Return to Contents

 

 

PROCEDURAL SEDATION

 

 

Indications

 

            Procedural sedation is a clinical technique that creates a decreased level of awareness for a patient yet maintains protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis during a potentially painful or frightening procedure.

            Pharmacologic agents used in procedural sedation are of three general classes: sedatives, analgesics, and systemic agents. Using a combination of a sedative/analgesic provides a synergistic combination that generally gives consistent clinical results; using systemic agents provides very rapid sedation and relaxation with some analgesia. Patients should be NPO for at least 4-6 hours prior to procedure if at all possible.

            Patients should be triaged to the appropriate Physical Status Classification before conscious sedation is performed:

 

Class I: Normally healthy

Class II: Patient with mild systemic disease (e.g. hypertension)

Class III: Patient with severe systemic disease (e.g. CHF), non-decompensated

Class IV: Patient with severe systemic disease, decompensated

Class V: Moribund patient, survival unlikely

 

            Procedural sedation is appropriate for patients in Classes I, II and III. Patients in classes IV and higher are better suited for the OR.

 

            Procedures appropriate for procedural sedation include ANYTHING painful: debridement of wounds, placement of central lines, chest tube placement, abscess drainage, reduction of fractures and dislocations.

 

 

Contraindications

 

1.                  Recent (<2 hr) ingestion of large food or fluid volumes

2.                  Physical class IV or greater

3.                  Lack of support staff or monitoring equipment

4.                  Lack of experience/credentialing on part of clinician

 

 

Materials

 

1.                  Monitoring equipment: BP cuff, pulse oximeter, cardiac monitor

2.                  IV access

3.                  Oxygen delivery by nasal prongs or mask

4.                  Resuscitation equipment: Endotracheal tubes, Ambu bag and mask, defibrillator, emergency cardiac drugs, naloxone, flumazenil

5.                  Personnel trained in airway management, and recovery of sedated patients

6.                  Informed consent as appropriate

 

Medication combinations for conscious sedation:

 

1.                  Ketamine, atropine (or glycopyrrolate), and benzodiazepine

2.                  Benzodiazepine and analgesic

3.                  Systemic agents (propofol or etomidate) and analgesic

 

Preprocedure patient education

 

1.                  Discuss with the patient/parent(s)/guardian the need for sedation in light of the presenting clinical situation

2.                  Obtain informed consent

3.                  Explain the major steps of procedural sedation

4.                  Inform the patient of the possibility of transient unpleasant sensations of pain, nausea, dizziness; stress benefits of improved comfort, relaxation, and analgesia

 

NOTE:  Procedural sedation should be appropriate to the procedure being performed. A laceration on a child may require only ketamine, whereas a hip dislocation on an obese adult probably requires a systemic agent and analgesic for proper sedation and relaxation.

 

Procedure

 

Using Ketamine, atropine and a benzodiazepine

-this is an excellent combination for children under 11 years of age. Older children and adults do not require the addition of atropine.

-emergence reactions are more common in adults, and combination treatment with a benzodiazepine may alleviate this

-ketamine is an excellent sedation agent for asthmatics, as it does not cause airway hyperreactivity

 

Time     0                      Attach monitoring equipment and obtain baseline readings

+1 minute         Ketamine 1-2 mg/kg IV OR 3-5 mg IM, PLUS atropine 0.01 mg/kg IV/IM, OR gylcopyrrolate 0.005 mg/kg IM/IV

                                    PLUS midazolam 0.05 mg/kg IV/IM

            +5-10 min        Begin procedure

            +30-120 min    Recover patient

 

 

Using Analgesic and a benzodiazepine

 

Time     0                     Attach monitoring equipment and obtain baseline readings

+1 minute         fentanyl 0.001-0.002 mg/kg IV OR morphine 0.1-0.2 mg IV, PLUS midazolam OR lorazepam 0.05 mg/kg IV

+3-5 min          Begin procedure

+10-120 min    Recover patient

 

 

Using a systemic agent and an analgesic

 

Time     0                      Attach monitoring equipment and obtain baseline readings

+1 minute         Propofol 1-2 mg/kg IV OR etomidate 0.3 mg/kg IV, PLUS morphine 0.05 mg/kg IV (NOTE THE LOWER DOSE OF ANALGESIA…this is due to the synergistic effect of the anesthetic)

+3-5 min          Begin procedure

+10-120 min    Recover patient

 

 

 

 

Reversal of Sedation

 

            Rarely should reversal of agents used in procedural sedation be necessary if they are titrated appropriately.

 

            Naloxone is a competitive antagonist of the opioid receptors; it is used for reversal of narcotic analgesics. Use 0.001 mg/kg IM/IV titrated to effect. Be aware that the duration of naloxone is less than the duration of action for most opiates. Be prepared to re-bolus the naloxone, or use a naloxone drip at .01-.05 mg/min.

 

            Flumazenil is a pure benzodiazepine antagonist, and can be used for reversal of benzodiazepine sedation. Like naloxone, it has a shorter duration of action than the benzodiazepine agents it reverses. Prepare to re-bolus with flumazenil, or run a flumazenil drip at 0.1 mg/min. Use 0.2 mg IV every 2-5 minutes titrated to effect, or up to 2-3 mg in total if needed.

 

Complication, Prevention, and Management

 

1.         Inadequate amnesia or analgesia:

a.                   Dosage of amnesic or analgesic agents are based upon patient weight. Make sure weights are accurate, and dosages are adequate. As a general rule, the elderly need less, muscular young men need more, and agitated children may also require slightly more medication.

b.                  Allow sufficient time for the agents to work. It is tempting to start the procedure(s) immediately upon drug administration, but do allow time to titrate the effect of the sedation medications.

2.                  Decreasing oxygen saturation: apply nasal cannula or a non-rebreather mask for increased oxygenation. Occasionally, a bag-valve-mask with positive pressure ventilation may be required transiently.

3.                  Prolonged recovery: prolonged offset of sedation is dependent on several factors of which the most important are drug distribution in the patient, and the patient’s own clearance of the sedation agents. Be prepared to recover the patient for a prolonged period, with adequate oxygenation and clearance of any airway secretions.

 

Documentation in the medical record

 

1.                  Consent (obtain if possible)

2.                  Indications and any contraindications for the procedure; ASA physical classification

3.                  Medications used, and dosages

4.                  Any complications of “none”

5.                  Who was notified of any complications (family, attending MD)

 

NOTE: Many hospitals have an institutional conscious sedation record which fulfils most of the above criteria.

 

 

Items for evaluation of the person performing this procedure

 

1.                  Indications and contraindications for conscious sedation

2.                  Pharmacology of commonly used agents, and their indications in appropriate situations

3.                  Understanding recovery of patients

4.                  Understanding possible failure of the procedure and why

5.                  Appropriate documentation