Template:Sedative agents: Difference between revisions
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==[[Sedative agents]]== | ==[[Sedative agents]]== | ||
The ideal combination is a short acting agent with minimal respiratory or hemodynamic depression | *The ideal combination is a short-acting agent 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 used often due to profound relaxation that occurs for orthopedic related procedures but can cause respiratory depression and hypotension | |||
===[[Fentanyl]]/[[Midazolam]]=== | ===[[Fentanyl]]/[[Midazolam]]=== | ||
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*Follow with 1-2 mg of [[midazolam]] | *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 | ||
**Combination of other [[ | **Combination of other [[opioids]] with [[benzodiazepines]] such as [[Lorazepam]] is possible | ||
*Duration | *Duration 30min | ||
===[[Etomidate]]/[[Fentanyl]]=== | ===[[Etomidate]]/[[Fentanyl]]=== | ||
*Similar to versed/fentanyl but better | *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 | **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]]=== | ===Brevital (Methohexital)/[[Fentanyl]]=== | ||
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*Noncompetitive NMDA receptor antagonist that produced dissociative state | *Noncompetitive NMDA receptor antagonist that produced dissociative state | ||
*Sedation, analgesia, and amnesia | *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> | *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 | **Versed can be used subsequently if emergence reaction occurs | ||
*1-2 mg/kg IV, followed by 0.5-1 mg/kg IV PRN | *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 | *4-5 mg/kg IM → repeat 2-4 mg/kg IM after 10 min if first dose unsuccessful | ||
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===[[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 | ||
**Propofol associated hypotension and respiratory depression can theoretically be reduced with increases in circulatory norepinephrine induced by ketamine | **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 | **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> | *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) | *Dose: 0.5mg/kg propofol with 0.5mg/kg ketamine (may be mixed in same syringe) | ||
Revision as of 02:08, 16 August 2016
Sedative agents
- The ideal combination is a short-acting agent 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 used often due to profound relaxation that occurs for orthopedic related procedures 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
Etomidate/Fentanyl
- 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)
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
- ↑ 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.