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Sedation and Analgesia

Sedation and Analgesia. Dan Quan, DO Department of Emergency Medicine Maricopa Medical Center Phoenix, Arizona. Goals of Sedation and Analgesia. Provide patient comfort for procedures Anxiolysis Pain control Decreases risk to both provider and patient

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Sedation and Analgesia

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  1. Sedation and Analgesia Dan Quan, DO Department of Emergency Medicine Maricopa Medical Center Phoenix, Arizona

  2. Goals of Sedation and Analgesia • Provide patient comfort for procedures • Anxiolysis • Pain control • Decreases risk to both provider and patient • Sedation without compromising oxygenation • Choose agents with reliable effects to achieve rapid results • Make your emergency department noise free

  3. Levels of Sedation • Minimal sedation (anxiolysis) • Awake and responsive, no airway problems • Moderate sedation/analgesia (conscious sedation) • Patient able to follow commands but level of consciousness is decreased • Able to maintain airway and spontaneous breathing

  4. Levels of Sedation • Deep sedation/analgesia • Deeply sedated, but able to follow commands • May require ventilatory support and supplemental oxygen • Anesthesia • Uh oh, this better be happening in the operating room

  5. Routes of Administration • Intravenous (IV) • Direct route, pharmacokinetics are predictable, IV access may be difficult to obtain • Intramuscular (IM) • Indirect route, sporatic absorption, slightly unpredictable • Intraossesous (IO) • Direct route, similar to IV pharmacokinetics

  6. Routes of Administration • Oral (PO) • Affected by first pass effects and metabolism through the liver so exact dosing is difficult, unpredictable absorption (empty stomach vs. full), • Rectal (PR) • Indirect route, may require longer to absorb, unpredictable absorption • Nasal • Direct route, nasal irritation

  7. Nebulizer vs. Nasal Plasma Concentration

  8. General Preparation • Obtain procedural consent before administering drugs • Good IV site preferably two with maintenance fluids running • Administer supplemental oxygen • Cardiac monitoring with pulse oximetry

  9. General Preparation • End tidal CO2 monitoring is helpful • Pulse oximetry indicates hypoxia earlier than end tidal CO2 detection • Ready at hand = bag valve mask, suction and intubation equipment • Size up the patient for intubation success • Mouth opening, thyromental distance, range of neck motion

  10. Choosing an Agent(s) • Procedure duration • Analgesic requirement • Local vs systemic • Most sedating medications do not control pain • Recovery time • Hemodynamic effects • Side effects

  11. Fentanyl Morphine Hydromorphone Midazolam (Versed) Lorazepam (Ativan) Diazepam (Valium) Opioids and Benzodiazepines • May be used in any combination • Most common combination = fentanyl and • midazolam • Sedating medications are not analgesics

  12. Fentanyl (Sublimaze) • Used for anxiolysis, analgesia, and anesthesia • May cause bradycardia and hypotension • Does not release histamine • Skeletal and chest wall rigidity have been reported after rapid high-dose administration • Dose: 1-10 mcg/kg IV (adult 100-300 mcg) • Onset of action <1 minute, duration of 30 minutes

  13. Opioid Adverse Effects • Respiratory depression • Reverse with naloxone 0.2-0.4 mg for respiratory depression • Histamine release • Itching • Hypotension • Vomiting • May cause bradycardia and hypotension

  14. Midazolam (Versed) Produces amnesia, anesthesia, and anxiolysis No analgesia Commonly used in combination with opioids such as fentanyl Respiratory depression Decreases heart rate and blood pressure

  15. Midazolam: Adult Dosing IV 1 – 2.5 mg over 2 minutes, titrate in 2 minute increments Onset 1 minute, Duration of action 30 minutes Lower dose 50% in > 55 years

  16. Midazolam: Pediatric Dosing PO/PR 0.5 - 0.75 mg/kg Onset 10 - 20 minutes, duration 60 minutes < 6 years old may require 1 mg/kg IM 0.1 – 0.15 mg/kg (max total dose 10 mg) Onset 15 minutes, duration 120 minutes IN 0.2 - 0.5 mg/kg (max total dose 10 mg) Onset 10 minutes, duration 60 minutes Causes mucosal irritation, lidocaine may help

  17. Midazolam: Pediatric Dosing IV (titrate to max total dose 6 mg) 6 months – 5 years 0.05 - 0.1 mg/kg Dose increased because of increased metabolism and enzyme activity 6 – 12 years 0.025-0.05 mg/kg Onset 1 minute, Duration of action 30 minutes

  18. Midazolam Up to 15% of children have a paradoxical reaction Crying, combativeness, agitation, and restlessness

  19. Benzodiazepine Reversal • Romazicon (flumazenil) • Adult • 0.2 mg (2 mL) IV repeat every one minute up to 4 doses • Children • 0.01 mg/kg (up to 0.2 mg) up to 4 doses (maximum total dose of 0.05 mg/kg or 1 mg) • Use caution in patients who are on chronic benzodiazepine therapy • Refractory seizures (status epilepticus)

  20. Propofol (Diprivan) • Mechanism of action • Inhibits NMDA receptors, GABAA receptor agonist • Produces amnesia and anesthesia but not analgesia • Antiemetic (serotonin receptors) • Decreases ICP, cerebral blood flow (increased vascular resistance) and intraocular pressure

  21. Propofol: Dose • IV 0.5-1 mg/kg • Repeat by 0.5 mg/kg increments q 3-5 min • Onset 30 to 60 seconds • Duration 5 to 10 minutes

  22. Cautions Dose dependent hypotension > 30% reduction in SBP and DBP Decreased cardiac output Avoid in egg (emulsifier) or soybean allergic patients Propofol (Diprivan)

  23. Etomidate (Amidate) • Mechanism of action • GABA agonist • No analgesia • Minimal respiratory and cardiovascular effects • Myoclonus in 20-45% • Blocks 11-β-hydroxylation to cause adrenal suppression

  24. Etomidate (Amidate) • Dose > 10 years • 0.1 - 0.2 mg/kg IV repeat 0.05 mg/kg every 3 – 5 minutes • Onset 30 – 60 seconds, Duration 3 - 5 minutes • Decrease dose • Elderly • Liver and kidney dysfunction

  25. Barbiturates GABAA receptor agonist No analgesia Good for non painful procedures such as imaging Sedation in infants Pentobarbital has longer duration of action, multiple routes of administration Methohexital is shorter acting

  26. Barbiturates: Cautions Decreases cardiac output and systemic arterial pressure Peripheral vasodilatation Causes histamine release Rash May cause anaphylactoid reactions Extravasation Pain, edema, erythema and tissue necrosis

  27. Pentobarbital: Adult Dosing • IM 150 to 200 mg • Onset 10 – 15 minutes, Duration 1 – 2 hours • IV 100 mg to total dose 200-500 mg • Onset 1 - 2 minutes, Duration 15 - 45 minutes

  28. Pentobarbital: Pediatric Dosing • Infants (maximum total dose 8 mg/kg) • PO 4 mg/kg repeat 2 - 4 mg/kg every 30 minutes • Children (maximum dose 100 mg) • IM 2 - 6 mg/kg • Onset 10 – 15 minutes, Duration 1 – 2 hours • IV 1 - 2 mg/kg (repeat 1 - 2 mg/kg, every 3 -5 minutes) • Onset 1 - 2 minutes, Duration 15 - 45 minutes • PO/PR < 4 years 3-6 mg/kg • 4 or more years 1.5 - 3 mg/kg • Onset 10 - 20 minutes, Duration 1 – 4 hours

  29. Methohexital (Brevital) • Adults: 0.75 - 1 mg/kg IV repeat 0.5 mg/kg every 2 to 5 minutes • Pediatric (more than 1 month of age) • IV 0.5 mg/kg repeat 0.5 mg/kg every 2 - 5 minutes (max 2 mg/kg) • PR 25 mg/kg every 5 - 15 minutes (max 500 mg) • IV Onset 1 minute, duration 4-6 minutes • PR Onset 5-15 minutes, duration 45 minutes

  30. Chloral Hydrate • Metabolized to trichloroethanol (TCE) by alcohol dehydrogenase • A good agent for those less than 3 years old • Rapidly absorbed • Cautions • Oversedation, respiratory compromise can occur especially at higher doses • Avoid in liver and renal impairment

  31. Chloral Hydrate • Adults PO/PR • 500 - 1000 mg • Children PO • 50 - 75 mg/kg repeat 25 – 50 mg/kg in 30 minutes (Max total dose = 120 mg/kg or 1 g) • Onset 30 - 60 minutes, duration 4 - 8 hours

  32. Ketamine (Ketalar) Dissociative anesthetic similar to phencyclidine (PCP) Provides analgesia Increases heart rate and blood pressure but no respiratory depression Increases skeletal muscle tone Potent bronchodilator, increases bronchial and oral secretions

  33. Ketamine (Ketalar) Emergence reactions occur in up to 30% of adults (elderly, females, doses > 2 mg/kg) Can give midazolam or propofol to decrease reaction Use with caution in psychiatric patients Nausea and vomiting (5 to 15%) Rapid IV push can cause apnea

  34. Ketamine: Dosing Adult 1 - 1.5 mg/kg IV over 1 minute Pediatric IV 0.5 - 1 mg/kg repeat 0.25 - 0.5 mg/kg q10 - 15 minutes IM 2 - 5 mg/kg IV: Onset 30 seconds, duration 5 - 10 minutes IM: Onset 5 minutes, duration 12 - 30 minutes

  35. Ketofol • Using both agents was thought to • Decrease the total amount of medication required to achieve sedation • Decrease hypotension induced by propofol • Decrease respiratory depression induced by propofol • Shorter recovery time • Decrease ketamine induced recovery phase agitation and vomiting

  36. Ketofol • Administered 1:1 amounts • 1 mg/mL propofol with 1 mg/mL ketamine • May be associated with increased respiratory depression than with propofol alone

  37. Dexmedetomidine (Precedex) • 2-agonist • Sedative, anxiolysis, analgesic • Use with caution in patient’s with liver and kidney problems • No studies have looked at its use in painful procedures • Has analgesic properties

  38. Dexmedetomidine (Precedex) • Does not have respiratory depression • Does not interfere with EEG findings • Adverse effects • Hypertension then hypotension • Bradycardia • Sinus arrest

  39. Dexmedetomidine: Dose • 1 mcg/kg IV over 10 minutes then 0.6 mg/kg/hour (titrate 0.2 to 1 mcg/kg/hour) • Dosing that appears to be the best in > 2 years old • 3 mcg/kg over 10 minutes then 2 mcg/kg/hour infusion

  40. 32 year old man playing basketball • Fell backward and has severe right shoulder pain • Holding his right shoulder • There is an obvious deformity to the right shoulder

  41. 10 month old girl fell from a bed onto a concrete floor • Mother is unsure if there was loss of consciousness • Crying and agitated during the examination

  42. 65 year old man in a motorcycle accident • Posteriorly dislocated knee that requires reduction because his pulses are diminished • History of CAD, DM, Afib, HTN, hypercholesterolemia, COPD, hypothyroidism

  43. Summary • Choose an agent that will adequately sedate the patient for the procedure duration and lowest risk for adverse events • Most sedating medications do not control pain • Evaluate patient and have all resque equipment ready for use • Consider co-morbid conditions that may impact your choice of agents

  44. References • Tobias JD, Ross AK. Intraosseous infusions: a review for the anesthesiologist with a focus on pediatric use. Anesth Analg. 2010 Feb 1;110(2):391-401. • Sivilotti ML, Messenger DW, van Vlymen J, Dungey PE, Murray HE. A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air. CJEM. 2010 Sep;12(5):397-404. • Mandt MJ, Roback MG, Bajaj L, Galinkin JL, Gao D, Wathen JE. Etomidate for short pediatric procedures in the emergency department. Pediatr Emerg Care. 2012 Sep;28(9):898-904. • Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, Willman E. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012 Jun;59(6):504-12.e1-2. Epub 2012 Mar 7. • Smally AJ, Nowicki TA, Simelton BH. Procedural sedation and analgesia in the emergency department. Curr Opin Crit Care. 2011 Aug;17(4):317-22. • McMorrow SP, Abramo TJ. Dexmedetomidine sedation: uses in pediatric procedural sedation outside the operating room. Pediatr Emerg Care. 2012 Mar;28(3):292-6. • Lexi-Drugs

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