Procedural Sedation and Analgesia

Aka: Procedural Sedation and Analgesia, Procedural Sedation, Conscious Sedation, Sedation, Deep Sedation, PSAA

1. See Also
   1. Labor Sedation
   2. Local Skin Anesthesia
2. Definitions
   1. Procedural Sedation and Analgesia (PSAA) has replaced term Conscious Sedation
3. Indications
   1. Adult precedural Sedation
      1. Fracture or dislocation reduction
      2. Significant Wound Debridement
      3. Rectal foreign body
      4. Ketamine is usually preferred in children
   2. Child Procedural Sedation
      1. Fracture or dislocation reduction
      2. Laceration Repair or Wound Debridement
      3. Abscess Incision and Drainage
      4. Imaging studies
      5. Ear Foreign Body
      6. Entrapment of penis in zipper
4. Contraindications
   1. Significant or unstable cormorbid illness
5. Preparation
   1. Requires provider experienced in Sedation
      1. Knowledgeable about sedatives and monitoring
      2. Skilled in ABC Management
      3. Assign one person (e.g. clinician, RN, RT, anesthesia) to monitor and manage anesthesia and respiratory status
         1. Capnography (end-tidal CO2) may be adequate for monitoring (without additional required staff)
   2. Fasting is preferred prior to procedure
      1. Food intake is not absolute contraindication
         1. Aspiration is less likely with fasting
         2. Urgent procedures may be performed without fast
      2. Guidelines
         1. No food in last 6 hours
         2. No clear liquids in last 2 hours
   3. Monitoring during procedure
      1. Continuous waveform end-tidal CO2 Monitoring (capnography)
         1. Significantly increases early detection of repiratory depression and apnea
         2. Attaching to face mask
            1. Insert a 14 gauge angiocatheter through holes in face mask outflow
            2. Attach 14 gauge catheter to capnography
      2. Cardiac monitoring
      3. Pulse oximetry
         1. Not useful for timely diagnosis of apnea if Supplemental Oxygen used
         2. Identifying apnea during Sedation may be delayed as much as 4 minutes using Oxygen Saturation alone
         3. Use end tidal CO2 for patients on Supplemental Oxygen
   4. Emergency equipment
      1. Oxygen Delivery
         1. Apply Supplemental Oxygen to all patients undergoing Procedural Sedation
      2. Airway Suction equipment
      3. Bag-valve mask
      4. Intubation equipment
      5. Resuscitation cart
      6. Reversal agents
         1. Naloxone
         2. Flumazenil
6. Preparation: Positive Pressure Ventilation
   1. Indications
      1. Sleep Apnea patient with risk of airway compromise during procedure
      2. Elderly
   2. Starting setting
      1. Inspiratory pressure: 10 cm H2O
      2. Expiratory pressure: 5 cm H2O
7. Protocol: Difficult IV Access options
   1. Fentanyl and Versed intranasally
   2. Ketamine IM
8. Preparations: Sedatives
   1. Ketamine (preferred sedative in children)
      1. Analgesic and anesthetic properties
      2. IV (onset in 1 min, dissociation for 15 min, and recovery over 60 min)
         1. Initial
            1. Adult: 1.0 mg/kg slow IV over 1-2 min
            2. Child: 1.5 mg/kg slow IV over 1-2 min
         2. Next: Administer 1/2 of intial dose every 10 min as needed
      3. IM (onset in 3-5 min, dissociation for 15-30 min, and recovery over 90-150 min)
         1. Initial: 4-5 mg/kg IM (adult and child)
         2. Repeat 4-5 mg/kg IM after 10 min for one dose if needed
      4. Indicated for ASA Physical Status Score 2 and 3
      5. Risk of emergence reaction (e.g. agitation)
      6. Older data recommends avoiding in Closed Head Injury (risk of Increased Intracranial Pressure)
         1. Newer data suggests safe in Head Injury
      7. Atropine 0.1 to 0,5 mg may be used to decrease Ketamine-induced Hypersalivation
   2. Propofol (preferred sedative in adults)
      1. Risk of Hypotension
      2. Indicated for ASA Physical Status Score 2 (non-hypotensive, stable)
      3. Primarily anesthetic
         1. Administer concurrent Analgesics
      4. Intravenous
         1. Adult
            1. Initial: 1 mg/kg IV over 20-30 seconds (typically given as smaller increments)
            2. Next: 0.5 mg/kg IV as needed
         2. Child
            1. Initial: 1 mg/kg IV (up to 40 mg) over 20-30 seconds (typically given as smaller increments)
            2. Next: 0.5 mg/kg IV (up to 20 mg) as needed
         3. Typically no respiratory depression at 1 mg/kg dose
            1. Amnesia occurs at this dose
         4. Perform painful procedures immediately following infusion
            1. Amnestic effect wears off prior to Sedation
   3. Etomidate
      1. IV: 0.15 to 0.2 mg/kg
      2. Indicated for ASA Physical Status Score 2 and 3
      3. Avoid in Sepsis (risk of adrenal suppression)
      4. Consider for Sedation in hypotensive adult patient
         1. Otherwise Propofol is preferred adult sedative due to greater efficacy and less Myoclonus than Etomidate
         2. Miner (2007) Ann Emerg Med 49(1): 15-22
   4. Pentobarbital
      1. Indicated in brief Sedation
         1. Ideal for CT Head (brief action, Seizure Prophylaxis)
         2. May be accompanied to CT with RN (low risk of respiratory depression, or other serious adverse effects)
      2. Observe for Hypotension
      3. Dose: 2.5 mg/kg IV (may repeat additional 1.25 mg/kg as needed twice)
   5. Ketaphol (Ketamine with Propofol)
      1. Postulated to reduce risk of Hypotension and apnea of Propofol by cutting dose with Ketamine
      2. If used, ratio must be at least Profofol to Ketamine in 4:1 ratio (1:1 ratio is not effective)
      3. No significant benefit over Propofol alone
         1. Andolfatto (2012) Ann Emerg Med 59(6): 504-12
         2. Nejati (2011) Acad Emerg Med 18(8): 800
   6. Midazolam (Versed)
      1. Intravenous (onset 2-3 min and lasts 45-60 min)
         1. Age 6 months to 5 years
            1. Initial: 0.05 to 0.1 mg/kg IV
            2. Titrate: Up to 1 mg increments IV every 3 min to max of 0.6 mg/kg
         2. Age 6 to 12 years
            1. Initial: 0.025 to 0.05 mg/kg IV
            2. Titrate: Up to 1 mg increments IV every 3 min to max of 0.4 mg/kg
         3. Adults (and over age 12 years)
            1. Initial: 0.02 mg/kg IV
            2. Titrate: 1 mg increments IV every 3 min
      2. IM (onset 10-20 min and lasts 60-120 min)
         1. Child: 0.1 to 0.15 mg/kg
         2. Adult: 0.07 mg/kg up to 5mg
      3. Oral: 0.5 mg/kg
      4. Nasal: 0.2 to 0.5 mg/kg intranasal (1/2 in each nostril) using 5 mg/ml up to 10 mg
      5. Rectal 0.25 to 0.5 mg/kg per rectum
      6. Commonly used in combination with Fentanyl
         1. When combined with Opioids (e.g. Fentanyl), use lower Midazolam dose
      7. Unpredictable at increased doses (risk of respiratory and cardiovascular depression)
         1. Best delivered in incremental doses (e.g. 1 mg increments)
         2. Exercise extra caution in elderly, debilitated and children
      8. Reversal: Flumazenil
9. Preparations: Analgesics
   1. Fentanyl
      1. Nasal: 2 mcg/kg intranasal (1/2 in each nostril)
      2. Nebulized: 4 mcg/kg in breath activated neb
      3. IV (onset in 3-5 min, lasting 30-60 min)
         1. Adult: 50 mcg/dose every 3 minutes, titrating to effect
         2. Child: 1 mcg/kg/dose IV every 3 minutes, titrating to effect
            1. Age 1-3 years old: 2-3 mcg/kg/dose every 30-60 minutes as needed
            2. Age 3-12 years old: 1-2 mcg/kg/dose every 30-60 minutes as needed
            3. Age >12 years old: 0.5-1 mcg/kg/dose every 30-60 minutes as needed
      4. Reversal: Naloxone
      5. Use lower doses in combination with Midazolam (Versed)
   2. Morphine
      1. IV/IM/SC: 0.05 to 0.2 mg/kg every 2-4 hours up to 15 mg (typically given in 2-4 mg increments)
      2. Reversal: Naloxone
   3. Oxycodone (immediate release)
      1. Oral route (better than IM opiods, without significant delay)
         1. Adults (and over age 12 years) 5-10 mg every 4-6 hours as needed
         2. Child: 0.05 to 0.3 mg/kg/dose (up to 10 mg) every 4-6 hours as needed
      2. Reversal: Naloxone
   4. Hydrocodone-Acetaminophen (Vicodin or Lortab) 2.5 mg/5 ml elixir
      1. Oral: 0.2 mg/kg (up to 1.25 mg if under age 2 years, and up to 5 mg if age 2-12 years)
      2. Reversal: Naloxone
   5. Ketorolac (Toradol)
      1. IV/IM: 0.5 mg/kg (up to 30 mg)
   6. Nitrous Oxide
      1. Mixed with 40% oxygen (pre-set)
      2. Dose is self administered by patient breathing through demand valve mask
      3. Onset within 5 minutes and duration <5 minutes after discontinuing
      4. Activity is similar to Opioids
      5. Consider for for IV Access start
10. Preparations: Older agents to avoid (replaced by other agents above)
    1. Chloral Hydrate
       1. Older oral Sedation agent similar to Ethanol with GABA-receptor mediated effects
       2. Rapidly metabolized to the active form, trichloroethanol
       3. Agitation and Nausea are common
       4. Common use among pediatric dentists (with case reports of outpatient pediatric deaths)
       5. Ketamine or oral/intranasal Midazolam are far preferred over oral Chloral Hydrate
11. References
    1. Weingart in Majoewsky (2012) EM:RAP 12(2): 8
    2. Miner (2012) APLS Lecture, HCMC, Minneapolis
    3. Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
    4. Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
    5. University Minnesota Childrens - Pediatric Emergency Drug Card
    6. Becker (2012) Anesth Prog 59:28-42
    7. Brown (2005) Am Fam Physician 71:85-90
    8. Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208