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Procedural Sedation and AnalgesiaProcedural Sedation and Analgesia
Paleerat Jariyakanjana, MD
Faculty of Medicine
Naresuan University
31 Jan 2013
Procedural sedation administration of sedatives or dissociative
anesthetics induce depressed level of consciousness maintaining cardiorespiratory function little or no patient reaction or memory
Procedural sedation and analgesia (PSA) addition of agents to reduce or eliminate pain
Sedation LevelSedation Level
Sedation LevelSedation Level
Minimal sedation procedures that require patient cooperation and
those in which pain is controlled by local or regional anesthesia
Procedures: lumbar puncture, sexual assault examinations, simple fracture reductions, abscess I&D
Agents: nitrous oxide, midazolam, fentanyl, pentobarbital, low-dose ketamine
Sedation LevelSedation Level
Moderate sedation procedures in which detailed patient cooperation
is not necessary, and diminished pain reaction and muscular relaxation is desired
Procedures: reduction of shoulder dislocation, thoracostomy tube insertion, synchronized cardioversion
Agents: propofol, etomidate, ketamine, methohexital, and combination of fentanyl and midazolam
Sedation LevelSedation Level
Deep sedation procedures that are painful and require muscular
relaxation with minimal patient reactionProcedures: reduction of dislocated hipAgents: same as moderate sedation, but with
larger doses
PATIENT EVALUATIONPATIENT EVALUATION
History and Comorbidities: ASAPatient AssessmentProcedural Urgency
Patient AssessmentPatient Assessment
Hx: fasting state, prior experiences with PSA or anesthesia, current medications, and allergies
PE: potentially difficult airway or cardiorespiratory problems
Patient AssessmentPatient Assessment
Routine laboratory studies: not necessaryDirected ancillary testing
airway abnormalities, infections, advanced age, hepatic or renal disease, dehydration, fever, or hypovolemia
RISKS AND PRECAUTIONSRISKS AND PRECAUTIONS
Fasting StateFasting State
Number of Physicians NeededNumber of Physicians Needed
2 physicians1. perform sedation and monitor patient
2. perform procedureminimal & moderate levels of sedation
1 emergency physician administering sedation and performing procedure
EquipmentEquipment
equipment for airway management and resuscitation
defibrillatorreversal agentsIV access
not required for minimal sedation equipment for IV access should be immediately
available
PROCEDURAL SEDATION MONITORINGPROCEDURAL SEDATION MONITORING
Interactive Monitoring: by dedicated observers Mechanical Monitoring
Mechanical MonitoringMechanical Monitoring
STEP-BY-STEP TECHNIQUESTEP-BY-STEP TECHNIQUE
Preprocedure Pain ManagementPreprocedure Pain Management
The administration of morphine or fentanyl for pain control before the start of PSA will provide the patient with analgesia during PSA.
Preprocedure Pain ManagementPreprocedure Pain Management
PSA should begin after last dose of analgesic has been given and has reached its peak affect 3-5 minutes for IV morphine 2-3 minutes for IV fentanyl
Supplemental Oxygen during Procedural Sedation and Analgesia
Supplemental Oxygen during Procedural Sedation and Analgesia
administration of supplemental oxygen can delay recognition of hypoventilation
Sedation ManagementSedation Management
1. patient has been evaluated
2. appropriate sedation target level is selected
3. monitoring modalities are applied
4. preparations are made for possible adverse events
5. PSA
Sedation ManagementSedation Management
Once the patient has achieved the target sedation level, the actual procedure may begin.
SEDATION AGENTSSEDATION AGENTS
Nitrous OxideNitrous Oxide
can be used alone for minimal sedation or as adjunct with IV medications for moderate sedation
MidazolamMidazolam
sole agent for minimal sedation can be combined with opioid for moderate or
deep PSA
Adverse side effectsmild cardiovascular depression, and
hypotension can arise when this agent is given to patients who are hypovolemic
paradoxical agitation
FentanylFentanyl
easily titratable when used alone for minimal sedation
can be used in combination with midazolam for moderate and deep PSA
MethohexitalMethohexital
best used for brief moderate and deep sedation joint dislocation reduction
Adverse side effectsrespiratory depression
PentobarbitalPentobarbital
excellent agent for minimal sedation for neuroimaging in children
KetamineKetamine
state of dissociation profound analgesia, sedation, and amnesia
both analgesic and anxiolytic propertiesonly sedative agent that typically preserves
patient's ventilatory effort and has minimal effect on blood pressure
KetamineKetamine
Adverse side effectshypersalivationlaryngospasm, vomitingemergence reactions
mild agitation to recurrent nightmares and hallucinations
increases intracranial pressure avoid in patients with head injuries
increase intraocular pressure avoided in patients with eye injuries or glaucoma
EtomidateEtomidate
rapid onset and short duration of effect
Adverse side effectsless cardiovascular depression but similar
respiratory depressionmyoclonic jerking suppression of adrenal-cortical axis
PropofolPropofol
frequently used for moderate and deep PSA
PropofolPropofol
Adverse side effectsassociated with fewer complications than
etomidate or methohexital in patients who received multiple doses and is much easier to titrate
most serious adverse effect: sudden respiratory depression and apnea
hypotensionC/I: allergic to eggs or soy protein
Follow-Up and Patient InstructionsFollow-Up and Patient Instructions
At the completion of the PSA procedure, patients are monitored until a return to baseline mental status.
Return to a preprocedure baseline score or a score of at least 18 indicates the patient is safe for discharge.
ANY QUESTIONS?ANY QUESTIONS?