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SEDATION ISSUES
IN ENDOSCOPY
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ALAN BREWSTER CRNANorthland Anesthesia
North Kansas City Hospital
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No Declarationsor
Conflicts of Interest
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Did You Know?
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March 21
80th day of the Year
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285 days till 2016
14 Days till the next full moon
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Objectives
You will have a better understanding of pharmacy products that you may encounter
The environment you work in will be ready to handle most type of sedation cases
Special considerations when conducting moderate sedation
Take away one item you may have learned today and use or at least remember in practice
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se·da·tionsəˈdāSH(ə)n/nounnoun: sedationthe administering of a sedative drug to produce a state of calm or sleep.
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Definitions
Minimal Sedation
Moderate Sedation
Deep Sedation
Anesthesia
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Minimal Sedation
Create Anxiolysis
A drug induced state during which patients respond normally to verbal commands
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Moderate Sedation
Conscious Sedation
A drug induced depression of consciousness during which the patient responds purposefully to verbal commands
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Deep Sedation
AKA ‘Room air general’
A drug induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated or painful stimulation
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Anesthesia
A drug induced loss of consciousness during which patients are not arousable, even with painful stimulation
-CV changes-Loss of airway reflexes
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Moderate Sedation
What is it?
Why is it needed?
Where can it be carried out at?
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Moderate Sedation
A technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function
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Why is it needed?
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Exhibit A
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Exhibit B
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Exhibit C
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Which would patients prefer?
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OR
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Which would you prefer?
As a health care provider?
Being the patient?
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OR
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What we see
Vs
What they think
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In reality
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In the Patient’s mind
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Conscious SedationWhere can it be carried out at?
GI lab
ICU
Radiology
ER
Cath Lab
Patient’s room
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Behind the scenes
Goals-
Policies Standing orders
Safety
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Goals
Patient Satisfaction
GI Physician Happiness
Safety of Patient/ Staff
Completing the Mission
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Policies
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Policies
Per Hospital
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NKC Hospital Policy
Policy
Appendages
Monitor Tools
Summary Tools
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Policies
Per Unit
Per Physician
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Safety
Patient Safety– *Number 1 priority* Positioning Corneal Abrasions Delirium
Staff Safety
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Distractions
How easy is to be distracted?
-Procedure Screens-Monitors-Music-Social Interaction-’Your’ Day
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Risk vs Benefits
Benefits? Risk? Airway Obstruction
Apnea
Hypotension
Adverse incident
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Did You Know?
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March 21 Birthdays
Johann Sebastian Back
Ronaldinho
Timothy Dalton (007)
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What do you want to know?
NPO status Allergies, Allergens Medications Health issues of the patient Environment Procedure Type Staffing Issues
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NPO Status
Allergies
Medications Home
Beta Block, antihypertensive, blood thinners Did they take?
Floor meds Herbal meds
Procedure Type
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Health Issues
Acute Chronic
Single organ involvement Multi organ dysfuction
Unexpected Unexplained
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Health issues
Hypertension Heart Defects Renal History of stroke or transient ischemic
attack (TIA) (certain oral sedation methods may trigger a TIA)
Neuromuscular disorders (such as muscular dystrophy)
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Did You Know?
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Today in History
2006 Twitter founded
1970 First Earth Day
1963 Alcatraz Closed
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Patient Factors
Age
Size
Pathophysiology Single organ issues
Multi organ issues
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What if they looked like
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How would you handle each of these or others physically challenging
patients?
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Boy Scout Motto
Be Prepared!
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Environment
Pyxis Oxygen Source Suction Monitor Airway equipment
Ambu bag Code Cart
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Take One of those Items Away
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RECIPE FOR
DISASTER!
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Don’t Forget!
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Murphy’s Law
1. If anything can go wrong, it will.
2. If there is a possibility of several things going wrong, the one that will cause the most damage will be the first one to go wrong.
3. If anything just cannot go wrong, it will anyway.
4. If you perceive that there are four possible ways in which something can go wrong, and circumvent these, then a fifth way, unprepared for, will promptly develop.
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Murphy’s Law continued
4.5 An IV will work fine in the holding area, but when you get to your procedure room, it will not work fine and will stop working when you need it the most.
5. Left to themselves, things tend to go from bad to worse.
6. If everything seems to be going well, you have obviously overlooked something.
7. Nature always sides with the hidden flaw.
8. Mother nature is a bitch.
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Procedure Type
EGD
Colonoscopy
ERCP
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Issues That May Occur
EGD Aspiration Larygospasm Bradycardia Hypotension Apnea
Sudden Stimulus phenomenom
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Colonoscopy Vagal reflex Hypotension Aspiration Hypotension Apnea
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ERCP Issues
Positioning
Airway Control
Length of Procedure
In a nutshell- The worst candidate for the most aggressive procedure.
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Aspiration Larygospasm Bradycardia Hypotension Apnea
Sudden Stimulus phenomenom
Allergic reaction to contrast dye
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ERCP
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Staffing Issues
Experience
Trying to more with less personnel
Call crew
Safety in Transfering
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Did You Know?
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Today in History
U2 released ‘With or Without You’
Madonna released ‘Like a Prayer’
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Music
Soothes the Savage Soul
Decreases Stress in Patient
Decreases Stress in Staff
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What you should know and understand
What you are giving How much am I giving Why are you giving What happens if ……… Plan B?
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Sedation
Who do we have to thank for what we use today?
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Babylonians
Egyptians
Indians
?????
Romans
Greeks Chinese
Mayans?
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The Beginning of Modern Day Sedation Medications
Herbal
Opium
Alcohol
Combination
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Opium
Fentanyl Morphine
DemerolOpium Synthesis
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Pharmacy 101
Sedation agents Midazolam (Versed)
Synthesized in 1975 Diazepam (Valium) Lorazepam (Ativan)
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Medications
Benzodiazepenes Narcotics Local Anesthetics Others
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Benzodiapenes
Interferes with formation and consolidation of memories of new material and may induce complete anterograde amnesia
Binds to GABA-A receptor (CNS)
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Desired Effects
Sedation Hypnotic Anxiolytic Anticonvulsant Amnesiac Muscle Relaxant
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Side effects
Drowsiness Dizziness Decreases alertness
and concentration Hypotension Trembling
Nausea/Vomiting Confusion Blurred Vision Hypoventilation
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Special Consideration
Myasthenia Gravis COPD OSA Personality Disorders Elderly ETOH, controlled substance abuse Pregnancy
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Narcotics
Greek -- ‘to make numb’ --causing loss of feeling or paralysis
Predates recorded history
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Narcotics
Fentanyl (Sublimaze) Meperadine (Demerol) Morphine Dilaudid
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Desired Effect
↓ Perception of Pain ↓ Reaction to Pain ↑ Pain Tolerance
Relieve Pain Dulls senses Induces sleep
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Drug Potency of Narcotics
Morphine 1
Meperidine 0.1
Hydromorphone 10
Fentanyl 75-125
Sufentanil 500-1000
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Side effects
Nausea, Vomiting Itching Urinary Retention Constipation Drowsiness Dizziness
Euphoria Decreased
respiratory effort Cough Suppression
good? bad? Allergy?
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Local Anesthetics
Lidocaine Spray Viscous
Benzocaine Spray
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Other pharmacy agents
BenadrylReglanOndansetronCompazinePhenergan
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Interactions
Synergistic effects 1 + 1 does not always = 2
Unexpected reactions
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You can always give more, but…
TitrateVigilancePatienceAnticipate the stimulus
Every Patient is different
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Things you want to Know!
Are other medications on board?
Narcotics
Sedatives
Recreational drug usage
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Rescue Medications
Where are they at?
Which one do I administer?
How much do I give?
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Antagonist agents
Benzodiazepines Flumazanil
Narcotics Narcan Stadol Nubaine
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Antagonist potential problems
Chronic benzo users
Acute pain patients
Chronic pain patients
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ABC’STake care of A and B
you will avoid C
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Airway
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Airway issues OSA (obstructive sleep apnea
Did they bring their CPAP machine How often do they use it
Jaba the Hut Previous trach
How are you going to manage it?
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Breathing
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Breathing
O2 delivery system
Are they currently on O2?
Do they have limited reserves?
Do they use CPAP, BiPAP?
Do they use it at home?
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Circulation
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Circulation
Monitors are our best friend The Up, downs and every direction
Pulse Blood pressure O2 Saturation
Home Medications What do they take Did they take morning meds?
What are we going to do about it?
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Fluid Volume
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Bowel prep
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Circulation
Fluid deficit
Bowel prep
Chronic dehydration
Disease process
Is Their Tank Empty?
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Sedation Needs
Young vs Old
Healthy vs Sick
Male vs Female
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The needs of our population
Are they the same?
Who needs more?
Who needs less?
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Same age Same size Same health Same mom
Do they need the same amount of medication?
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The Young
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The Elderly
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The Elderly with Multiple Health Problems
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The Overweight
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Everyone is different
Sedation needs to be tailored to the individual
Don’t be fooled by your previous patient Simple guidelines
Titrate Patience Vigilance Anticipate
The most complex cases are the anticipated simple cases
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Evaluating your depth of Sedation
What signs are you looking for?
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Ramsay Sedation Scale
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Recovery
Airway Oxygenation Vitals stable? Orientation
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Discharge
Are they ready to go forward
To the floor
To home
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Aldrete Scoring system
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No doubts in your mind!
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Did You Know?
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The Month ofMarch is
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Caffeine Awareness Month
Frozen Food Month
Peanut Month
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Anesthesia
More and more have became involved
Benefits Risk Cost Patient Satisfaction Staff Satisfaction
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Anesthesia
My environment How is it different? Should it be different?
Health History Family History
Malignant Hyperthermia Trigger agents- Inhalation agents,
Succinylcholine
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Benefits
Rapid room to scope time Less stress on Room
GI Physican Procedure RN
Quicker discharge times Patient satisfaction
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Risk
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Anesthetic agents
Propofol Etomidate Ketamine Other mediacations
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Propofol
Diprivan
MJ (Michael Jackson White Stuff Milk of Amnesia
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Propofol
DIPRIVAN Injectable Emulsion is an intravenous sedative-hypnotic agent for use in the induction and maintenance of anesthesia or sedation. Intravenous injection of a therapeutic dose of Propofol induces hypnosis, with minimal excitation
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Key things about Propofol
It is a cardiac depressent
Will cause apnea
Irritating to vessels when injected
Apnea and Hypotension
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Etomidate
Etomidate is a short-acting hypnotic, which appears to have gamma-aminobutyric acid (GABA)–like effects. Unlike the barbiturates, etomidate reduces subcortical inhibition at the onset of hypnosis while inducing neocortical sleep
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Etomidate
In a retrospective review of almost 32,000 people, etomidate, when used for the induction of anaesthesia, was associated 2.5-fold increase in the risk of dying than those given propofol
Why? Are we using Etomidate in sicker patients?
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Key items about Etomidate
Less cardiac depressent
Adrenocortical suppression lasting 4-6 hours
May cause myoclonus
Irritable to vessels when injected
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Ketamine
Ketamine is a rapid-acting general anesthetic producing an anesthetic state characterized by profound analgesia, normal pharyngeal-laryngeal reflexes, normal or slightly enhanced skeletal muscle tone, cardiovascular and respiratory stimulation, and occasionally a transient and minimal respiratory depression.
The anesthetic state produced by Ketamine has been termed “dissociative anesthesia” in that it appears to selectively interrupt association pathways of the brain before producing somesthetic sensory blockade.
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Dissociative Anesthesia
Loss of some types of sensation with persistence of others. A loss of sensation for pain and temperature occurs without loss of tactile sense
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Ketmamine Side effects]
Cardiovascular: Arrythmias, bradycardia or tachycardia, hyper- or hypotension
Central nervous system: Ketamine is traditionally avoided in people with or at risk of intrcranial pressure (ICP) due to concerns about ketamine causing increased intracranial pressure. It does not increase ICP more than opioids.
Gastrointestinal: Anorexia, nausea, increased salivation, vomiting
Local: Pain or exanthema of the injection site Neuromuscular and skeletal: Increased skeletal muscle tone
(tonic-clonic movements) Ocular: Diplopia, increased intraocular pressure, nystagmus Respiratory: Airway obstruction, apnea, increased bronchial
secretions, respiratory depression, laryngospasm Other: Anaphylaxis, dependence, emergence reaction
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With Versed pre Ketamine
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Without Versed
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Sodium Pentothal
Rapid-onset short-acting barbiturate general anesthetic that is an analogue of Thiobarbital
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Sodium Pentothal Uses
Anesthesia
Medical induced Coma
Status Epilepticus
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Why is it gone?
Euthanasia
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Others
Benadryl Lidocaine Compazine Phenergan Droperidol
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Did You Know
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March was named for the Roman God "Mars
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Stages of Anesthesia
Stage I--Analgesia. This stage lasts from the beginning of the administration of anesthesia to the beginning of the loss of consciousness.
Stage II--Excitement. This stage lasts from the loss of consciousness to the loss of the eyelid reflex (which marks the beginning of surgical anesthesia).
Stage III--Surgical Anesthesia. Most operations are performed at this stage of anesthesia, which begins following the excitement stage.
Stage IV--Medullary Paralysis. This stage begins when the anesthetic depresses the medulla.
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Stages of Anesthesia
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Your shoes, my shoes
Be prepared Have a mental backup plan Know your rescue plan of action Don’t be afraid to ask for help If needed, say ‘Uncle’ **Stay Calm**
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Humor?
No Humor?
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Anesthesia is compared to
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Moderate Sedation
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Be prepared for an alternate way to land
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Take Home Message
Be Prepared Be Vigilant Expect the unexpected at anytime
Patient Safety is #1 Goal Patient satisfaction
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In Summary
Each and Every Patient is Different in their own way
Know your patient Know what you are administering Be Prepared Be Vigilant Plan B? ALWAYS remember– You can give more,
but you can’t take away what you have given
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Did You Know?
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March 21
National French Bread Day
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QUESTIONS
ANSWERS?
IF you are still awake
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Birth of Anesthesia
March 30,1842- First time ether was used
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