Medications Used for Sedation...Qsedative - hypnotic in large doses Qpatients who chronically take...

Copyright Ron Eslinger 2006

Medications Used for Sedation Medications Used for Sedation byby

NonNon--Anesthetist RNs: Anesthetist RNs:

Ron Eslinger, RN, CRNA, APN, MA

Benzodiazepines

– Most widely used drug for Sedation– Probably work in limbic system and amygdala of

the brain, where fear, anxiety and apprehension arise.

– When Benzodiazepines come to these receptors from the blood stream, they go into the receptor sites and cause specific effects:

Agents Used For Moderate SedationAgents Used For Moderate Sedation

BenzodiazepinesBenzodiazepines

EffectsEffects

anxiolysis ... reduction of anxietyamnesiac ... makes patient have antero-grade amnesia (not retrograde)anti-convulsive ... stops seizuresskeletal muscle relaxationsedative - hypnotic in large doses patients who chronically take Cimetidine (Tagamet) or Ranitidine (Zantac) are especially susceptible to Benzodiazepine overdose these H-2 blocking drugs may dramatically increase the sedative of even small doses of Benzodiazepine.

BENZODIAZEDPINESBENZODIAZEDPINES

Sedative hypnotic

No analgesic properties

Useful for seizures

BENZODIAZEPINES(2)BENZODIAZEPINES(2)

Little respiratory or cardiovascular depression when used alone, but synergistic effects seen when combined with other CNS depressants

Avoid use in pregnancy, alcohol intoxication, glaucoma, other CNS depressants

MIDAZOLAM (VERSED)MIDAZOLAM (VERSED)

Most commonly used sedative used for conscious sedation

3-5 times more potent than diazepam

Rarely precipitates or causes pain on injection (as valium will)

Midazolam (2)Midazolam (2)

Titrate to effect in 0.5 mg increments

2-6 hours30 minutes< 10 minutesOral2-6 hours15-60 minutes5-15 minutesIM

15min. – 6hours3-5 minutes1 minuteIV

Duration of Action

Peak EffectOnset of ActionRoute

Diazepam (Valium)Diazepam (Valium)

Used less than Midazolam

Titrate in 2.5mg increments

Incompatible with other agents, easily precipitates

Diazepam (2)Diazepam (2)

Painful on injection

Peak effect in less than 10 minutes

Long half-life due to metabolites

3-6 hours60 minutes15-60 minutesOral15-60 minutes3-5 minutes1-5 minutesIV

Duration of Action

Reversal for BenzodiazepinesReversal for Benzodiazepines

Flumazenil (Romazicon) (Specific Benzodiazepine antagonist)

Initial Dose: 0.2 mg

Administration Technique:

– Phase One: Initially 0.2 mg IV over 15 seconds. If patient does not reach desired level of consciousness after 45 seconds.

– Phase Two: Repeat dose at one minute intervals until a cumulative dose of 1mg has been administered (this includes initial dose in phase one).

Peak effect:

– 6 to 10 minutes – 80% of the maximum response is seen within 3

minutes. – Anesthesia should be involved if there is no

desired clinical response with the administration of the initial 1 mg dose.

Potential Adverse Reactions:– nausea, vomiting, sweating, hot flashes, agitation,

headache, injection site pain– do not use Flumazenil in patients who chronically take

Benzodiazepines. May precipitate:– tremors– profuse sweating– hypotension– seizure activity

Flumazenil (Romazicon)Flumazenil (Romazicon)

Indications: reversal of benzodiazepines’effects - sedation, respiratory depression, amnesia

Dose: 0.2 mg IV initially, titrate to effect

Caution in patients with seizure disorders - may reverse effects of anti-seizure medications

45-90 minutes

6-10 minutes (but 80% of the maximum response is seen within 3

minutes.) Call anesthesia if there is no

desired clinical response with the administration of the initial

1-2 minutesIV bolus or infusion

Duration of Action

Peak EffectOnset of Action

Reversal Flumazenil (Romazicon)Reversal Flumazenil (Romazicon)

NarcoticsNarcotics

Narcotics– (commonly given along with Benzodiazepines) – are great potentiators of respiratory depression when

mixed. (great synergistic effect)Most Common– Morphine– Fentanyl– Demerol

OpioidsOpioids

No amnestic effects

Provide analgesia and sedation

Adverse reactions: - Respiratory depression - Nausea and vomiting - Pruritis, urticaria- Urinary retention (young males) - Constipation

MorphineMorphine

Dose is up to 0.15 mg/kg

Peak effect in 5-20 minutes, onset time less than one minute, duration 2-7 hours.

Possible histamine release, all of opioid side effects most possible with morphine.

MorphineMorphine

6-12 hours1-2 hoursWithin 1 hourOral

4-7 hours30-60 minutes5 – 10 minutesIM

4-7 hours5 - 20 minutes<1 minuteIV

Duration of Action

Meperidine (Demerol)Meperidine (Demerol)

One tenth the potency of morphine

IV dose is 0.5-1.0 mg/kg

Onset in less than one minute, peak effect in 5-20 minutes, duration 2-4 hours.

Caution in patients with renal/hepatic impairment, Monoamine oxidase inhibitors (MAOIs) (used for depression, isoniazid (TB Treatment)

Meperidine (Demerol)Meperidine (Demerol)

2-4 hours60 minutes15-45 minutesOral

2-4 hours30-50 minutes1 – 5 minutesIM

2-4 hours5-20 minutes1 minutesIV

Duration of Action

Fentanyl (Sublimaze)Fentanyl (Sublimaze)

75-100 times more potent than morphine

Dose 0.7-1mcg/kg

Onset within 30 seconds, peak effect in 5-15 minutes, duration of effects 30-60 minutes

Titrate in 25 mcg increments

Fentanyl (Sublimaze)Fentanyl (Sublimaze)

1-2 hours20 – 30 minutes

5-15 minutesTransmucosal

1-2 hours15-20 minutes5-8 minutesIM

30-60 minutes5-15 minutes<1 minuteIV

Duration of Action

Naloxone (Narcan)Naloxone (Narcan)

Dose: 0.5-1.0 mcg/kg

All opioid effects, inclusive of analgesia, are reversed

Titrate to effect

Avoid rapid reversal - can lead to untoward sympathetic discharge, extreme pain, anxiety, pulmonary edema

Reversal Naloxone (Narcan)Reversal Naloxone (Narcan)

1-4 hours5-15 minutes1-2 minutesIV

Duration of Action

Ketamine (Ketamine (KetalarKetalar))

Dissociative anesthetic/analgesic agent

Derivative of phencyclidine(PCP)

Excellent analgesic and amnestic

Ketamine (2)Ketamine (2)

Indications: Short term procedures requiring intense analgesia

Given IV by the operator, monitored by the monitor

Contraindications: many

Ketamine (3)Ketamine (3)

Contraindications:• Increased ICP (increases ICP)• Corneal lacerations (increases intraocular

pressure)• Children with active URI (stimulates oral

secretions), psychiatric disorders (may cause extreme mood alteration), compromised airways (may induce apnea/anesthesia)

Ketamine(4)Ketamine(4)

Recommended dosages: 0.25-0.5 mg/kg IV, 1-2 mg/kg IM

Onset of action IV <30 sec, IM 5-20 min; peak effect IV 1 min, IM 3-4 min; duration of action IV 5-15 min, IM 12-25 min

5 to 10 minutes

15 to 30 seconds

ImmediateIV

DurationPeak EffectOnset of Action

PropofolPropofol

DIPRIVAN (Propofol) is an intravenous sedative-hypnotic agent commercially introduced in the United States in 1989 by Zeneca Pharmaceuticals. It was the first of a new class of intravenous anesthetic agents - the alkylphenols.

5-10 minutes1 minute40 secondsIV

Duration of Action

PropofolPropofol

Dosage/Administration – Adult dose: 25 – 50mg (0.5 – 1 mg/kg) IV, administered in 10 mg increments over several minutes. Pain on injection is decreased with IV lidocaine, 0.1 mg/kg, added to the diprivan emulsion. Strict aseptic technique must be maintained in handling, as diprivan is preservative free and will support bacterial growth. Diprivan injection should beprepared for single patient use only, just prior to the initiation of each procedure. Discard after opened for 6 hours.

Pediatric dose: 0.5 – 1.0mg/kg infused slowly and titrated to desired effect.

Adverse ReactionsAdverse Reactions

Respiratory effects – respiratory depression, apnea, hiccup, bronchospasm, laryngospasm

Cardiovascular effects –hypotension, arrhythmia, tachycardia, bradycardia, hypertension

CNS effects – headache, dizziness, euphoria, myoclonic/clonic movement, seizures, sexual illusions.

Emergency MedicationsEmergency Medications

Atropine: Increases heart rate by blocking vagal nerve stimulation. IV bolus 0.4-1.0 mg.

Lidocaine: Drug of choice for ventricular dysrhythmias -decreases automaticity. IV bolus 50-100 mg.

Ephedrine: Increases blood pressure and heart rate by indirect cardiac stimulation. IV bolus 5-10 mg.

Questions

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Medications Used for Sedation...Qsedative - hypnotic in large doses Qpatients who chronically take...

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