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Procedural Sedation PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "Procedural Sedation" by Christian La Rivière, MD, FRCPC.

This medical PowerPoint presentation talks about procedural sedation. Procedural sedation is a medical technique used to achieve a decreased level of consciousness in patients undergoing certain medical procedures or surgeries. The goal of procedural sedation is to reduce a patients anxiety, discomfort, and pain while still allowing them to remain conscious and responsive.

Procedural sedation is typically performed by administering medications such as benzodiazepines, opioids, or propofol, either orally, intravenously, or through inhalation. The dosage and type of medication used depend on the patients age, medical history, and the type of procedure being performed.

Procedural sedation is commonly used for procedures such as colonoscopies, endoscopies, and dental procedures. It is also used for certain diagnostic tests, such as MRI or CT scans. The level of sedation used varies depending on the specific procedure and the patients individual needs.

Tags : Procedural Sedation, medical procedures or surgeries, benzodiazepines, opioids, propofol, colonoscopies, endoscopies, dental procedures, Anesthesiology

Published on : Mar 16, 2023 | Views : 2300 | Downloads : 1

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Slide 1-

Procedural Sedation Christian La Rivière, MD, FRCPC
Slide 2-

“Conscious Sedation is very safe and therefore, occasionally, very dangerous.” Dr. J. Mansfield
Slide 3-

“…..the responsibility for administering conscious sedation ultimately lies with the individual practitioner. He or She must ensure that drugs are being administered safely and appropriately. The practitioner must be aware of his or her own limitations, and when it is appropriate to request assistance. These vary from individual to individual.” Dr. Steve Kowalski Physician Accreditation for Conscious Sedation
Slide 4-

Overview Know your facility, equipment, and personnel. Know your patient. Know your drugs, doses, adverse effects. Be aware of specific risks or problems associated with your procedure. Know how to avoid trouble, but what to do if something happens.
Slide 5-

Why use procedural sedation? “Premise: Painful procedures are inevitable in emergency medicine, but pain is not.” “Any physician who practices emergency medicine without using some form of sedation technique is either not practicing emergency medicine or not practicing it humanely.” Dr. Grant Innes
Slide 6-

Why use procedural sedation? “To provide analgesia and amnesia during painful diagnostic and therapeutic procedures in the ED. To minimize negative psychological responses associated with medical interventions” “In children or uncooperative adults it may expedite the conduct of procedures that are not particularly uncomfortable but require the patient not to move.” Dr. Grant Innes Dr. Jeffery Gross
Slide 7-

The Sedation Spectrum Simple anxiety reduction Light sedation Deep sedation Dissociative state Neurolepsis General anesthesia
Slide 8-

Potential Indications reducing fractures and dislocations scrubbing road rash deep, complex, or multiple lacerations not amenable to local anesthetic esp. tongue and vermilion border burn debridement chest tubes foreign body removal
Slide 9-

Potential Indications radiographic imaging neuro-imaging in a combative patient endoscopy,bronchoscopy,colonoscopy lumbar puncture
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Potential Indications cardioversion foley catheterization hernia reduction abscess incision and drainage terrified, uncontrollable child dilatation and curettage
Slide 11-

Contraindications Lack of personnel experienced at airway management or advanced life support Unfamiliarity with medications being administered for sedation Lack of appropriate monitoring equipment The unstable patient Allergy or sensitivity to relevant medication Potentially difficult airway (relative)
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Preparation and Planning Patient assessment and selection Airway assessment Equipment selection IV access Appropriate support staff Medication selection Consent
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Airway Examination
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Difficult Airway? Sometimes it is obvious Know when to ask for help
Slide 15-

Airway History previous problems with anesthesia or sedation stridor, snoring, or sleep apnea advanced rheumatoid arthritis
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Airway Physical exam habitus - obesity neck - movement, size, abnormalities mouth - opening, tongue, teeth jaw - movement, size
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Difficult Mask Ventilation M - Mask Seal O - Obesity / Obstruction A - Age (advanced age) N - No Teeth S - Sleep apnea / Stiff Lungs
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Potential Difficult Airway L - Look Externally E - Examine 3-3-2 M - Mallampati O - Obesity/Obstruction N - Neck Mobility
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Predicting the difficult airway: Mallampati scoring system Class I Class II Class III Class IV
Slide 20-

Experienced Personnel familiar with pharmacology cardiopulmonary resuscitation airway management Pediatrics: PALS RN or RT
Slide 21-

Monitoring & Equipment Adequate and accessible space Nurse, MD Equipment: Pulse oximeter BP machine continuous EKG monitor
Slide 22-

Equipment IV access oxygen - suction bag-valve mask that fits patient airway basket at the bed side defibrillator & emergency ACLS drugs reversal drugs at the bedside
Slide 23-

Monitoring & Equipment
Slide 24-

Documentation
Slide 25-

Discharge Criteria normal vital signs baseline mental status coherent speech sit unattended understand verbal post sedation instructions
Slide 26-

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Slide 27-

Overview of Drugs
Slide 28-

Drugs of Interest Opioids (fentanyl) Benzodiazepines (midazolam) Dissociative agents (ketamine) Propofol Other agents (Etomidate)
Slide 29-

Which Drug Should I Choose? choosing the drug or drug combination should depend on: the patient the procedure being performed your comfort level with the drug
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The Ideal Drug short half life predictable effects easily titratable reversible no side effects low cost
Slide 31-

The Ideal Route rapid, predictable, titratable; life line for fluids, reversal agents IV
Slide 32-

Opioids fentanyl is the best opioid for procedural sedation Morphine is no longer widely used in this setting
Slide 33-

Fentanyl potent, rapid-acting opioid physiologic effects mediated by binding to opiate receptors in the brain and spinal cord
Slide 34-

Fentanyl Pharmacokinetics onset of action begins in about 90 seconds clinical duration 20-30 minutes serum half life 90 minutes approximately 100x more potent than iv morphine (10 mg Morphine = 100 mcg Fentanyl)
Slide 35-

Fentanyl Dosing iv: 1-3 mcg/kg, titrated to effect in average sized adults, titrate in 25-75 mcg aliquots every 2-3 minutes
Slide 36-

Fentanyl- Adverse Effects respiratory depression: maximal respiratory depression occurs in about 5 minutes dependent on dose, and co-administration of other agents (e.g.: midazolam)
Slide 37-

Adverse Effects (cont’d) pruritis, but seldom causes any allergic reaction nausea and vomiting (less than the other opioids) muscular and glottic rigidity: this will only happen if you make a dosing error (e.g.: giving 50 mcg/kg, instead of 50 mcg x 1!)
Slide 38-

Benzodiazepines midazolam other agents are not as well suited for procedural sedation
Slide 39-

Midazolam acts on GABA receptors, resulting in anxiolytic, hypnotic, and amnestic effects midazolam is rapid acting and easily titratable compared to the other benzodiazepines water soluble and lipophilic
Slide 40-

Midazolam Pharmacokinetics onset of action 1-3 minutes clinical duration approximately 30 minutes serum half life 1.5-3 hrs
Slide 41-

Midazolam Dosing iv: recommended total is 0.02-0.1 mg/kg for average adult, titrate using 1-2 mg aliquots every 2-3 minutes
Slide 42-

Midazolam Adverse Effects respiratory depression severity of respiratory compromise increased with alcohol, barbituates, opioids clinically significant side effects with midazolam used alone are RARE if used in combination with fentanyl, hypotension may ensue
Slide 43-

Ketamine derivative of the street drug phencyclidine (PCP) the only dissociative agent used in procedural sedation
Slide 44-

Ketamine causes a dissociation between the thalamoneocortical and limbic systems prevents the higher order centres from perceiving visual, auditory, or painful stimuli “lights on, nobody’s home”
Slide 45-

Ketamine (cont’d) does not cause respiratory depression (unless given in a rapid bolus and large enough dose) muscle tone and airway protection maintained water soluble and lipophilic
Slide 46-

Other Physiological Effects inhibits re-uptake of catecholamines (may cause some tachycardia and hypertension) relaxes bronchial smooth muscle stimulates salivary and tracheobronchial secretions may increase ICP and IOP
Slide 47-

Ketamine Pharmacokinetics onset 1 minute (iv), 5 minutes (im) duration 15 minutes (iv), 30 minutes (im) complete recovery within 1-2 hrs
Slide 48-

Ketamine Dosing if given alone or with midazolam, start with 0.5-1.0 mg/kg, iv; repeat doses of 0.05-0.1 mg/kg, iv as needed if giving it im, the dose is 4-5 mg/kg if giving it in children, consider a premedication with atropine, 0.01-0.02 mg/kg, iv for the bronchial secretions
Slide 49-

Adverse Effects laryngospasm: reported almost exclusively in infants < 3 months old risk factors are infants and in patients with active upper respiratory tract infections overall, still quite rare in the peds world 0.4% incidence of laryngospasm in a study looking at 1022 cases in pooled data involving 11,589 kids > 3 y.o., laryngospasm occurred 0.017%
Slide 50-

Adverse Effects (cont’d) muscle rigidity, random movements, nystagmus this usually is of no clinical consequence
Slide 51-

Adverse Effects (cont’d) Emergence phenomenom: hallucinations and nightmares may occur in up to 30% adult PSA’s, and about 10-17% peds cases risk in adults if > 16 y.o., female, psychiatric history, illicit drug use, large doses some evidence to support pre-medication with benzos in adults, but not in children
Slide 52-

Propofol ultra-short acting sedative hypnotic derived from the alkylphenols highly lipid soluble
Slide 53-

Propofol ultra-short acting sedative hypnotic dose-depedent sedation, ranging from minimal sedation to a general anesthesia also possesses anti-emetic properties and can lower ICP during intubation does NOT provide analgesia
Slide 54-

Propofol Pharmacokinetics onset of action 15-30 seconds duration less than 10 minutes rapidly metabolized, does not accumulate in the blood or tissues
Slide 55-

Propofol Dosing most of the clinical trials use the following: 1 mg/kg, iv bolus, followed by 0.5 mg/kg, iv, q3-5 minutes be more cautious in elderly patients, hypovolemic patients, or other patients with significant co-morbidities
Slide 56-

Propofol Adverse Effects Hypotension: actually quite rare in kids and healthy adults; treatment is rarely required increased risk in elderly, hypovolemic patients, or if given rapidly
Slide 57-

Adverse Effects (cont’d) respiratory depression: dose-related apnea and respiratory depression risk increases if too much is given, or if it is given too rapidly also increased risk in those with respiratory co-morbidities
Slide 58-

Is Propofol Safe? respiratory depression is rare overall if it does occur, the most common intervention is a jaw thrust and supplemental oxygen the need for endotracheal intubation has not yet been reported during procedural sedation YES
Slide 59-

Rescue Agents Narcan and Flumazenil always important to have these close by with a knowledge about their indication and dose
Slide 60-

So, which drugs should I use? a number of factors determine the choice of agents: your comfort level with the drugs the type of procedure being performed the length of the procedure patient age, comorbidities, past history of sedations, drug allergies
Slide 61-

Getting Comfortable if you are using an agent for the first time, start with low doses and titrate to effect don’t be too cautious as the drug will wear off and sedation will not be achieved spend some time with others with more experience
Slide 62-

Type of Procedure noninvasive (sedation for imaging) low pain, high anxiety high pain, high anxiety
Slide 63-

Non-invasive Procedures e.g.: taking young child to CT, agitated elderly patient consider using a single agent with sedative, amnestic, and anxiolytic properties benzodiazepines (Versed, Ativan, etc.)
Slide 64-

Low Pain, High Anxiety laceration repair, lumbar puncture requires minimal sedation; analgesia usually provided with local anesthetic options: midazolam alone ketamine
Slide 65-

High Pain, High Anxiety fracture reduction, electrical cardioversion choice of agents depend on the anticipated length of procedure and depth of sedation required joint reductions: deep plane of sedation required best to choose short acting agents
Slide 66-

Complications respiratory depression hypotension vomiting emergence reactions
Slide 67-

The End!Questions?