Procedural Procedural Sedation in Sedation in AdultsAdults

Malik AL-Rawahi

ObjectivesObjectives

Introduction.Definitions.Common Terms.Indications.Contraindications and Precautions.Performing procedural sedation.Medication and reversal agents.Post-Sedation care.Summary and consideration.

IntroductionIntroduction

Practice of acute care requires the performance of procedures that can cause pain and anxiety.

Procedural sedation reduces the discomfort, apprehension, and potential unpleasant memories associated with such procedures, and facilitates their performance.

DefinitionsDefinitions

Procedural sedation involves the use of short-acting analgesic and sedative medications to enable clinicians to perform procedures effectively, while monitoring the patient closely for potential adverse effects.

This process was previously termed "conscious sedation" but because effective sedation often alters consciousness the preferred term is PSA.

Common TermsCommon Terms

Analgesia.

Minimal sedation.

Moderate sedation and analgesia.

Deep sedation and analgesia.

General anesthesia.

Dissociative sedation.

Minimal SedationMinimal Sedation

Response to verbal stimulation is normal.

Cognitive function and coordination may be impaired.

Ventilatory and cardiovascular functions are unaffected.

Moderate Sedation and Moderate Sedation and AnalgesiaAnalgesia

Depression of consciousness is drug-induced.

Patient responds purposefully to verbal commands.

Airway is patent, and spontaneous ventilation is adequate.

Cardiovascular function is usually unaffected. 

Deep Sedation and Deep Sedation and AnalgesiaAnalgesia

Depression of consciousness is drug-induced. Patient is not easily aroused but responds purposefully following repeated or painful stimulation. Independent maintenance of ventilatory function may be impaired. Patient may require assistance in maintaining a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

General General AnesthesiaAnesthesia

Loss of consciousness is drug-induced, where the patient is not able to be aroused, even by painful stimulation. Patient's ability to maintain ventilatory function independently is impaired. Patient requires assistance to maintain patent airway, and positive pressure ventilation may be required.Cardiovascular function may be impaired.

Dissociative Dissociative SedationSedationA trance-like cataleptic state.

Patient experiences profound analgesia and amnesia.

Airway protective reflexes, spontaneous respirations.

Cardiopulmonary stability.

Ketamine produces this state.

ASA classASA classI. Healthy patient.II. Mild systemic disease- no functional limitation.III. Severe systemic disease- definite functional

limitation.IV. Severe systemic disease that is a constant threat

to life.V. Moribund patient not expect to survive without the

operation.

(Usually ED sedation only for I and II unless emergent)

IndicationsIndications For any procedure in which a patient's pain or anxiety may be excessive.

Procedures where deep relaxation is needed (closed reduction of a dislocated joint).

Common procedures(electrical cardioversion, closed joint reduction, complicated laceration repair, abscess incision and drainage, lumbar puncture)

Contraindications and Contraindications and PrecautionsPrecautions

AbsoluteUnstable or advanced ASA score.

Lack of personnel experienced in airway management or ALS.

Unfamiliarity with medications.

Lack of appropriate monitoring equipment.

Allergy or sensitivity to relevant medications.

Problem with PSA or GA before.

RelativeAirway abnormality that would make intubation difficult.

High risk of vomiting and aspiration.

Hemodynamically or neurologically unstable.

How To Reduce the Risk of How To Reduce the Risk of Adverse EventsAdverse Events

Giving a lower starting dose.

Using slower rates of administration.

Redosing medications at less frequent intervals.

Combination of two medications.

Informed ConsentInformed Consent  

Clinician must discuss the risks, benefits, and alternatives of the procedure and the planned sedation with the patient and answer any questions.

A printed informed consent form may be used.

Implied consent is acceptable in some cases.

Prerequisites and Prerequisites and PersonnelPersonnel  Clinicians providing PSA should have in-depth knowledge of the relevant drugs and he should be good in ACLS.The number of clinicians needed to perform PSA at least one clinician and nurse.It remains controversial whether an additional clinician is needed.

Equipment and Equipment and SuppliesSupplies

Oxygen. Suction. Airway management equipment. Reversal agents for opioids or benzodiazepines (eg, naloxone, flumazenil) Resuscitation medications and equipment. Intravenous access.

MonitoringMonitoring Vital signs. ECG. Pulse oximetry. Observe the patient’s appearance. Airway patency. Response to physical stimuli and verbal command. Blood gas level may be required. Consider capnography for high-risk patients.

Considerations in Considerations in PregnancyPregnancy

Preprocedural administration of medication to improve gastric symptoms.

Preprocedural hydration and left lateral displacement of the uterus.

Fetal monitoring is not required.

Oxygen by face-mask.

MidazolamMidazolamIt is a Benzodiazepine.

Adult dose 0.02-0.1 mg/kg IV initially, may repeat with 25% of initial dose after 3-5 min, not to exceed 2.5 mg/dose, and 5 mg cumulative dose.

Onset of action 1-2 min, and duration 30-60 min.

Respiratory depression or hypotension may occur, particularly when rapidly administered or combined with fentanyl.

Does not provide analgesia.

Action reversed by flumazenil

EtomidateEtomidateIt is imidazole derivative.

Adult dose 0.1-0.2 mg/kg slow IV push over 30-60 sec.

Onset of action <1 min, and duration 3-5 min.Commonly causes myoclonus, pain upon injection, adrenal suppression, nausea, vomiting, and lower seizure threshold.Does not alter hemodynamics. Causes a slight to moderate decrease in intracranial pressure that only lasts for several minutes.Does not cause histamine release.Useful for patients with trauma and hypotension.

PropofolPropofolIt is alkylphenol derivative. Adult dose 0.5-1 mg/kg IV loading dose; may repeat by 0.5-mg increments q3-5min.Onset of action <1 min, and duration 3-10 min.Provides rapid onset and recovery phase, and brief duration of action.No analgesia.Has anticonvulsant properties.Can rapidly cause deep sedation.Causes cardiovascular depression and hypotension.

Short-Acting Short-Acting OpioidsOpioids   Opioids are often given alone or in combination with sedatives for PSA.

Short-acting agents, such as fentanyl, alfentanil, and remifentanil, are used.

FentanylFentanylIt is a short acting Opioid.Adult dose 1-2 mcg/kg slow IV push (over 1-2 min); may repeat dose after 30 min.Onset of action 1-2 min, and duration 30-60 min.Does not stimulate histamine release. May cause chest wall rigidity, apnea, respiratory depression, or hypotension.Elicits minimal cardiovascular depression. May cause dysphoria, nausea, vomiting, or EEG changes. Action reversed by naloxone.

RemifentanilRemifentanilIs opioid similar in structure and potency to fentanyl with a rapid onset and duration of action. It can be given in combination with propofol for PSA.Dose of 0.5 mcg/kg (and propofol 0.5 mg/kg) over one minute. Subsequent doses 0.25 mcg/kg and propofol 0.25 mg/kg every one to two minutes. When used alone for PSA, the initial dose is 0.5 to 3 mcg/kg and subsequent doses of 0.25 to 1 mcg/kg every two minutes.

Coadministration of Coadministration of Midazolam and FentanylMidazolam and Fentanyl

Give midazolam first: 0.02 mg/kg (maximum 2 mg) Wait 2 minutes and observe patient response. Give fentanyl: 0.5 mcg/kg. Observe patient; may repeat fentanyl dose every two minutes as necessary.

KetamineKetamineIt is a phencyclidine derivative that acts as a dissociative sedative. It produces a trance-like state and provides sedation, analgesia, and amnesia, while preserving upper airway muscle tone, airway protective reflexes, and spontaneous breathing. Because of its rapid onset, relatively short duration of action, and excellent sedative and analgesic properties, it is often used for brief, painful procedures such as fracture reduction or laceration repair.

KetamineKetamineGiven IV to adults, which enables immediate onset, can be IM.

The duration of effect is 10 to 20 minutes.

For PSA in adults, a dose of 1 to 2 mg/kg/IV/1-2min.

Doses of 0.25 to 0.5 mg/kg may be repeated every five to ten minutes.

KetamineKetamineSide effects include tachycardia, hypertension, hypersalivation, laryngospasm, nausea and vomiting, increased intracranial and intraocular pressure.Emergence reaction (disorientation, dream-like experiences, or hallucinations that may be frightening) the most reported side effect. It can be prevented by midazolam.It can lead to hypersalivation, which can be reduced by atropine.

BarbituratesBarbiturates

Usually it cause sedation. Methohexital is the most commonly used barbiturate for PSA.It has immediate onset, a duration of action less than 10 minutes, and provides sedation and amnesia but no analgesia. It is often given in combination with opiates, which can potentiate respiratory depression.

BarbituratesBarbiturates

The initial dose of methohexital is 0.75 to 1 mg/kg/IV; repeat doses of 0.5 mg/kg IV can be given every two minutes.

It causes myocardial depression, which can lead to hypotension and tachycardia.

It can exacerbate seizures.

Thiopental is a barbiturate used for GA.

KetofolKetofol  

It is a combination of ketamine and propofol.

The benefits are synergistic and allow lower doses.

Reduce the risk for potential side effects.

Studies are limited and to date have not shown ketofol to be more efficacious or safer than propofol alone.

KetofolKetofol  

One small randomized trial found that patients given ketamine (0.3 mg/kg IV) and propofol during PSA achieved similar analgesia but experienced fewer complications compared with patients given fentanyl (1.5 mcg/kg IV) and propofol.

Nitrous oxideNitrous oxide N2O is an ultra-short acting agent used for PSA that is inhaled as a 30 to 50 percent mixture, with 30 percent O2. It has an immediate onset of action and provides analgesia, anxiolysis, and sedation. It must be administered in a well-ventilated room with a scavenging system to prevent clinician exposure.Little evidence is available about its use in adults.

Medications Medications SelectionSelectionPatients without increased risk 

Ultrashort-acting sedatives, such as propofol or etomidate are suggested.

Propofol Versus Propofol Versus EtomidateEtomidate

Respiratory depression occurs at comparable rates during PSA with both.214 patients undergoing painful procedures in the emergency department were randomly assigned to sedation with either medication . Myoclonus was more frequent with etomidate. This likely accounts for the lower rate of procedural success. No clinically significant complications in both.

Patients at Risk of Patients at Risk of HypotensionHypotension

Due to recent illness and dehydration, cardiac disease, others.

Either etomidate or ketamine can be used.

Propofol has a greater blood pressure lowering effect.

Either agent will maintain hemodynamic stability.

Patient at Risk for Airway or Patient at Risk for Airway or Respiratory ComplicationsRespiratory Complications

In this group ketamine can be used.

It allows the patient to maintain protective airway reflexes and does not cause respiratory depression.

Elderly PatientsElderly PatientsOlder patients are at increased risk of complications during PSA. Sedatives, should be given at a lower dose with slower rates and less frequent. If there is no major comorbidities, ultrashort-acting sedative such as propofol can be used.Patients with major comorbidities are best performed in OR.

Ketamine Versus Short-Acting Ketamine Versus Short-Acting Opioids for AnalgesiaOpioids for Analgesia  

Ultra short-acting opioids provide analgesia during PSA but can contribute to respiratory depression.

Some researchers hypothesize that a subdissociative dose of ketamine can provide adequate analgesia without the risk of respiratory depression.

Procedure TypeCommon Emergency Department Examples

RecommendationAlternativesComments

NoninvasiveRadiologic imagingMethohexital (PR)Methohexital (IV)

IV access is often not required in these patients. Methohexital given rectally is likely safer than methohexital or etomidate given IV. Midazolam does not consistently render children motionless.

Echocardiography Etomidate (IV)

  Midazolam (IV)

Low painSimple laceration repairMidazolamKetamine (IM)These procedures generally do not require more than moderate sedation, and analgesia can usually be provided using local or topical anesthesia.

High anxietyLumbar puncture(IV, PO, IN, PR)Nitrous oxide

Simple foreign body removal

  

Eye irrigation  

Slit lamp examination  

High painAbscess irrigation and drainage

Midazolam andPropofol (IV) or

Evidence now exists to support the use of any of these agents. However, there are far more data supporting the safety and efficacy of midazolam/fentanyl and ketamine for emergency department use than the other regimens. In children, administer ketamine IV or IM with atropine or glycopyrrolate. In adults, administer ketamine IV preceded by midazolam IV.

High anxietyFracture/joint reductionFentanyl (IV)Etomidate (IV) or

Burn debridementorMethohexital (IV) plus:

Chest tube placementKetamine (IM/IV)Fentanyl (IV)

Cardioversion  

Sexual assault examination  

Reversal Agents, Naloxone

It reverses opioid agonists.

Adults dose in postanesthetic or dependent: 0.1-0.2 mg/kg IV; may repeat q2-3min prn, in overdose: 0.4-2 mg IV; may repeat q2-3min prn.

Onset of action for IV is 1-3 min,10-15 min for IM.

Rebound sedation may occur.

If used in patient with chronic opioid use, will precipitate acute withdrawal.

FlumazenilFlumazenilIt reverses benzodiazepines.

For sedation reversal: 0.1-0.2 mg IV infused over 15 sec, may repeat after 45 sec and then every min; not to exceed 1 mg.

For overdose: 0.2 mg IV infused over 30 sec, may repeat with additional doses of 0.5 mg over 30 sec at 1-min intervals; not to exceed 3 mg.Rebound sedation may occur.If used in patient with chronic BZP use, will precipitate acute withdrawal.May precipitate seizures unresponsive to BZPs.

Reversal Agents Use

Naloxone indicated If the procedure not completed, but the patient becomes overly sedated or experiences respiratory depression, and sometimes in long-acting opioid.

Flumazenil indicated in hypoventilation unresponsive to stimulation or a brief period of bag/mask ventilation or deep sedation with loss of protective airway reflexes.

Post-Sedation Post-Sedation CareCare

Monitor VS and respiratory status until awake and alert.D/C when the following are met:

Airway, ventilation, CV function, hydration satisfactory.LOC baseline.Baseline motor function. Can tolerate oral intake.Normal VS.Resolved nausea and vomiting.Patient or responsible person can understand D/C instructions. Send home with someone if can.

Sedative instructions should be given.

Must be sure pt won’t drive or do dangerous activity for 24 hs. Cognitive change/drowsiness can last 8+ hs.If IV reversal agents given then observe for 2 hours to ensure no re-sedation.

Summary and Summary and ConsiderationConsideration PSA involves the use of short-acting analgesic and sedative medications.PSA may be used for any procedure in which a patient's pain or anxiety may be excessive.The number of clinicians needed to perform PSA may vary.Proper monitoring during PSA is crucial. Serious complications attributable to PSA are rare.

Summary and Summary and ConsiderationConsideration

Ideal drugs for PSA have a rapid onset, short duration of action, maintain hemodynamic stability, and do not cause major side effects.

PSA is most often performed in patients without major comorbidities or hemodynamic instability.

Older patients are at increased risk of complications.

Sometimes clinicians may perform PSA in patients at some increased risk of complications.

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