CONSCIOUS SEDATION SEMINAR IV SEDATION

Conscious Sedation by definition is a medically controlled state of depressed consciousness that allows protective reflexes to be maintained, and retains that patients ability to maintain a patent airway and the ability to respond appropriately to physical and verbal stimulation. The various degrees of sedation occur on a continuum. The patient may progress from one degree to another, based on the medications administered, route and dosages. The determination of the patient monitoring and staffing requirements should be bases on the patients acuity and the potential response of the patient to the procedure. Minimal sedation: The administration of oral medications for the reduction of anxiety. In this stage the following should be present: Normal respiration Normal eye movements, Intact protective reflexes. Amnesia may or may not be present. The patient is technically awake, but under the influence of the drug administered. Moderate sedation/analgesia-Conscious sedation. A medically controlled state of the depressed consciousness that: allows protective reflexes to be maintained in the majority of patients retains the patients ability to maintain a patient airway independently and continuously, permits appropriate response by the patient to physical stimulation or verbal command for example,open your eyes. Deep sedation: A medically controlled state of depressed consciousness from which the patient is not easily aroused. It may accompanied by a partial or complete loss of protective reflexes, and includes the inability to maintain a patient airway independently and respond purposefully to physical stimulation verbal command. Anesthesia: General anesthesia is a drug-induced loss of consciousness during which individuals served often required assistance in maintaining a patient 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.

Pre-Procedure Evaluation is the same as for anesthesia: A good pre-op evaluation may reduce adverse outcomes.

Assessment of Physical status Ascribe ASA Classification (in ED all patients as ASA E) Emergency vs. elective time or opportunity to optimize patients physical condition

For non-emergent (Elective): A. 1) NPO 7-8 hours (ideally) ED All patients are considered full stomachs Gastric Emptying Liquids 1-2 hours Solids 5-6 hours Delays by: 1. 2. 3. 4. 5. 6. 7. 8. 9. Pain Anxiety Hypotension Peptic Ulcer Disease Diabetic Mellitus Thyroid Disease narcotics Obesity Pregnancy

( tones of LES) Risk of Aspiration At risk .3 - .4 cc/Kg and ph 2.5 > Decrease Risk by NPO 2) Bicitra (Alka Seltzer) Non-particulate 3) Prokinetics 45-60 minutes prior 4) H2 Antagonist B. Continue 1) Antihypertensive Meds 2) Cardiac Meds (? Digoxin) Hold 1) Insulin (Oral Hypoglycemic) 2) Diuretics

C. Lab Studies as pre departmental guidelines D. Document what was discussed and what patient accepted

E. Procedure IV (prior) Monitors BP EKG Sao2 (Variable Tone) Check Emergency Equipment Remember that a decrease in O saturation on the pulse ox is a late sign; the patient may be apnecic. Medications Prefer rapid onset/rapid offset and antagonizability Medications Versed Propofol Pentothal Demerol Fentanyl Alfenta BP P - - RR (+ -) Others

Rapid offset/tonic, conic motions Growth medium Nausea Nausea Rapid offset

Give small boluses observe response and titrate as needed The pulmonary cause of morbidity is respiration depression; monitoring ventilation decreases the risk of adverse outcomes. Vital signs should be checked before and after administering medications then q5-q15 depending on patients response - Chronic / Acute tolerance - Sedation cannot mask pain antianalgesia - Poly Pharmacology Reversal (Who needs it) - those who experience the following 1) 2) 3) 4) Pros Alertness/ no respiratory depression Marked respiratory depression Prolonged awakening Bizarre Behavior Planned awakening Cons Reverse Analgesia

Less time in PACU Early discharge

Startle Effects Both Romazicon and Narcan can lead to: Increase Catecholamines, Hypertension/Tachycardia/Seizures Prolonged PACU time Pulmonary Edema/Nausea and Vomiting

To PACU Floor Home

Preoperative Testing for Ambulatory Surgery Patients After an extensive review of texts and journals there is still very little agreement about what preoperative testing is required for patients appearing for ambulatory surgery. In an attempt to contain cost and only perform studies, which are indicated by the nature of the procedure and the patients history and physical status, the department of anesthesiology has recommended the following guidelines ASA Classifications CLASS I II III IV V ASA CBC SMA Pregnancy Ages (12-50) ECG (Ages > 40) Chest X-Ray X X DESCRIPTION Healthy Patient Mild Systemic Disease No Functional Limitation Severe Systemic Disease No threat to Patients life Severe Systemic Disease Constant Threat to patients Life Moribund Patient Unlikely to Survive 24 Hours I X II X III X X X

X X X Only in patients with active pulmonary disease or presenting for Thoracic procedures

Note: 1) ECG, Chest X-Ray, U/A, Cross match or other tests may be ordered based on clinical relevance 2) Medical evaluation when clinically indicated. 3) Pregnancy testing may not be indicated in the following:

a. b. c. d.

Actively menstruating women Patients who have had tubal sterilization procedures Menopausal women Women who have had hysterectomies.

PRINICIPAL INFORMATION ON SELECTED MEDICATIONS

SEDATIVES Midazolam (versed) Onset: Duration: Elimination route: Dose: Light sedation dose: Induction of Anesthesia: Dose adjustment: [Benzadiazepine]; Sedative, Amnestic; anterograde amnesia 1 -2 minutes 30 minutes to 2 hours Hepatic 1 2 mg bolus IV initially. Additional doses of 1 -2 mg can be given at 2 to 5 minute intervals to desired level of sedation. 0.075 mg/kg (about 5 mg / 70 kg patient) 0.2 0.3 mg/kg Dose must be reduced in the elderly (>60 y.o.), debilitated patients, and chronically ill patients. Patients who receive concomitant opioids must have the dose reduced by 30-50% Respiratory depression (decreased tidal volume and respiratory rate) Apnea Respiratory Arrest Hypotension Tachycardia Inability to maintain airway [Benzadiazepine]; Sedative, Amnestic 1 -2 minutes 2 - 4 hours Hepatic Irritating to veins & significant accumulation occurs

Adverse effects:

Diazepam (Valium) Onset: Duration: Elimination route: Concerns:

Dose: Adverse effects:

1 2 mg slow IV bolus; may repeat at 2 to 5 minute intervals to desired level of sedation is achieved Respiratory depression (decreased tidal volume and respiratory rate) Apnea Respiratory Arrest Hypotension Tachycardia Inability to maintain airway [Benzadiazepine]; Sedative, Amnestic 20 - 40 minutes 4 - 6 hours Hepatic Fewer cardiovascular effects than Diazepam Less irritating to veins Half-life is less variable No active metabolites Slow onset, duration can become elimination dependent and Accumulation can occur 2 - 4 mg IV bolus; wait at least 30 minutes to assess the effect before giving additional dose. Respiratory depression (decreased tidal volume and respiratory rate) Apnea Respiratory Arrest Inability to maintain airway Benzadiazepine Antagonist 1 -2 minutes 30 - 60 minutes Hepatic Administration of an antagonist is not a substitute for appropriate monitoring. Patients must be monitored for at least one hour after administration of Flumazenil due to the risk of re-sedation occurring 30 60 minutes after the dose.

Lorazepam (Ativam) Onset: Duration: Elimination route: Notes:

Concerns: Dose: Adverse effects:

Flumazenil (Romazicon) Onset: Duration: Elimination route: Concerns:

Dose:

0.2 mg IV every minute until sedation is reversed; most patients do not require more than 1 mg for reversal after sedation; effective dose may need to be repeated if re-sedation occurs Patients must be monitored for ONE HOUR if Flumazenil is used as reversal due to the risk of re-sedation. The availability of this drug is not an excuse for over sedation Seizures, agitation, emotional liability; Arrhythmia, tachycardia, angina, nausea/vomiting

Adverse effects:

NARCOTICS Fentanyl (Sublimaze) Onset: Duration: Elimination route: Notes: Narcotic analgesic 1 -2 minutes 30 - 45 minutes (Single dose, distribution limited) Hepatic (Inactive metabolites) Rapid onset sedative and analgesic effect synergy with Benzodiazepines. Minimal histamine release Equianalgesic dose: Fentanyl 100 mcg = 10 mg morphine = Meperidine 75 mg Tolerance develops; accumulates over time 25 50 mcg initially (1-2 ug/kg), IV bolus. Additional doses 25 50 ug may be given at 5 10 minute intervals Respiratory depression (decreased tidal volume & respiratory rate) Apnea / Respiratory arrest Inability to maintain airway Narcotic analgesic 10 - 20 minutes 2 - 4 hours Hepatic / renal May produce less intense smooth muscle spasm. Equianalgesic dose: Fentanyl 100 mcg = Meperidine 75 mg = 10mg morphine 25 50 mg IV bolus. Additional doses may be given at 15 20 minute intervals

Concerns: Dose: Adverse effects:

Meperidine (Demerol) Onset: Duration: Elimination route: Notes:

Dose:

Adverse effects:

Respiratory depression (decreased tidal volume & respiratory rate) Apnea / Respiratory arrest Seizure (due to the metabolite normeperidine) Inability to maintain airway Myocardial depression CNS excitation in high doses Monoamine oxidase inhibitors do not give Meperidine -Delirium and Hyperthermia

Drug interaction:

Morphine Onset: Duration: Elimination route: Concerns:

Narcotic analgesic 10 - 20 minutes 2 - 4 hours Hepatic Hypotension due to histamine release (especially with rapid IV administration) May accumulate Tolerance develops Decrease GI motility 2 4 mg IV bolus. Additional doses may be given at 15 20 minute intervals Hypotension due to histamine release Respiratory depression Apnea Respiratory arrest Nausea/vomiting Inability to maintain airway Opioid Antagonist 1 - 2 minutes 45 minutes Hepatic; Metabolism 95% renal elimination

Dose:

Adverse effects:

Naloxone (Narcan) Onset: Duration: Elimination route:

Concerns:

The effects of the opiates can recur 30 60 minutes after Naloxone administration because of the short half-life of the antagonist. Patients must be monitored at least 1 HOUR after reversal to detect possible reaction. Adult: 0.04 -0.4 mg IV bolus; may repeat at 2 3 minute intervals until opiate effects are reversed; most do not need more than 0.8 mg to reverse the opioids effects during sedation. Peds: 1 10 micrograms / kg IV Tremulousness, reversal of analgesia seizures, agitation; Arrhythmia Tachycardia, hypertension, angina; pulmonary edema, delirium, Nausea/vomiting; withdrawal syndrome, sweating

Dose:

Adverse effects:

Generic name Ketamine

Brand Name Dose Ketalar PO (mixed in cola or Other beverage) 510mg/kg given 30 minutes before procedure. IM 0.5-2mg/kg given 30 minutes before procedure. IV 0.5-1mg/kg (range 0.52mg/kg) DO NOT EXCEED 0.5mg/kg/min DO NOT ADMINISTER Any faster than over 60 seconds.

Special Consideration Is a fairly short-acting anesthetic It is a desirable agent for patients who are hypotensive. The patients airway remains intact due to maintenance of pharyngeal & laryngeal reflexes. To treat emergence phenomenon a benzodiazepine may be necessary. Anti-sialagogue may be necessary secondary to production of copious secretions.

Etomiadate-Short acting IV anesthetic. -Maintains BP better than propofol -Onset is one circulation time 30-60 sections. -Half life 75 minutes, but effects despite in 10 minutes because it is re-distributed from plasma to other tissues -Metabolism is ester hydrolysis -Excretion is 85% renal and 15% biliary -Agonest at GABA receptors -Induction dose is .3 mg/kg -Sedation dose starts @.1mg/kg -Many suppress steroid synthesis (even 1 dose) for 24hours -May seize seizure like activity Propofol -Short acting IV anesthetic -Can be used for induction, maintenance of anesthesia, and sedation, both short and long term -Not an analgesic -Onset time 30-60 seconds -Half life 2-24 hrs, but effects dissipate within minutes due to rapid distribution -95% protein bond -Hepatic metabolism and renal excretion -painful on injection -no reversal agent -3 mg/kg for induction; 1mg/kg for sedation; decrease for the elderly