Template: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

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 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[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

  • 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 [4]
  • 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

Propofol/Ketamine (Ketofol)

  • 1:1 mixture of ketamine and propofol[5]
  • 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[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)
  • 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
  • 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
  • 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.