Otto F Sabando DO FACOEPProgram Director

Emergency Medicine ResidencySt. Joseph’s Regional Medical Center

Paterson NJ

Dr MurrayUsing cocktail for sleepJune 25 the following administered:

valium 10 mgativan 2 mg

repeated dosesversed 2mg

repeated dosespropofol 25mg

Procedural Sedation and Analgesia (PSA) Administer sedatives, analgesics, and/or

dissociative agents to induce a state allowing the patient to tolerate an unpleasant procedure while maintaining cardiorespiratory function

Minimal sedation (anxiolysis) Drug induced state during which patients

respond normally to verbal commands Cognitive function and coordination may be

impaired

Moderate sedation (formerly “conscious sedation”) Drug induced depression of consciousness

during which patients respond purposefully to verbal commands either alone or accompanied by light tactile stimulation

No interventions for airway mgt. spontaneous ventilation is adequate along with cardiovascular function

Dissociative sedation: Trans-like cataleptic state induced by

dissociative agent (ketamine) and characterized by profound analgesia and amnesia

Airway reflexes and cardiopulmonary systems are maintained by patient

Deep sedation: Drug-induced depression of consciousness

and respond to painful stimuli Ventilation usually needs to be assisted Cardiovascular function is maintained

General anesthesia Drug-induced loss of consciousness Not arousable by painful stimuli Positive pressure ventilation is usually

required Cardiovascular function may be impaired

Green SM, Krauss B: Procedural sedation terminology: Moving

beyond “conscious sedation.” Ann Emerg Med 39:433,2002

Ideal pharmacologic agent for sedation Effective, rapid onset, easily titratable with

predictable duration of action Quickly eliminated or reversible No adverse effects Easy and painless to administer

Anesthetic agents Propofol (diprivan)

Lipid soluble Onset of action 6-7 min. Resolves rapidly 5-10 min Adult dose: 2-2.5 mg/kg Pediatric dose: 1mg/kg

Side effects: Painful at injection site Respiratory depression

Apnea incidence similar to thiopental, methohexital and etomidate

Cardiovascular Hypotension (peds and elderly)

Allergies Eggs and soy, propofol is contraindicated

Benefits Intractable seizure, trauma patients

Etomidate: Carboxylated imidazole-containing compound Induces sedation through GABA receptors in

CNS Induction agent

Rapid onset 2 min Lacks cardiovascular side effects Pain on injection Adult 0.1-0.3 mg /kg Peds 0.3-0.4 mg/kg

Side effects Myoclonic activity Emergence phenomenon Adrenal suppression with prolonged use

Anxiolytics: Benzodiazepines Treat anxiety, unruly intoxicated patients,

belligerent patients, drug induced psychosis etc.

Anticonvulsant properties No change in intracranial pressure

Midazolam (Versed) .02-.03mg/kg Amnesia Inhibit GABA Onset of action 3

minutes Duration of action

60-120 minutes

Side effects: Decreased respiratory drive Cytochrome P450 inhibitors can reduce

metabolism of versed Elderly and chronically ill patients, reduce the

dose by half

Dissociative agent Ketamine: sedative

analgesic, dissociates cortical and limbic systems Produces sedation,

analgesia and amnesia

1mg/kg

Onset of action 1 minute Effective in asthma/COPD

Bronchdilator effect Emergence reaction

Tx with benzodiazepine Multiple routes of administration

Contraindications to ketamine use: Age of 3 months or younger Active pulmonary infection Procedures resulting in large amounts or oral

secretions or blood History of tracheal stenosis History of angina, CHF, aneurysm,

uncontrolled HTN Intracranial increase pressure, glaucoma Psychiatric illness

Opioids Fentanyl (sublimaze) 80-100 times more

potent than morphine 2-4 mcg/kg titrated in

doses of 0.5-1.0 mcg/kg every 3-5 min

1/3 the dose is used in infants as metabolism is prolonged

Side effects Rigid chest syndrome

Non reported in the EM literature Respiratory depression

Less than morphine or meperidine

Fentanyl Lollipops 10-15 mcg/kg Onset of action 12-30 min. Mean time to discharge 90 min from ED Side effects

Pruritis common Vomiting 10% of patients

Rarely indicated Used in life-

threatening cases Should not be used

for the sake of a more rapid discharge from the ED

Chloral Hydrate: considered as a second line agent Sedative/hypnotic, no analgesic properties

Primarily used for infants and young children for painless diagnostic procedures

Time to sedation: 45-60 minutes

Dose 25-50 mg/kg can be given PR Time to recovery

40 minutes

Side effects: Ectopic ventricular beats seen 10% of patients

Always review the medical history of the patient.

Use certain medications in certain situations and watch for contraindications

Review the dosages with the nurse and make sure the weight base dose is accurate

Always monitor the patient and be prepared for unexpected complications

Make sure the patient is back to baseline prior to discharge