Template:Sedative agents: Difference between revisions
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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 | ||
*Level A reccomendation: Ketamine safe to use in children<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> | |||
*Maintain upper airway tone, protective reflexes, spontaneous breathing | *Maintain upper airway tone, protective reflexes, 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> | ||
Revision as of 00:27, 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 over all but should be used with caution in the ederly or patients with known cardiovascular disease due to the sympathetic surge. Propofol is used often due to the 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
- If titrate to deep sedation, when painful stimulus stops the patient may become apneic
- Combination of other Opioids with Benzodiazepines is possible
- Duration = 30min
- Can substitute midazolam for Lorazepam if the former is not available.
Etomidate/Fentanyl
- Similar to versed/fentanyl but better b/c of shorter duration of action
- Good for brief sedation if don't have access to propofol
- E.g. shoulder/hip reduction, cardioversion
- Dose fentanyl first: 0.5-1mcg/kg
- Etomidate 0.15mg/kg (8-10mg avg)
- Wears off in 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
- Level A reccomendation: Ketamine safe to use in children[1]
- Maintain upper airway tone, protective reflexes, 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 once sedation is complete
- 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[3]
- Theorized that side-effect profiles counter one another
- 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
- ↑ 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