Moderate Conscious Sedation

1. Moderate �Conscious� Sedation/Analgesia in the Pediatric Patient  Cindy Asher, RN, CNS The Children�s Medical Center

2. You are preparing to sedate a 5-year-old girl for bone marrow aspiration. The child has suspected acute lymphoblastic leukemia. What information do you need to develop a safe plan for sedation of this child? Does this patient need sedation, analgesia, or both? What agents can you use to achieve your goals safely? What monitoring does this child require before, during, and after the procedure?

3. The objectives of this module are: To identify components of a presedation assessment and plan appropriate monitoring of patients. To explain the difference between sedation and analgesia and the indications for each.

4. The objectives of this module are: (cont.) To describe common adverse effects of sedative and analgesic agents. To explain the post procedure monitoring guide-lines including criteria for discharge.

5. Ill or injured children frequently require sedation and analgesia. For many years hospitalized young children, especially infants, were inadequately treated for pain and anxiety. Recent physiologic observations show that the very young are actually more sensitive to pain than adults.

6. Sedation and analgesia are not benign treatments; they can have adverse consequences, especially if used incorrectly. The Joint Commission on Accreditation of Hospital Organizations, American Society of Anesthesiologists, American College of Emergency Physicians, and American Academy of Pediatrics emphasize that sedation should be administered in a safe environment by personnel with appropriate training and credentials.

7. There is a difference between sedation and analgesia Sedation reduces the state of awareness. Many sedatives produce amnesia, the inability to remember. (Benzodiazepines, barbiturates - sedative agents have no analgesic effects) Analgesia reduces or eliminates the perception of pain and most have sedative effects. (Narcotics are primarily analgesics; examples include Morphine and Fentanyl)

8. Types of Sedation The American Society of Anesthesiologists and JCAHO Define 4 Levels of Anesthesia Minimal sedation (anxiolysis): A drug-induced state during which patients respond to verbal commands. This level of sedation may impair cognitive function and coordination. Minimal sedation does not affect ventilatory or cardiovascular function.

9. Types of Sedation The American Society of Anesthesiologists and JCAHO Define 4 Levels of Anesthesia (con�t.) Moderate sedation/analgesia (formerly called �conscious sedation�): A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or with light tactile stimulation. The patient requires no interventions to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

10. Types of Sedation The American Society of Anesthesiologists and JCAHO Define 4 Levels of Anesthesia (cont.) Deep sedation/analgesia: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposely to repeated or painful stimulation. This level of sedation may impair the patient�s ability to independently maintain ventilatory function. A patient may require assistance to maintain a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

11. Types of Sedation The American Society of Anesthesiologists and JCAHO Define 4 Levels of Anesthesia (con�t.) General anesthesia: A drug-induced loss of consciousness during which patients cannot be aroused even by painful stimulation. This level of sedation includes general anesthesia and spinal or major regional anesthesia. It does not include local anesthesia. General anesthesia frequently impairs the ability to independently maintain ventilatory function. Patients often require assistance to keep their airway patent. Patients may need positive-pressure ventilation because general anesthetics may depress spontaneous ventilation and neuromuscular function. General anesthesia may impair cardiovascular function.

12. Continuum of Depths of Sedation

13. Consent Moderate �conscious� sedation must only be performed after appropriate consents are obtained. It is the responsibility of the physician, dentist or APN practitioner providing the sedation to initiate a conversation regarding informed consent. The discussion should be with the patient�s legal guardian and/or patient and the discussion should include the need for conscious sedation and the risk, benefits and alternatives (informed consent) to the sedation process. Documentation of the informed consent discussion should be included in the patient�s medical record. (The Written Consent Form �Consent for Surgery, Anesthesia, Sedation, Blood Product Administration and/or other Special Procedure� is utilized to document the patient�s or legal guardian�s signature.)

14. Pre-Sedation Evaluation Includes a History/Physical and an Immediate Pre-Sedation Assessment Before moderate �conscious� sedation is administered, an appropriate licensed practitioner shall perform a health evaluation, and significant findings recorded in the sedation record. This may be performed by the referring physician within 30 days prior to the sedation for the diagnostic of therapeutic procedure.

15. Pre-Sedation Evaluation Includes a History/Physical and an Immediate Pre-Sedation Assessment (con�t.) If the history and physical is performed prior to the day of the moderate �conscious� sedation, it must be reviewed at the time of treatment; and any interval changes in the patient�s status noted. The purpose of the evaluation is to identify patients at an increased risk for complications based on their past history, (previous sedation and/or anesthesia history) their current state of general health and any pertinent physical findings that may influence the safety, known drug reactions and success of their sedation.

16. Physical Examination(Airway/Breathing/Circulation) The pre-sedation physical exam should include evaluation of the ABCs: airway patency and the need for support, breathing pattern and breath sounds, and a cardiovascular exam focused on heart sounds and distal perfusion.

17. Physical Examination(Airway/Breathing/Circulation) (con�t.) When you evaluate the airway you should look for characteristics that increase the risk of airway obstruction during the procedure. In particular, you should check for a large tongue, micrognathia (small lower jaw), limited airway opening, severe obesity, excessive secretions, snoring, and decreased airway protective reflexes. Carefully evaluate breath sounds and work of breathing to ensure that the patient�s respiratory status is not compromised. Document baseline oxygen saturation by pulse oximetry. Assess baseline heart rate, heart sounds, and distal perfusion (skin temperature, color, and capillary refill.) Examine other organ systems if the patient�s history suggests potential problems.

18. Anesthesiologists often assess sedation risk using the ASA system. This system classifies risk on a scale of I to V (See Table 2). For patients in ASA Class III or higher, consult an airway or sedation specialist before elective sedation. Class ASA Score Selection Criterion I A healthy patient. II A patient with mild systemic disease, no functional limitation. III A patient with severe systemic disease that limits activity but is not incapacitating. IV A patient with an incapacitating systemic disease that is a constant threat to life. V A moribund patient not expected to survive 24 hours with or without operation.

19. An immediate pre-sedation assessment includes the following information: Allergies, Medications, Past history (focus on airway/cardiopulmonary reserve), Last meals and Events (leading to the sedation). This mnemonic spells AMPLE.

20. In general, a patient should not undergo elective sedation for a procedure within six hours of eating solid foods or drinking milk. Clear Liquids 2 Hours Breast Milk 4 Hours Formula/Light Solids 6 Hours The above guidelines are recommended to allow gastric emptying prior to the procedure. Patient�s with known gastro-esophageal reflux, esophageal dysmotility, impaired or delayed gastric emptying (i.e., diabetics) or known of suspected airway problems may require a longer period of pre-procedure fasting in order to minimize risks of aspiration of gastric contents and may benefit from appropriate pharmacological treatment to reduce gastric volume and increase gastric pH.

21. Non-elective situations When proper fasting has not been assured, the increased risks of sedation must be carefully weighed against its benefits, and the lightest effective sedation should be used. An emergent patient may require protection of the airway before sedation. If the responsible physician has questions regarding the appropriateness of sedation in an emergent or non-elective situation, consultation with the anesthesia staff is strongly encouraged.

22. Monitoring and Training of Personnel The level of monitoring required during the procedure depends on the anticipated and subsequently observed level of sedation. In all cases a clinical staff member trained in sedation practice must be present to observe the patient and document his/her status; this designated provider should not perform the procedure. This staff member must be able to recognize airway compromise and provide airway and breathing support (open the airway, administer oxygen, and begin noninvasive ventilation) if required. The clinical staff member must complete PALS (Pediatric Advanced Life Support) and the Moderate �Conscious� Sedation module.

23. Equipment - Any area of the hospital where sedation is administered must have appropriate equipment available. This equipment includes: Emergency code cart in immediate vicinity. Oxygen delivery system including ventilation bag, appropriate sized masks, oxygen, wall suction equipment.

24. Equipment - Any area of the hospital where sedation is administered must have appropriate equipment available. This equipment includes: (con�t.) Monitoring equipment, which includes a stethoscope, automated blood pressure machine, cardiac monitor with rhythm preferred, and pulse oximeter. Defibrillator readily available. Drug antagonist readily available (available in Code Carts).

25. Sedation Method Non-Pharmacologic Measures A number of nonpharmacologic adjunctive techniques can decrease anxiety and pain perception in children. These techniques include explanation and preparation before the procedure, distraction, visual imagery, and hypnosis. Many of these techniques are used at The Children�s Medical Center. Child Life may be available to assist as needed.

26. Medications Selecting a Sedative Agent There are a number of features to consider when selecting a sedative agent. Sedatives can provide three distinct effects: sedation, analgesia or amnesia. Select a sedative to treat anxiety, an analgesic to treat pain, and an amnesic to prevent memory of the procedure.

27. Medications (con�t.) Medications Sedation Analgesic Amnesia Barbiturates +++ - - Benzodiazepines +++ - +++ Narcotics* ++ +++ - Ketamine +++ +++ + Ketorolac - +++ - Propofol +++ - + Chloral Hydrate ++ - - ** Different narcotics produce different levels of sedation. For example, when given in an equi-analgesic dose, morphine provides deeper sedation then fentanyl. The sedation medication is titrated as indicated to the patient�s response and the planned procedure. The Sedation Formulary provides suggested guidelines for dosing. The final order for medication rests ultimately with the ordering physician. The Sedation Formulary offers suggested dosing ranges and intervals between doses. Because the sedation response is a continuum, individual patient requirements may exceed the suggested ranges. (Refer to the CMC Policy - Moderate �Conscious� Sedation/Analgesia)

28. Barbiturates Short-acting barbiturates (i.e., pentobarbital) are sedative-hypnotic agents. They have a rapid onset of action when given intravenously (1 to 5 minutes) and a short duration of action (15 to 60 minutes). None has analgesic properties. A short-acting barbiturate is typically the sedative of choice for patients with head trauma, status epilepticus, or suspected increased intracranial pressure (ICP) because they decrease brain oxygen consumption and ICP. Side effects of barbiturates include dose-dependent myocardial depression and hypotension. You can reduce these adverse effects by decreasing the rate of administration and by providing isotonic crystalloid volume infusion.

29. Barbiturates (con�t.) You should generally avoid use of these drugs in hypotensive or hypovolemic patients. If you use barbiturates in these patients, decrease the dose by at least half. Other adverse effects include respiratory depression (enhanced by benzodiazepines and narcotics), bronchospasm, cough, laryngospasm and anaphylaxis. You should usually avoid use of barbiturates in children with severe or acute asthma because these drugs stimulate histamine release.

30. Benzodiazepines Benzodiazepines are sedative-hypnotic agents with potent amnestic effects. When used alone, they are very safe because their mechanism of action is to accentuate inhibitory pathways in the brain. Benzodiazepines potentiate narcotics. As a result, it may be possible to decrease the dose of the narcotic and still provide an effective sedation. However, when combined with other agents, benzodiazepines may have potent sedative effects and may suppress ventilation.

31. Benzodiazepines (con�t.) Benzodiazepines can cause respiratory depression, especially with concomitant use of barbiturates or narcotics. Occasionally a paradoxical excitatory reaction occurs. Hypotension occurs less frequently with these drugs than with barbiturates. For patients who are hemodynamically unstable (i.e., hypotensive or hypovolemic), you should decrease the recommended dose (typically by 50%). Like barbiturates, benzodiazepines possess no analgesic properties.

32. Narcotics Narcotics remain the gold standard for treatment of severe pain. Morphine is a common choice. It has been widely and safely used in infants and children. Pruritus occurs in some patients. Hemodynamically compromised patients may develop hypotension. Both effects are mediated by histamine release. Use caution in patients with severe or acute asthma because of the histamine release.

33. Narcotics (con�t.) Fentanyl, a synthetic narcotic, also has been widely used in children. It is 50 to 100 times more potent and has a shorter duration than morphine, and it produces less histamine release. The hemodynamic stability associated with fentanyl and its closely related analogs makes it a preferred agent in cardiovascular surgery. An unusual complication, chest wall rigidity, may occur with large doses (usually >5 microgram/kg) given rapidly, especially in infants. You may need to use neuromuscular blockade and tracheal intubation to treat this complication.

34. Narcotics (con�t.) Meperidine has also been used in children. One of its metabolites causes central nervous system excitation and may cause seizures. Use of other narcotics is preferable. The most common adverse effects of narcotics are hypoventilation, apnea, and hypotension. The incidence of apnea is higher in very young infants (less than 2 months old) than in older infants and children. To support a patient with apnea or hypoventilation, open the airway as needed, provide assisted ventilation, and give naloxone, a specific narcotic reversal agent. Other potential side effects of all narcotics include nausea, vomiting and constipation.

35. Other Medications Dissociative anesthetics (Ketamine) Ketamine is a dissociative anesthetic that produces a cataleptic (i.e., trancelike) state in which the eyes remain open with a slow nystagmic gaze. Patients are non-communicative but they appear awake. Ketamine, a phencyclidine derivative, produces potent analgesia and rapid sedation; it preserves respiratory drive and airway protective reflexes when used in appropriate doses. Ketamine can produce general anesthesia when given in sufficient doses. Its duration of action is variable (15 to 60 minutes). Use the lower dose range for hemodynamically compromised patients.

36. Other Medications (con�t.) Ketamine-induced catecholamine release helps maintain blood pressure. It may decrease or protect against bronchospasm and improve ventilation in asthmatic patients. These beneficial effects may not occur in catecholamine-depleted, chronically ill patients. Adverse effects of ketamine include increased systemic, intracranial, and intraocular pressures; hallucinogenic emergence reactions (more frequent in adults than children); laryngospasm; and excessive airway secretions.

37. Chloral Hydrate Chloral hydrate is a hypnotic (sleep-inducing) agent that has been used extensively for sedation of children. Chloral hydrate has no analgesic activity and it has minimal respiratory depressant effect when appropriate doses are used. For these reasons it is a frequent choice for children who require a prolonged diagnostic imaging study ( i.e., nuclear medicine or MRI scan). It is most useful in children less than 3 years old.

38. Chloral Hydrate (con�t.) In some children chloral hydrate may have a paradoxical excitatory effect. The onset of action is relatively slow and sometimes unreliable. Some children experience prolonged sedation, necessitating prolonged observation and monitoring. Because of these limitations, short-acting barbiturates are often preferable for sedation for radiographic procedures.

39. Reversal Agents Although you should be familiar with specific reversal agents of narcotics and benzodiazepines to provide safe sedation, you should rarely need to used these agents. If respiratory depression occurs during sedation, you should immediately open and clear the airway. Then provide assisted ventilation and 100% oxygen as needed. Beware of the adverse effects of reversal agents. Weigh the benefit of immediate reversal against provision of respiratory assistance until the adverse effects of the narcotic or benzodiazepine dissipate. If you decide to give a reversal agent, consider the following agents. For narcotic reversal: Naloxone For benzodiazepine reversal: Flumazenil Note that the half-life of the reversal agent is frequently shorter than the half-life of the sedative agent. Observe for recurrence of sedation after the effects of the reversal agent dissipate.

40. Naloxone Naloxone is the prototypical narcotic receptor antagonist. When you suspect that respiratory depression is caused by narcotic effect, use naloxone in small doses (1 to 10 microgram/kg). This dose will maintain some analgesia for the underlying pain. Note that this dose is intentionally much lower than the dose recommended for immediate and full reversal of narcotic poisoning (i.e., 100 microgram/kg or 0.1 microgram/kg). If the initial dose is ineffective, repeat titrated doses every 1 to 2 minutes. You may give naloxone by the IV, IM or tracheal route.

41. Naloxone (con�t.) Potential Adverse Effects of Naloxone Naloxone may cause adverse effects. For example, naloxone may cause acute pain in patients receiving analgesics. It can result in sudden hypertension and acute pulmonary edema. Correction of hypercarbia before administration of naloxone may minimize the risk of this complication. Naloxone has a shorter duration of action than many narcotics, so you may need to give repeated doses of naloxone to treat the narcotic overdose.

42. Flumazenil Flumazenil, a benzodiazepine receptor antagonist, can reverse benzodiazepine-induced respiratory depression and paradoxical excitatory reactions. It is ineffective for narcotic reversal. Providers generally give flumazenil in doses of 0.01 to 0.02 mg/kg; you may repeat these doses every 1 to 2 minutes up to a maximum dose of 1 mg. Like naloxone, flumazenil may have a shorter duration of action than the sedative. The patient will require prolonged observation to ensure that respiratory depression does not recur. Use caution if the patient has a history of seizures because flumazenil may induce seizures.

43. Pre-Procedure Assessment by the Clinical Staff The initial assessment must be completed by a registered nurse. The goals of the pre-procedure assessment include: collection of data through assessment and interview; provision of accurate information to the patient and family; assurance of appropriate pre-procedure compliance; improving lines of communication between the physician/other clinical staff and the patient/family, provide emotional support; reduce anxiety; verify patient identification and planned procedure; review history and physical; interview patient/family for relevant medical/surgical/ adverse medication history; obtain written consent and develop the nursing care treatment plan. All documentation occurs on the Moderate �Conscious� Sedation record.

44. The registered nurse is responsible for initiating the prescribed plan for the patient: Vital signs including heart rate with rhythm (preferred), level of consciousness, respiration rate and oxygen saturation. Medication allergies, and sensitivities. Medication history. Patient�s current weight. NPO status. Level of consciousness.

45. The registered nurse is responsible for initiating the prescribed plan for the patient: (con�t.) Medical problems. Physical assessment. IV access, if indicated, and document location with type of IV fluid. Determines physiological evaluation utilizing modified Aldrete guidelines. Any category score >2 must be addressed in the nursing record. Any category score �1�, evaluate patient assessment with the shift coordinator/charge nurse or designee. No patient is sedated if any score is �0� without physician notification and documentation. Verifies pertinent labs.

46. The registered nurse is responsible for initiating the prescribed plan for the patient: (con�t.) Specific medical equipment needs (trachs, pumps). Pregnancy screening. (Female oncology patients who are medically amenorrheic are excluded from pregnancy evaluation.) Written consent documentation. Patient/parent education.

47. Intra-Procedure Monitoring The clinical staff monitoring the patient has no responsibilities other than attending the patient receiving sedation. Prior to the administration of any sedation medication, an assessment is completed. The clinical staff is available to evaluate the patient�s condition every 5 to 15 minutes during the sedation procedure.

48. Intra-Procedure Monitoring(con�t.) This monitoring consists of respiratory rate/rhythm, pulse rate/rhythm, peripheral perfusion, pulse oximetry, and blood pressure. Observation and/or pulse oximetry are utilized instead of blood pressures in certain procedures including, but not limited to, MRI, and CT Scan. The frequency of monitoring depends on the patient�s condition, and is at the discretion of the physician performing the procedure.

49. The clinical staff assesses the level of comfort and patient�s tolerance of the procedure. Also, occurrence of significant events including blood loss, nausea, vomiting, respiratory distress, vagal reaction or diaphoresis must be documented. Patient Positioning - Patient positioning should be checked frequently to ensure a patent airway and to prevent chest restriction. Extremities should be checked as indicated to ensure proper positioning and adequate circulation.

50. Post Procedure Monitoring/Discharge One of the highest-risk periods for sedation-related complications is the recovery phase. For this reason physiologic monitoring should continue during this period. To be discharged, patients should be arousable, at their baseline level of verbal ability, able to sit unassisted (if appropriate for age), and able to follow age-appropriate commands.

51. Post Procedure Monitoring/Discharge(con�t.) Pulse oximeter readings and vital signs should be normal or baseline for that patient. You should document airway patency, protective reflexes, and adequate hydration.

52. Post Procedure Monitoring/Discharge(con�t.) You should document if the patient received any reversal agents (i.e., naloxone of flumazenil), you must observe the patient for at least 2 hours after the last dose of the reversal agent, Other discharge criteria, such as the ability to tolerate fluids, are site specific.

53. The CMC Discharge/Routine Patient Care Status Criteria Before discharge to home or to routine patient care status after sedation and/or or a procedure, the patient must: Have a modified Aldrete score recorded Pre and Post procedure in the first five categories and any other pertinent categories as indicated. (See addendum 2: Moderate �Conscious� Sedation Record) Meet a minimal Post Procedure modified Aldrete score in the following categories: Consciousness - 1 Respirations - 2 O2 Saturation - 2 Activity - 1 Circulation - 2 Obtain a total Score for the above categories must be at least �9� in order to meet discharge criteria.

54. The CMC Discharge/Routine Patient Care Status Criteria (con�t.) Meet the minimal Post Procedure modified Aldrete score in the following categories, if applicable: Temperature - 1 Nausea & Vomiting - 1 Surgical Site - 1 Pain - 2 Have any modified Aldrete category score < �2� addressed in the nursing record. Any category score �1�, must be evaluated with shift coordinator/charge nurse or designee prior to discharge and must be addressed in the nursing record. No patient will be discharged if any score is �0� without physician notification and documentation. The Total Modified Score must be at least �16� in order to meet discharge criteria.

55. Patient Education/Legal Guardian It is important to instruct patients and caretakers to restrict activities such as walking or crawling alone in the first few hours after sedation. Patients should not participate in high- risk activities such as bicycling, skateboarding, skating, roller-blading, or operating any motorized equipment (car, lawnmower, etc.) for at least 8-10 hours after sedation. Patients and families are given CHI sheets which describe post sedation care.

56. Summary Points Safe sedation and analgesia for procedures require careful assessment before administration of any agent. The AMPLE mnemonic is useful to recall the key points of this assessment. Patients with significant ongoing medical or surgical issues (ASA class III or above) should receive sedation under the supervision of an anesthesiologist or other expert sedation provider.

57. Summary Points (con�t.) The level of sedation desired (light, moderate, or deep) and achieved determines the intensity of required monitoring. For all levels of sedation a trained provider should be designated to monitor the patient. Monitoring the patient should be this provider�s only responsibility. There is no one correct agent for all scenarios requiring sedation and analgesia. Providers should be familiar with various agents and alternatives and specific reversal agents.

58. References: ? PALS manual, AHA, 2002 The CMC Moderate �Conscious� Sedation/Analgesia Email-asherc@childrensdayton.org

59. Questions: 1. You need to sedate a child for a procedure. You do not yet know about the child or the specific procedure. Which of the following should be part of all pre-sedation assessments? a. complete blood count b. 12-lead EKG c. chest x-ray d. oxygen saturation by pulse oximetry 2. You are gathering equipment to sedate a child for a painful procedure. Which of the following equipment or personnel is essential for this sedation? a. one provider assigned to both assist in the procedure and monitor the patient b. capnograph (exhaled CO2 monitor) c. appropriately sized resuscitative equipment such as endotracheal tubes, suction catheters, iv equipment. d. soft, flexible suction catheters in sizes 6F and 8F

60. 3. You cared for a child with acute lymphoblastic leukemia who was sedated for bone marrow aspiration. The child is now awake, and her mother asks when she can take her daughter home. Which of the following criteria should the patient meet before discharge after recovery from sedation. a. ability to ambulate unassisted b. ability to follow age appropriate commands c. 1 hour has passed since any reversal agent (i.e., naloxone) was given d. ability to tolerate solids without vomiting 4. You must sedate a child for a painful procedure. The child has a possible closed head injury. Which of the following medications should you avoid in patients with increased intracranial pressure? a. thiopental b. midazolam c. ketamine d. pentobarbital

61. 5. A 5-year-old boy is sedated for bone marrow aspiration. After the child receives midazolam and fentanyl, gurgling respirations develop and oxygen saturation falls to 83%. Which of the following is the most appropriate initial intervention. a. open the airway and provide suction b. perform tracheal intubation using rapid sequence intubation c. administer IV naloxone d. administer IV flumazenil 6. A 4-year old girl requires long term parenteral nutrition. She is scheduled for placement of a central venous catheter. You need to sedate her for the procedure. Essential preparations include: a. a review of the patient�s history, and to obtain a baseline of vital signs b. the administration of a sedative agent only to calm the patient c. making sure that the general consent to admit is signed; no other consent form is required d. identifying that a second health care provider is available to assist if needed

62. 7. A targeted physical exam for sedation includes the following: a. weight for appropriate mediation dosage b. airway assessment c. assessment of cardiac function including heart sounds and skin perfusion d. all of the above 8. Chloral hydrate is a medication used for non-painful procedures primarily in children under 3 years of age. True False 9. Fentanyl is a potent narcotic analgesic which is very useful for painful procedures because it has a shorter duration then other narcotics. True False

63. 10. When administering Fentanyl it is important to remember that: a. it does not have the risk of causing respiratory depression b. an amnesic effect is produced c. rapid administration may cause chest wall muscle rigidity d. the only method of reversing respiratory depression induced by Fentanyl is ventilation 11. Ketamine, a disassociative agent, is: a. likely to cause depression of ventilation b. a drug which doesn�t produce amnesia c. frequently administered in the neonatal period d. contraindicated in patients with a head injury 12. Midazolam (Versed) is an amnesic which may be used alone for painful procedures True False

64. 13. Morphine is potentiated by the following medications: a. antihypertensives b. antibiotics c. benzodiazepines d. Diuretics 14. Pentobarbital (Nembutal) is a barbiturate which causes drowsiness leading to a deep sleep. True False 15. All sedation medications are titrated to the patient�s response and given in incremental dosages. True False