PROCEDURAL SEDATION INTERN LECTURE SERIES JULY 2003

PROCEDURAL SEDATIONPROCEDURAL SEDATION

INTERN LECTURE SERIESINTERN LECTURE SERIES

JULY 2003JULY 2003


Procedural sedation and analgesia is a Procedural sedation and analgesia is a complex interaction between the physician complex interaction between the physician nurse, and patient which allows proper nurse, and patient which allows proper administration of drugs to obtund, dull or administration of drugs to obtund, dull or reduce the intensity of pain or awareness.reduce the intensity of pain or awareness.


The administration of drugs by any route is The administration of drugs by any route is intended to allow the patient to maintain intended to allow the patient to maintain airway control independently and airway control independently and continously, but carries the risk of loss of continously, but carries the risk of loss of protective reflexed.protective reflexed.

anxiolysis conscious sedation deep sedation general anesthesia



Relevant History and Physical Exam:Relevant History and Physical Exam:1. Pt age1. Pt age2. H/o abnormalities of major organ 2. H/o abnormalities of major organ

systems, including heart, lung, kidneys or systems, including heart, lung, kidneys or airway ( sleep apnea, snoring, stridor)airway ( sleep apnea, snoring, stridor)

3. Pregnancy test as needed3. Pregnancy test as needed4. Current medications4. Current medications


Relevant History and Physical Exam:Relevant History and Physical Exam:5. H/o any adverse or allergic drug 5. H/o any adverse or allergic drug

reactions with anesthesia or reactions with anesthesia or sedation/analgesiasedation/analgesia

6. H/o prior sedation/ analgesia, including 6. H/o prior sedation/ analgesia, including adequacy of pain control for those adequacy of pain control for those proceduresprocedures

7. H/o tobacco, alcohol, or substance 7. H/o tobacco, alcohol, or substance abuse or useabuse or use


Relevant History and Physical Exam:Relevant History and Physical Exam:8. Vital signs (wt, HR, BP, RR, pulse ox)8. Vital signs (wt, HR, BP, RR, pulse ox)9. Cardiopulmonary exam9. Cardiopulmonary exam10. Airway exam10. Airway exam11. Labs and/or relevant findings that may 11. Labs and/or relevant findings that may

effect plan for sedation/analgesiaeffect plan for sedation/analgesia


Indicators of Potential Problematic AirwayIndicators of Potential Problematic AirwayDecreased mouth openingDecreased mouth openingMicrognathiaMicrognathiaRetrognathiaRetrognathiaSignificant malocclusionSignificant malocclusionDenturesDenturesMacroglossiaMacroglossia


Indicators of Potential Problematic AirwayIndicators of Potential Problematic AirwayNonvisible uvulaNonvisible uvulaDecreased neck flexibilityDecreased neck flexibilityAdvanced rheumatoid arthritisAdvanced rheumatoid arthritisDysmorphic facial featuresDysmorphic facial features

Pierre Robin syndromePierre Robin syndromeTrisomy 21Trisomy 21< 3cm hyoid-mental distance (adult)< 3cm hyoid-mental distance (adult)

Tracheal deviationTracheal deviation


Equipment:Equipment:2 physicians2 physiciansPulse oximetry, continuousPulse oximetry, continuousCardiac monitoring, continuousCardiac monitoring, continuousSedation agentsSedation agentsReversal agentsReversal agentsProcedural consent formsProcedural consent forms


Equipment:Equipment: Intubation materialsIntubation materialsOxygen delivery equipmentOxygen delivery equipmentNurse, continuous monitoringNurse, continuous monitoringAge-appropriate resusciation equipmentAge-appropriate resusciation equipmentPre-measured doses for pediatric patientsPre-measured doses for pediatric patients


Adult Sedation and Analgesia Adult Sedation and Analgesia DrugsDrugs

And And

Reversal AgentsReversal Agents

Adult Sedation and Analgesia DrugsAdult Sedation and Analgesia DrugsAnd And


EtomidateEtomidate



Etomidate:Etomidate:

Recommended dosage: 0.1-0.3 mg/kgRecommended dosage: 0.1-0.3 mg/kgRoute: IV over 30-60 secsRoute: IV over 30-60 secsOnset: ultra rapid 2-3 minOnset: ultra rapid 2-3 minDuration: 1 hourDuration: 1 hour




Considered a general anesthetic; also Considered a general anesthetic; also sedation and amnesticsedation and amnestic

Cardiac, respiratory and BP monitoring Cardiac, respiratory and BP monitoring requiredrequired




Contraindications/ PrecautionsContraindications/ PrecautionsNot approved for kids < 12 yoNot approved for kids < 12 yoAvoid if seizure d/o, N/VAvoid if seizure d/o, N/VMay cause myoclonic jerksMay cause myoclonic jerksPain at injection sitePain at injection site



Fentanyl Citrate (Sublimaze)Fentanyl Citrate (Sublimaze)



Fentanyl Citrate:Fentanyl Citrate:

Dosage: 1-5 mcg/kg induction Dosage: 1-5 mcg/kg induction (50-100 mcg = 1-2 cc)(50-100 mcg = 1-2 cc)

Route: IVRoute: IVOnset: 1.7 minOnset: 1.7 minDuration: 30-60 minsDuration: 30-60 mins



Fentanyl Citrate:Fentanyl Citrate: Potent narcotic analgesicPotent narcotic analgesic

100 mcg (2cc)=10 mg MSO4 or 75 mg Demerol100 mcg (2cc)=10 mg MSO4 or 75 mg Demerol

Acts as respiratory depressant (5-15 mins after Acts as respiratory depressant (5-15 mins after injection)injection)

Reduce dose in elderly and debilitiated ptsReduce dose in elderly and debilitiated pts CNS depressant drugs have additive or CNS depressant drugs have additive or

potentiating effects with fentanylpotentiating effects with fentanyl



Fentanyl Citrate:Fentanyl Citrate:Contraindications/PrecautionsContraindications/PrecautionsLarge doses produce apneaLarge doses produce apneaChest wall rigidity may occur if pushed too Chest wall rigidity may occur if pushed too

quicklyquicklyDuration of respiratory depressant may be Duration of respiratory depressant may be

longer than the analgesic effectlonger than the analgesic effect



Fentanyl Citrate:Fentanyl Citrate:Contraindications/PrecautionsContraindications/PrecautionsMay produce bradycardia and May produce bradycardia and

bronchoconstrictionbronchoconstrictionUse with caution in pts with COPD, liver Use with caution in pts with COPD, liver

disease, kidney dysfunctiondisease, kidney dysfunctionAdverse reactions: hypotension, HTN, Adverse reactions: hypotension, HTN,

emesis, laryngospasmemesis, laryngospasm



Lorazepam (Ativan)Lorazepam (Ativan)



Lorazepam:Lorazepam:

Dose: 0.02-0.05 mg/kgDose: 0.02-0.05 mg/kgRoute: IVRoute: IVOnset: 15 minsOnset: 15 minsDuration: 2 hoursDuration: 2 hours




Useful as anxiolytic, sedation for Useful as anxiolytic, sedation for radiographic procedures, some minor radiographic procedures, some minor surgical procedures (burns, FB removal, surgical procedures (burns, FB removal, laceration repair)laceration repair)




Precautions/ ContraindicationsPrecautions/ ContraindicationsSevere liver diseaseSevere liver diseaseSevere respiratory diseaseSevere respiratory disease

Adult Sedation and Analgesia DrugsAdult Sedation and Analgesia Drugs and Reveral Agents and Reveral Agents

Meperidine (Demerol)Meperidine (Demerol)



Meperidine:Meperidine:

Dose: 0.3-1.5 mg/kgDose: 0.3-1.5 mg/kgRoute: IVRoute: IVOnset: 10-15 minOnset: 10-15 minDuration: 1 ½- 2 hour half-life, effective Duration: 1 ½- 2 hour half-life, effective

duration 2-3 hoursduration 2-3 hours


Meperidine:Meperidine:

Precautions/ ContraindicationsPrecautions/ ContraindicationsMetabolite normeperidine may cause CNS Metabolite normeperidine may cause CNS

toxicity, seizures in sickle cell pts or renal-toxicity, seizures in sickle cell pts or renal-impaired ptsimpaired pts

Contraindicated if pt on MAOIContraindicated if pt on MAOI



Methohexital (Brevital)Methohexital (Brevital)


Brevital:Brevital:

Dose: 1-3 mg/kgDose: 1-3 mg/kgRoute: IVRoute: IVOnset: 1 minOnset: 1 minDuration: 10 minsDuration: 10 mins



Brevital:Brevital:

Discontinue immediately if extravasation Discontinue immediately if extravasation occurs since tissue necrosis can occuroccurs since tissue necrosis can occur

May cause hemodynamic instability and May cause hemodynamic instability and bronchospasmbronchospasm


Brevital:Brevital:Precautions/ ContraindicationsPrecautions/ Contraindications If given intraarterially, thrombosis and If given intraarterially, thrombosis and

gangrene can occurgangrene can occurContraindicated in severe hepatic Contraindicated in severe hepatic

dysfunction or porphyriadysfunction or porphyriaMay cause respiratory depression, May cause respiratory depression,

hypotensionhypotension



Midazolam (Versed)Midazolam (Versed)



Versed:Versed:Dose: 0.05-0.1 mg/kg (1-2 mg)Dose: 0.05-0.1 mg/kg (1-2 mg)

(total dose 0.1 mg/kg)(total dose 0.1 mg/kg)Route: IVRoute: IVOnset: 3-5 minsOnset: 3-5 minsDuration: 2 hr half-life Duration: 2 hr half-life

At total dose 0.1 mg/kg = 60 minsAt total dose 0.1 mg/kg = 60 mins



Versed:Versed: Short-acting benzodiazepine CNS depressantShort-acting benzodiazepine CNS depressant Do not give as a bolus dose; administer over at Do not give as a bolus dose; administer over at

least 2 mins and allow an additional 2 mis to least 2 mins and allow an additional 2 mis to evaluate sedative effectevaluate sedative effect

Reduce dosage in older (>60 yrs) or debilitated Reduce dosage in older (>60 yrs) or debilitated pts.pts.

Causes impairment in memory and recallCauses impairment in memory and recall


Versed:Versed:Precautions/ ContraindicationsPrecautions/ ContraindicationsAssociated with respiratory depression Associated with respiratory depression

and respiratory arrestand respiratory arrestMay cause hypotension from venous May cause hypotension from venous

poolingpoolingContraindicated in pts with acute narrow Contraindicated in pts with acute narrow

angle glaucomaangle glaucoma



Versed:Versed:Precautions/ ContraindicationsPrecautions/ ContraindicationsPts with chronic RF and CHF eliminate Pts with chronic RF and CHF eliminate

versed slowlyversed slowlyPotentiates respiratory depression in acute Potentiates respiratory depression in acute

ETOH intoxicationETOH intoxicationReduce dose by 30% in pts > 60 yo or Reduce dose by 30% in pts > 60 yo or

chronic illnesschronic illness



Morphine SulfateMorphine Sulfate



Morphine Sulfate:Morphine Sulfate:

Dose: 0.03-0.15 mg/kg (2-10mg)Dose: 0.03-0.15 mg/kg (2-10mg)Route: IVRoute: IVOnset: 1-3 min; peak effect = 15 minOnset: 1-3 min; peak effect = 15 minDuration: 3-5 hr half-life/ effective durationDuration: 3-5 hr half-life/ effective duration



Morphine Sulfate:Morphine Sulfate:

Can be given with hydroxyzine 0.5 mg/kg Can be given with hydroxyzine 0.5 mg/kg IM or PO in childrenIM or PO in children



Morphine Sulfate:Morphine Sulfate:Precautions/ ContraindicationsPrecautions/ ContraindicationsBronchospasm, Bronchospasm, respiratory depression,respiratory depression, histamine releasehistamine releaseHypotensionHypotensionbradycardiabradycardia



Morphine Sulfate:Morphine Sulfate:Precautions/ ContraindicationsPrecautions/ Contraindications

Prolonged sedationProlonged sedationGI dysmotilityGI dysmotilityChest wall rigidityChest wall rigidity


Propofol (Diprivan)Propofol (Diprivan)


Reversal AgentsReversal Agents Propofol:Propofol: Dose:Dose:

50-200 mcg/kg/min sedation50-200 mcg/kg/min sedation (2-3 mg/kg induction)(2-3 mg/kg induction) 1-2 mg/kg for orthopedic procedures, joint reduction, 1-2 mg/kg for orthopedic procedures, joint reduction,

burns requiring sedationburns requiring sedation (10 mg/cc concentration)(10 mg/cc concentration)

May be used as an infusion 100-200 mcg/kg/minMay be used as an infusion 100-200 mcg/kg/min (10-20mg/min in a typical adult, titrated for (10-20mg/min in a typical adult, titrated for

effect)effect)



Propofol:Propofol:

Route: IVRoute: IVOnset: 1-2 minOnset: 1-2 minDuration: 5-10 minDuration: 5-10 minTitrate to effectTitrate to effect



Propofol:Propofol:

Use with caution in volume-depleted pts (may Use with caution in volume-depleted pts (may need fluid bolus prior to giving propofol)need fluid bolus prior to giving propofol)

Causes pain on injection so use larger Causes pain on injection so use larger antecubital vein and/or add lidocaine 0.5-1.0 antecubital vein and/or add lidocaine 0.5-1.0 mg/kgmg/kg

Lidocaine may be given w/ propofol drip or as Lidocaine may be given w/ propofol drip or as bolus alonebolus alone



Propofol:Propofol:Precautions/ ContraindicationsPrecautions/ ContraindicationsSide effects: hypotension, bradycardia, Side effects: hypotension, bradycardia,

apnea, N/Vapnea, N/VTransient apnea in up to 40%Transient apnea in up to 40%As propofol as no analgesic properties, As propofol as no analgesic properties,

may need to add 0.1 mcg/kg fentanylmay need to add 0.1 mcg/kg fentanylAnaphylaxis with soy and egg allergyAnaphylaxis with soy and egg allergy






NaloxoneNaloxone



Naloxone (Narcan)Naloxone (Narcan)Dose: 5-10 mcg/kg titrated to desired Dose: 5-10 mcg/kg titrated to desired

effecteffect0.4 mg-2 mg standard historical dose for OD0.4 mg-2 mg standard historical dose for OD

Route: IV, IM, ETRoute: IV, IM, ETOnset: 1-2 minOnset: 1-2 minDuration: dependent upon the dose and Duration: dependent upon the dose and

route of administration, 30-60 min typicalroute of administration, 30-60 min typical



Naloxone (Narcan):Naloxone (Narcan):A narcotic antagonist, preventing or A narcotic antagonist, preventing or

reversing the effects of opoids, including reversing the effects of opoids, including respiratory depression, sedation, and respiratory depression, sedation, and hypotensionhypotension

Titration is preferred to rapid bolusTitration is preferred to rapid bolusMaximum dose = 10 mgMaximum dose = 10 mgOnly applies to suspected unknown ODOnly applies to suspected unknown OD


Naloxone (Narcan):Naloxone (Narcan):Precautions/ ContraindicationsPrecautions/ ContraindicationsThe pt who has responded satisfactorily to The pt who has responded satisfactorily to

narcan should be kept under continued narcan should be kept under continued surveillance; repeated doses may be surveillance; repeated doses may be required as necessary since the duration required as necessary since the duration of action of some narcotics may exceed of action of some narcotics may exceed that of naloxone.that of naloxone.



Reversal AgentReversal Agent

Flumazenil (Mazicon)Flumazenil (Mazicon)



Flumazenil:Flumazenil:Dose: 0.01 mg/kgDose: 0.01 mg/kg

May repeat 60 secs x 3 (0.2 mg)May repeat 60 secs x 3 (0.2 mg)Max dose = 1 mgMax dose = 1 mg

Route: IVRoute: IVOnset: 1-2 minOnset: 1-2 minDuration: 20 minsDuration: 20 mins



Flumazenil:Flumazenil:Use for reversal of benzodiazepine-Use for reversal of benzodiazepine-

induced sedationinduced sedationAdminister slowly to avoid the adverse Administer slowly to avoid the adverse

consequences of abrupt awakening such consequences of abrupt awakening such as dysphoria and agitationas dysphoria and agitation

Repeated doses may be given at 20-min Repeated doses may be given at 20-min intervals as needed to reverse resedationintervals as needed to reverse resedation



Flumazenil:Flumazenil:Maximum dose of 1 mg at any one time; Maximum dose of 1 mg at any one time;

no more than 3 mg in 1 hour.no more than 3 mg in 1 hour.A 1 mg dose sustains antagonism for 48 A 1 mg dose sustains antagonism for 48

minsmins



Flumazenil:Flumazenil:Precautions/ ContraindicationsPrecautions/ ContraindicationsSeizures may occur as reversal of Seizures may occur as reversal of

sedative effects performedsedative effects performedDuration of action of flumazenil is shorter Duration of action of flumazenil is shorter

than versed and other benzosthan versed and other benzosResedation may occur following initial Resedation may occur following initial

reversalreversal


Reversal AgentsReversal Agents Flumazenil:Flumazenil: Precautions/ ContraindicationsPrecautions/ Contraindications Monitoring must be performed for an appropriate Monitoring must be performed for an appropriate

period after initial reversalperiod after initial reversal Contraindicated inContraindicated in

Status epilepticusStatus epilepticus Increased intracranial pressureIncreased intracranial pressure TCA odTCA od Chronic benzodiazepine use (> 2 weeks)Chronic benzodiazepine use (> 2 weeks)



Dissociative AgentsDissociative Agents



Ketamine (Ketalar):Ketamine (Ketalar):Dosage and Route:Dosage and Route:

1 mg/kg sedation (2 mg/kg induction) IV1 mg/kg sedation (2 mg/kg induction) IV2-5 mg/kg IM2-5 mg/kg IM6 mg/kg intra-nasal6 mg/kg intra-nasal6-10 mg/kg PO6-10 mg/kg PO10-15 mg/kg PR10-15 mg/kg PR



Ketamine:Ketamine:Onset:Onset:

IV 1-3 mins with 10-20 mins durationIV 1-3 mins with 10-20 mins duration IM 5-20 minsIM 5-20 mins Intra-nasal 15-30 minsIntra-nasal 15-30 minsPO 15-30 minsPO 15-30 minsPR 15-30 mins PR 15-30 mins



Ketamine:Ketamine:Duration:Duration:

IV 10-20 minsIV 10-20 mins IM, PO, PR and intra-nasal 30-60 minsIM, PO, PR and intra-nasal 30-60 minsAnalgesic duration = 45 minsAnalgesic duration = 45 minsAnesthesia duration = 15-20 minsAnesthesia duration = 15-20 mins



Ketamine:Ketamine:Pre-treatment with glycopyrrolate at 0.01 Pre-treatment with glycopyrrolate at 0.01

mg/kg (or atropine 0.01 mg/kg) to mg/kg (or atropine 0.01 mg/kg) to decrease secretions should be givendecrease secretions should be given

Combine glycopyrrolate with IV, IM or PO Combine glycopyrrolate with IV, IM or PO dose to give all at once; I.e., ,may combine dose to give all at once; I.e., ,may combine in syringe for one injectionin syringe for one injection



Ketamine:Ketamine:Precautions/ ContraindicationsPrecautions/ Contraindications Increases intracranial pressureIncreases intracranial pressurePositive side effect = bronchodilation (can Positive side effect = bronchodilation (can

be used in asthmatics)be used in asthmatics)Hallucinatory emergence reactions are Hallucinatory emergence reactions are

common in adults but uncommon in kidscommon in adults but uncommon in kids


Ketamine:Ketamine: Can treat with versed 0.2 mg/kg concurrentlyCan treat with versed 0.2 mg/kg concurrently Potential for laryngospasm so avoid if active Potential for laryngospasm so avoid if active

pulmonary or upper respiratory infection or pulmonary or upper respiratory infection or excessive salivation or bleedingexcessive salivation or bleeding

Avoid if coronary artery disease or if pt has Avoid if coronary artery disease or if pt has elevated intraocular pressureelevated intraocular pressure

Possible HTNPossible HTN



Adult Drugs For AgitationAdult Drugs For Agitation



Adult Drugs for AgitationAdult Drugs for Agitation

Droperidol (Inapsine)Droperidol (Inapsine)



Droperidol (Inapsine):Droperidol (Inapsine):

Dose: 1-10 mgDose: 1-10 mgRoute: IV or IMRoute: IV or IMOnset: 10 minsOnset: 10 minsDuration: 2 hoursDuration: 2 hours


Droperidol:Droperidol:

Agitated pts, CT scan or procedures on an Agitated pts, CT scan or procedures on an uncooperative patientuncooperative patient


Droperidol:Droperidol:Precautions/ ContraindicationsPrecautions/ ContraindicationsContraindicated if cardiac condution Contraindicated if cardiac condution

abnormalityabnormalityQT prolongation with torsade de pointesQT prolongation with torsade de pointes

Rare hypotensionRare hypotensionRare neuroleptic malignant syndromeRare neuroleptic malignant syndrome



Adult Drugs for AgitationAdult Drugs for Agitation

Haloperidol (Haldol)Haloperidol (Haldol)


Haloperidol (Haldol):Haloperidol (Haldol):Dose: 1-10 mgDose: 1-10 mgRoute: IV or IMRoute: IV or IMOnset:Onset:

IV 10 minsIV 10 mins IM 20 minsIM 20 mins

Duration: 2 hours Duration: 2 hours


Haldol:Haldol:

Agitated, combative patientsAgitated, combative patientsPts requiring rapid sedationPts requiring rapid sedation



Haldol:Haldol:Precautions/ ContraindicationsPrecautions/ ContraindicationsContraindicated if:Contraindicated if:

Cardiac conduction abnormalityCardiac conduction abnormalityHistory of dystonic reactionsHistory of dystonic reactions

Conscious SedationConscious Sedation

Pediatric Sedation and Analgesia Pediatric Sedation and Analgesia Drugs andDrugs and




Methohexital (Brevital)Methohexital (Brevital)

Pediatric Sedation and Analgesia Drugs andPediatric Sedation and Analgesia Drugs andReversal AgentsReversal Agents

Brevital:Brevital:Dose and Route:Dose and Route:

1 mg/kg IV1 mg/kg IV25 mg/kg PR25 mg/kg PR

Onset: IV within 1 min; PR within 2-5 minsOnset: IV within 1 min; PR within 2-5 minsDuration:Duration:

IV lasts 10 minsIV lasts 10 minsPR lasts 45 mins PR lasts 45 mins


Brevital:Brevital:

Discontinue immediately if extravasation Discontinue immediately if extravasation occurs, since tissue necrosis can occuroccurs, since tissue necrosis can occur

May cause hemodynamic instability and May cause hemodynamic instability and bronchospasmbronchospasm


Brevital:Brevital:Precautions/ ContraindicationsPrecautions/ Contraindications If given intraarterially, thrombosis and If given intraarterially, thrombosis and

gangrene can occurgangrene can occurContraindicated:Contraindicated:

Severe hepatic dysfunctionSevere hepatic dysfunctionporphyriaporphyria



Midazolam (Versed)Midazolam (Versed)


Versed:Versed: Dose and Route:Dose and Route:

0.05-0.1 mg/kg IV0.05-0.1 mg/kg IV 0.1 mg/kg IM0.1 mg/kg IM 0.2-0.5 mg/kg intra-0.2-0.5 mg/kg intra-

nasalnasal 0.5-1.0 mg/kg PO/PR0.5-1.0 mg/kg PO/PR

Versed:Versed: Onset and Duration:Onset and Duration:

1-3 min for 1 hour1-3 min for 1 hour 15-30 mins for 1-2 hrs15-30 mins for 1-2 hrs 2-5 mins for 1-2 hrs2-5 mins for 1-2 hrs

10-30 mins for 1-2 hrs10-30 mins for 1-2 hrs


Versed:Versed:Suggested Pedi combo: Versed 0.02 Suggested Pedi combo: Versed 0.02

mg/kg + 1 mcg/kg fentanyl when used IVmg/kg + 1 mcg/kg fentanyl when used IV IV : may repeat 0.1 mg/kg by giving IV : may repeat 0.1 mg/kg by giving

increments of 0.05 mg/kg until adequate increments of 0.05 mg/kg until adequate sedation to a maximum total of 2 mgsedation to a maximum total of 2 mg

IM: use 5 mg/cc concentration to reduce IM: use 5 mg/cc concentration to reduce volume. Max total= 2 mgvolume. Max total= 2 mg


Versed:Versed:PO: max total = 15-20 mgPO: max total = 15-20 mg

Mix w/ small amt juice or w/ tylenol (15mg/kg)Mix w/ small amt juice or w/ tylenol (15mg/kg)Po or intra-nasal, use 5 mg/cc concentration Po or intra-nasal, use 5 mg/cc concentration Syrup (cherry flavored): 0.25-1.0 mg/kg, most Syrup (cherry flavored): 0.25-1.0 mg/kg, most

effective dose 0.5 mg/kg (up to 20 mg) onset effective dose 0.5 mg/kg (up to 20 mg) onset 20 mins; duration 1 hr20 mins; duration 1 hr

Excellent amnestic, anxiolyticExcellent amnestic, anxiolytic



Fentanyl (Sublimaze)Fentanyl (Sublimaze)


Fentanyl:Fentanyl: Dose and Route:Dose and Route:

1-3 mcg/kg IV1-3 mcg/kg IV 1-2 mcg/kg IM1-2 mcg/kg IM 5-10 mcg/kg Oralet5-10 mcg/kg Oralet 1-2 mcg/kg Nasal1-2 mcg/kg Nasal

Dose can be titratedDose can be titrated Oralet: 100, 200, 300, Oralet: 100, 200, 300,

400 mcg400 mcg

Fentanyl:Fentanyl: Onset and Duration:Onset and Duration:

1-2 mins ; peak 10 min1-2 mins ; peak 10 min 7-15 mins; variable7-15 mins; variable 15 mins; 1 ½-2 hrs15 mins; 1 ½-2 hrs 10 mins; 1 hr10 mins; 1 hr


Fentanyl:Fentanyl: Max dose: 5 mcg/kgMax dose: 5 mcg/kg

PO: for wt < 40 kg, dose 5-10 mcg/kg up to max of PO: for wt < 40 kg, dose 5-10 mcg/kg up to max of 400 mcg400 mcg

PO: for wt > 40 kg, give adult dose of 400 mcgPO: for wt > 40 kg, give adult dose of 400 mcg Can cause respiratory depressionCan cause respiratory depression Oralet may cause N/VOralet may cause N/V Can cause bradycardia, hypotension, chest wall Can cause bradycardia, hypotension, chest wall

rigidity rigidity





Naloxone (Narcan):Naloxone (Narcan): 5-10 mcg/kg titrated 5-10 mcg/kg titrated

to desired effect to desired effect IV/IM/ETIV/IM/ET Onset: 1-2 minsOnset: 1-2 mins Duration: 30-60 minsDuration: 30-60 mins

Flumazenil (Mazicon):Flumazenil (Mazicon): 0.2 mg/kg IV with 0.2 mg/kg IV with

onset of 1-2 mins; onset of 1-2 mins; duration of 20 minsduration of 20 mins

Smaller kids= 0.01 Smaller kids= 0.01 mg/kg IVmg/kg IV


Topical Agents:Topical Agents: EMLA Cream (lidocaine 2.5%, prilocaine, 2.5%)EMLA Cream (lidocaine 2.5%, prilocaine, 2.5%)

2.5 gm2.5 gm Venipuncture and venous cannulation, lumbar Venipuncture and venous cannulation, lumbar

puncture, arterial puncture)puncture, arterial puncture) Onset ½-1hr Onset ½-1hr Duration 1 hr after removal of occlusive dressingDuration 1 hr after removal of occlusive dressing


Topical Agents:Topical Agents: EMLA CreamEMLA Cream

Apply at least ½ hr Apply at least ½ hr prior to procedureprior to procedure

After 1-1 ½ hr, wipe off After 1-1 ½ hr, wipe off cream, clean the area cream, clean the area with antiseptic and do with antiseptic and do procedureprocedure

Topical Agents:Topical Agents: EMLA CreamEMLA Cream

Contraindication: kids Contraindication: kids < 1 month of age< 1 month of age

Do not apply to broken Do not apply to broken skinskin

Conditions associated Conditions associated w/ w/ methemoglobinemia methemoglobinemia (prilocaine)(prilocaine)


Topical Agents:Topical Agents:TAC (tetracaine 0.5%/ adrenaline 0.05% TAC (tetracaine 0.5%/ adrenaline 0.05%

/cocaine 4-11%)/cocaine 4-11%)Max dose = 1.5cc/10 kgMax dose = 1.5cc/10 kgSuture of lacerationsSuture of lacerationsOnset 10-20 minsOnset 10-20 minsDuration 45-60 minsDuration 45-60 mins


TACTAC Soak gauze pad in Soak gauze pad in

soln and place directly soln and place directly over wound for 5-10 over wound for 5-10 minsmins

Anesthesia = Anesthesia = blanching appearance blanching appearance of woundof wound

TACTAC ContraindicationsContraindications

Mucus membranesMucus membranes Areas w/ end-organ Areas w/ end-organ

circulation ( ears, circulation ( ears, fingers, toes, nose, fingers, toes, nose, penis)penis)


Topical Agents:Topical Agents:Tetracaine (amethocaine) CreamTetracaine (amethocaine) Cream

4% cream4% cream suturing, venipuncturesuturing, venipunctureOnset 40 minsOnset 40 minsDuration 4 hrsDuration 4 hrs


Topical Agents:Topical Agents:Tetracaine CreamTetracaine Cream

Apply under occlusion for 40 mins in kids Apply under occlusion for 40 mins in kids undergoing IV placementundergoing IV placement


Topical Agents:Topical Agents: IontophoresisIontophoresis

2% lidocaine with epi, 0.6-1 cc2% lidocaine with epi, 0.6-1 ccPlace electrode well over intact skinPlace electrode well over intact skinOnset 10 minsOnset 10 minsDuration 10 min without epi, 60 mins w/ Duration 10 min without epi, 60 mins w/

epinephrineepinephrine


Topical Agents:Topical Agents: IontophoresisIontophoresis

Tingling, burning, Tingling, burning, itching of skin over itching of skin over both electrodes may both electrodes may occuroccur

Do not use in pts with Do not use in pts with pacemakers or over pacemakers or over metal indwelling metal indwelling catheter ports or end-catheter ports or end-organsorgans


Topical Agents:Topical Agents:LET ( lidocaine 5%, epinephrine 0.1%, LET ( lidocaine 5%, epinephrine 0.1%,

tetracaine 0.5%)tetracaine 0.5%)Recommended dose = 1-3 ccRecommended dose = 1-3 ccEffective 75-98% of facial & scalp lacerationsEffective 75-98% of facial & scalp lacerationsOnset 20-30 minsOnset 20-30 minsDuration 45-60 minsDuration 45-60 mins


Topical Agents:Topical Agents:LETLET

May need to supplement with injected May need to supplement with injected buffered lidocaine before suturingbuffered lidocaine before suturing

Only 40-60% effective in extremity wounds Only 40-60% effective in extremity wounds


Ramsey Sedation ScaleRamsey Sedation ScaleAwakeAwakeLevel 1: anxious and agitatedLevel 1: anxious and agitatedLevel 2: cooperative, oriented, tranquilLevel 2: cooperative, oriented, tranquilLevel 3: responds to commandLevel 3: responds to command


Ramsey Sedation ScaleRamsey Sedation ScaleAsleepAsleepLevel 4: brisk response to light glabellar Level 4: brisk response to light glabellar

tap or loud auditory stimulustap or loud auditory stimulusLevel 5: sluggish response to light Level 5: sluggish response to light

glabellar tap or loud auditory stimulusglabellar tap or loud auditory stimulusLevel 6: no response to light glabellar tap Level 6: no response to light glabellar tap

or loud auditory stimulusor loud auditory stimulus


Recommended Fasting Time to Reduce Recommended Fasting Time to Reduce Aspiration Risk:Aspiration Risk:

Clear liquidsClear liquids 2 hrs2 hrs Breast milkBreast milk 4 hrs4 hrs Infant formulaInfant formula 6 hrs6 hrs Non-human milkNon-human milk 6 hrs6 hrs Light mealLight meal 6 hrs6 hrs Regular mealRegular meal 8 hrs8 hrs



Documents

PROCEDURAL SEDATION INTERN LECTURE SERIES JULY 2003