drug=Dexmedetomidine|dose=1 mcg/kg loading then 0.2-1 mcg/kg/hr|route=IV|context=Procedural sedation|indication=Procedural sedation|population=Adult|notes=Avoid in heart blocks; may supplement with midazolam 1-2 mg}}
*Side effects include bradycardia and hypotension
 
===[[Etomidate]]===
*{{MedicationDose|drug=Etomidate|dose=0.1-0.2 mg/kg|route=IV|context=Procedural sedation (solo)|indication=Procedural sedation|population=Adult|notes=One-time dosing; max 10 mg}}

Latest revision as of 15:48, 20 March 2026

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
  • Ketamine 1-2 mg/kg IV (duration 10-20 min) — Followed by 0.5-1 mg/kg IV PRN
  • Ketamine 4-5 mg/kg IM (duration 10-20 min) — Repeat 2-4 mg/kg IM after 10 min if unsuccessful
  • Ketamine 1.5-2 mg/kg IV — Safe for children (Level A)
  • Ketamine 4-5 mg/kg IM
  • Ketamine 3-6 mg/kg IN[3]

Propofol

  • Potentiates GABA receptors, sedative hypnotic agent without analgesic properties
  • Rapid onset <1 min, short duration <10 min, predictable dose dependent potency
  • Propofol 0.5-1 mg/kg IV over 3-5 min IV (onset <1 min, duration <10 min) — 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 [4]

Fentanyl/Midazolam

Fentanyl/Etomidate

  • Similar to fentanyl/midazolam, but better because shorter duration of action
  • An alternative to propofol for brief sedation (e.g. shoulder/hip reduction, cardioversion)
  • Can cause myoclonus[5]
  • Fentanyl 0.5-1 mcg/kg IV — Dose fentanyl first
  • Etomidate 0.15 mg/kg IV (duration 6 min) — Average 8-10 mg

Brevital (Methohexital)/Fentanyl

  • Suppresses the reticular activating center in the brainstem and cerebral cortex, thereby causing sedation
  • Sedation and amnesia, no analgesia
  • Fentanyl 0.5-1 mcg/kg IV — Dose fentanyl first
  • Brevital 0.75-1 mg/kg IV (onset immediate, duration <10 min) — Repeat 0.5 mg/kg IV q2 min PRN

Propofol/Ketamine (Ketofol)

  • 1:1 mixture of ketamine and propofol[6]
  • Safe in children and adults undergoing procedural sedation and anesthesia (Level B Recommendation)[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]
  • Ketofol 0.5 mg/kg propofol + 0.5 mg/kg ketamine IV — May be mixed in same syringe or given separately

Dexmedetomidine

  • Dexmedetomidine 1 mcg/kg loading then 0.2-1 mcg/kg/hr IV — Avoid in heart blocks; may supplement with midazolam 1-2 mg
  • Side effects include bradycardia and hypotension

Etomidate

  • Etomidate 0.1-0.2 mg/kg IV — One-time dosing; max 10 mg
  1. ↑ 1.0 1.1 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
  2. ↑ 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
  3. ↑ Hall, D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014; 31:789-90.
  4. ↑ 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
  5. ↑ Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
  6. ↑ 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
  7. ↑ 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.
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