Rosens 188: Procedural Sedation And Analgesia

Front 1

Minimal sedation (anxiolysis)

Back 1

A drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

verbal

cognitive,coordination

ventilatory

cardiovsacular

Front 2

Moderate sedation

Back 2

(formerly “conscious sedation”): A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Front 3

Deep sedation:

Back 3

A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

Front 4

General anesthesia:

Back 4

A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or

-drug-induced depression of neuromuscular function.

-Cardiovascular function may be impaired.

Front 5

Dissociative Sedation:

Back 5

A trancelike cataleptic state induced by the dissociative agent ketamine characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability.

Front 6

ASA Classes?

Back 6

Front 7

Who should we consult anesthesia for PSA?

Back 7

· Difficult airway
· ASA III - V

Front 8

Ketamine IV Vs IM

Back 8

1mg/kg give over 1min peak 1min duration 10min add 0.5

IM 5mg/kg effective 5min lasts 15min repeat 2.5 after 15

-more vomiting on emergence
-less easy titrate
-long recovery 120 vs 80

Front 9

Mechanism of analgesia for ketamine

Back 9

Sub-dissociative’ doses (<1mg/kg IV or <2 mg/kg IM) of ketamine provide potent analgesia, due to agonism of mu, delta, and kappa opioid receptors.

Front 10

Mechanism of dissociation

Back 10

The dissociative state is a lack of response to external stimuli due to ‘disconnection’ of the thalamoneocortical system from the limbic system, as a result of non-competitive antagonism at NMDA receptors.

Front 11

Epi of emergence with ketamine?

Back 11

emergence?
adults: 10-20% (as high as 30% in some studies), with 1-2% clinically significant.
children: 7.6%, with 1.4% clinically significant.
routine benzo dec vomiting inc resp compl

Front 12

Ketmaine in peds?

Back 12

dont routinely give atropine(no benefit) or glycol(may harmful) - for hypersaliva

dont give <3mo , animal studies NMDA

Front 13

Ketamine - adverse effects and advantages and contra indications

Back 13

Hypertension
Tachycardia
Laryngospasm (rare)
Increased intracranial and intraocular pressure

Emergence phenomena
Emesis

++++++

Rapid onset
Short duration
No respiratory depression
Airway reflexes maintained
Can administer via multiple routes
Predictable when given IM
Effective bronchial dilator

Contraindications include

-children younger than 3 months of age,

-active pulmonary infection,

-cardiovascular disease (angina, heart failure, aneurysm, uncontrolled hypertension),

-traumatic brain injury,

-CNS mass lesions,

-hydrocephalus,

-glaucoma, and

-acute globe injury.

Front 14

Ketamine Dose, IV,IM,PR,IN,PO?

Back 14

IV 1 mg/kg 1 min 15 min

IM 5 mg/kg 5 min 15min

PR 5 mg/kg 5 min 15min

IN 5 mg/kg 5 min

PO 5 mg/kg 30–45 min 2–4 hrs

Front 15

Fentanyl dose,adverse effects, issues?

Back 15

2–3 μg/kg 1–2 min 20–30 min

Respiratory depression
Muscular/glottic rigidity

Respiratory depression is more pronounced when coadministered with other respiratory depressants.
Does not cause histamine release.

Front 16

Propofol Dosage, IV/Infusion

Back 16

IV 1.0 mg/kg ≤1 min
Infusion 25–125 μg/kg/min 8–10 min

Front 17

Propofol complications, advantages, issues

Back 17

Respiratory depression
Hypotension
Injection pain

Rapid onset
Short duration
Cerebral protective
Antiemetic effects

Procedures lasting ≥8–10 min will require repeat boluses or a constant infusion.

Safety has not been documented for extended emergency department administration.

To prevent injection pain, administer IV lidocaine, 0.5 mg/kg with a rubber tourniquet in place, 30 to 120 sec before propofol.

Front 18

Etomidate Dosage IV,PR,PO

Back 18

IV 0.1mg/kg <1min 6 min

PO 50mg (adult dose) 10min 60min

PR 4.5mg/kg 4min 40min

Front 19

Etomidate complications, features?

Back 19

Respiratory depression
Myoclonus
Emesis
Injection pain
Adrenal suppression

Rapid onset
Short duration
Minimal cardiovascular effects
Cerebral protective

Adrenal suppression is not clinically relevant with one-time administration.

Front 20

Ramsey sedation scale

Back 20

1. anxious and agitated or restless, or both
2. cooperative, oriented, and calm
3. responsive to commands only
4. exhibiting brisk response to light glabellar tap or loud auditory stimulus
5. exhibiting a sluggish response to light glabellar tap or loud auditory stimulus
6. unresponsive