procedural sedation and analgesia

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?