Diferencia entre revisiones de «Procedural sedation»
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==Sedation Levels== | ==Sedation Levels== | ||
{{Sedation levels}} | {{Sedation levels}} | ||
==Checklist<ref>http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf</ref>== | |||
*Consent in chart | |||
*PIV w/ fluids attached | |||
*ETCO2 and NC | |||
*Airway preparation | |||
**Suction with yankaeur attached | |||
**BVM attached to wall oxygen | |||
**Oral/nasal airway | |||
**Mac/miller blade | |||
**ETT with stylet placed and 10 cc syringe | |||
*Meds at bedside | |||
**Sedation Meds | |||
**Narcan 0.4 mg if opioid being used, not drawn up | |||
**Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle | |||
**Glycopyrollate, 1 vial; not drawn up | |||
{{Sedative agents}} | {{Sedative agents}} | ||
Revisión del 22:03 28 oct 2015
Background
- Placing pt on ETCO2 + SpO2 is best
- If do not have ETCO2 consider placing pt on room air alone[1]
- Works as indirect measure of ventilation (as CO2 incr, SpO2 decr)
- If do not have ETCO2 consider placing pt on room air alone[1]
- Position pt in position you would intubate them (ear at level of sternal notch)
- Consider nasal airway in pt with likely OSA
Sedation Levels
Sedation levels
| Level | Definition | Comments |
| Minimal Sedation | Standard pain medications | |
| Moderate Sedation | Awake and able to respond to questions | use in: LP, I+D |
| Dissociative Sedation | Trance-like state, airway reflexes preserved | |
| Deep Sedation | React purposefully to painful stimuli | use in: Reduction |
| General Anesthesia | Unarousable, requires intubation/advanced airway |
Checklist[2]
- Consent in chart
- PIV w/ fluids attached
- ETCO2 and NC
- Airway preparation
- Suction with yankaeur attached
- BVM attached to wall oxygen
- Oral/nasal airway
- Mac/miller blade
- ETT with stylet placed and 10 cc syringe
- Meds at bedside
- Sedation Meds
- Narcan 0.4 mg if opioid being used, not drawn up
- Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle
- Glycopyrollate, 1 vial; not drawn up
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
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)[3]
- 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)[4]
- Versed can be used subsequently if emergence reaction occurs
- Ketamine 1-2 mg/kg IV (duration 10-20 min) — Followed by 0.5-1 mg/kg IV PRN
- Ketamine 4-5 mg/kg IM (duration 10-20 min) — Repeat 2-4 mg/kg IM after 10 min if unsuccessful
- Ketamine 1.5-2 mg/kg IV — Safe for children (Level A)
- Ketamine 4-5 mg/kg IM
- Ketamine 3-6 mg/kg IN[5]
Propofol
- Potentiates GABA receptors, sedative hypnotic agent without analgesic properties
- Rapid onset <1 min, short duration <10 min, predictable dose dependent potency
- Propofol 0.5-1 mg/kg IV over 3-5 min IV (onset <1 min, duration <10 min) — 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 [6]
Fentanyl/Midazolam
- Fentanyl 0.5-1 mcg/kg IV — Dose fentanyl first
- Midazolam 1-2 mg IV (duration 30 min) — Follow fentanyl; designed for moderate sedation
- Combination of other opioids with benzodiazepines such as lorazepam is possible
Fentanyl/Etomidate
- Similar to fentanyl/midazolam, but better because shorter duration of action
- An alternative to propofol for brief sedation (e.g. shoulder/hip reduction, cardioversion)
- Can cause myoclonus[7]
- Fentanyl 0.5-1 mcg/kg IV — Dose fentanyl first
- Etomidate 0.15 mg/kg IV (duration 6 min) — Average 8-10 mg
Brevital (Methohexital)/Fentanyl
- Suppresses the reticular activating center in the brainstem and cerebral cortex, thereby causing sedation
- Sedation and amnesia, no analgesia
- Fentanyl 0.5-1 mcg/kg IV — Dose fentanyl first
- Brevital 0.75-1 mg/kg IV (onset immediate, duration <10 min) — Repeat 0.5 mg/kg IV q2 min PRN
Propofol/Ketamine (Ketofol)
- 1:1 mixture of ketamine and propofol[8]
- Safe in children and adults undergoing procedural sedation and anesthesia (Level B Recommendation)[3]
- 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[9]
- Ketofol 0.5 mg/kg propofol + 0.5 mg/kg ketamine IV — May be mixed in same syringe or given separately
Dexmedetomidine
- Dexmedetomidine 1 mcg/kg loading then 0.2-1 mcg/kg/hr IV — Avoid in heart blocks; may supplement with midazolam 1-2 mg
- Side effects include bradycardia and hypotension
Etomidate
- Etomidate 0.1-0.2 mg/kg IV — One-time dosing; max 10 mg
Side Effects
- Desaturation
- Stimulate
- Try pressure behind ear
- Jaw thrust
- Nasal airway
- BVM (just 10 breaths/min) count to 5 between breaths
- NIV
- LMA
- Intubation
- Stimulate
See Also
References
- ↑ Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.
- ↑ http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf
- ↑ 3.0 3.1 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
- ↑ Hall, D, et al. Intranasal ketamine for procedural sedation. Emerg Med J. 2014; 31:789-90.
- ↑ 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
- ↑ Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
- ↑ 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.