//fpnotebook.com/
Procedural Sedation and Analgesia
Aka: Procedural Sedation and Analgesia, Procedural Sedation, Procedural Anesthesia, Conscious Sedation, Deep Sedation, Sedative, PSAA
- See Also
- Labor Sedation
- Local Skin Anesthesia
- Regional Anesthesia (Nerve Block)
- Emergency Procedure
- Trauma in Pregnancy
- Definitions
- Procedural Sedation and Analgesia (PSAA)
- Replaces the term Conscious Sedation
- Administer Sedatives (e.g. Propofol) or dissociative agents (e.g. Ketamine), with or without Analgesics (e.g. Fentanyl)
- Induce and Altered Level of Consciousness while still preserving cardiopulmonary function
- Minimal Sedation
- Anxiolysis
- Normal response to verbal stimuli
- Near baseline level of alertness
- Coordination or cognition may be impaired
- No Ventilatory depression
- No cardiovascular depression
- Moderate Sedation
- Depressed Level of Consciousness
- Purposeful response to verbal commands or light stimulation
- Drooping Eyelids and slurred speech
- Delayed verbal response
- Often associated with amnesia around the period of the procedure
- No airway compromise
- No Ventilatory depression
- No cardiovascular depression
- Dissociative Sedation (i.e. Ketamine)
- Trance state (cataleptic) induced by Ketamine
- Potent Analgesic and amnestic properties
- Maintains airway reflexes and spontaneous respirations
- Cardiovascular function maintained
- Deep Sedation
- Depressed Level of Consciousness
- Response only to repeated or painful stimuli
- Ensure airway protection
- Ventilatory depression may occur
- No cardiovascular depression
- General Anesthesia
- Depressed Level of Consciousness
- Not arrousable to painful stimuli
- Airway and Ventilatory support required
- Cardiovascular depression may occur
- Indications
- Adult precedural sedation
- Fracture or dislocation reduction
- Significant Wound Debridement
- Rectal Foreign Body
- Endoscopy
- Bronchoscopy
- Electrical cardioversion
- Child Procedural Sedation
- Fracture or dislocation reduction
- Laceration Repair or Wound Debridement
- Abscess Incision and Drainage
- Imaging studies
- Ear Foreign Body
- Entrapment of penis in zipper
- Contraindications
- Significant or unstable cormorbid illness
- History
- Last oral intake
- Medications
- Medication Allergies
- Prior reaction to Anesthesia or analgesia
- Serious medical conditions (affecting major organ systems)
- See ASA Physical Status Classification System
- Cerebrovascular Disease
- Coronary Artery Disease, Congestive Heart Failure or Arrhythmia
- Obstructive Sleep Apnea, COPD
- Chronic Kidney Disease
- Diabetes Mellitus
- Asthma or active Upper Respiratory Infection
- Increased risk of laryngospasm
- Exam
- Baseline Vital Signs
- Body weight and height (for dosing)
- Assess for difficult airway
- Lemon Mnemonic
- Mallampati Score
- Preparation: Fasting
- Fasting is preferred but not required prior to procedure
- Food intake is not absolute contraindication
- Aspiration is less likely with Fasting
- Urgent procedures may be performed without Fasting
- Formal guidelines for elective procedures (per Anesthesia)
- No clear liquids in last 2 hours
- No Breast Milk in 4 hours (or infant formula in 6 hours)
- No food, milk, solids in last 6 hours
- Consider risk factors for pulmonary aspiration
- Advanced age
- Comorbid medical conditions
- Pregnancy
- Gastroesophageal Reflux risks (e.g. Hiatal Hernia, Bowel Obstruction, ileus, Peptic Ulcer Disease)
- Ketamine is associated with peri-procedural Vomiting in up to 28% of children
- No evidence to support Vomiting prophylaxis
- No evidence for pre-procedural Antacids, H2 Blockers or Anticholinergics
- However, H2 Blockers or Metoclopramide is often given prophylactically in pregnancy
- Pre-procedural Ondansetron may be considered if higher aspiration risk
- However, no consistent evidence of benefit
- Lee (2014) J Paediatr Child Health 50(7): 557-61 [PubMed]
- Lee (2008) Ann Emerg Med 52(10: 30-4 [PubMed]
- Emergency department guidelines for NPO prior to Procedural Sedation
- Evidence does not support the same NPO guidelines in Emergency Department as for elective procedures
- ACEP guidelines note that recent food intake is not a contraindication to Procedural Sedation
- Godwin (2014) Ann Emerg Med 63(2): 247-58 +PMID:24438649 [PubMed]
- NPO duration prior to Procedural Sedation does not appear to impact risk of Vomiting or aspiration
- Molina (2010) Int J Evid Based Healthc 8(2): 75-8 [PubMed]
- Bell (2007) Emerg Med Australas 19(5): 405-10 [PubMed]
- Preparation: Emergency Preparedness
- Requires provider experienced in sedation
- Knowledgeable about Sedatives and monitoring
- Skilled in ABC Management
- Assign one person to monitor and manage Anesthesia and respiratory status (e.g. clinician, RN, RT, Anesthesia)
- Capnography (End-Tidal CO2) may be adequate for monitoring (without additional required staff)
- However, many organizations require one trained practitioner dedicated to monitoring Anesthesia
- Monitoring during procedure
- Continuous waveform End-Tidal CO2 Monitoring (Capnography)
- Commonly used for emergency department Procedural Sedation
- Not required per ACEP guidelines as of 2014
- Significantly increases early detection of repiratory depression and apnea
- Decreased Hypoxia risk by 10-20%
- Alerts to apnea 4-8 minutes before Oxygen Saturation changes
- Supplemental Oxygen delays oxygen desaturation during apnea
- Deitch (2010) Ann Emerg Med 55(3): 258-64 [PubMed]
- May not alter outcomes compared with standard monitoring
- van Loon (2014) Anesth Analg 119(1): 49-55 [PubMed]
- Available as part of a Nasal Cannula type device
- Technique for attaching to Face Mask
- Insert a 14 gauge angiocatheter through holes in Face Mask outflow
- Attach 14 gauge catheter to Capnography
- Cardiac monitoring
- Pulse Oximetry
- Not useful for timely diagnosis of apnea if Supplemental Oxygen used
- Identifying apnea during sedation may be delayed as much as 4 minutes using Oxygen Saturation alone
- Use end tidal CO2 for patients on Supplemental Oxygen
- Emergency equipment
- Oxygen Delivery
- Consider High Flow Oxygen for Apneic Oxygenation
- Apply Supplemental Oxygen to all patients undergoing Procedural Sedation
- Supplemental O2 is controversial, as some argue it delays apnea recognition (if not on EtCO2)
- Airway Suction equipment
- Nasopharyngeal Airway (Nasal Trumpet)
- Bag-valve mask
- Administer a few breaths initially to assure that patients may be supported with with bag-valve mask
- Be ready for airway collapse (e.g. Sleep Apnea patient with a large Tongue)
- Jaw Thrust alone can significantly open the airway
- Assistant may be required to perform Jaw Thrust, while a second provider provides bag-valve-mask
- Consider inserting 2 Nasal Airways (and an Oral Airway may be inserted if no Gag Reflex)
- Intubation equipment
- Resuscitation cart
- Reversal agents
- Naloxone
- Flumazenil
- Only use if not on chronic Benzodiazepines (risk of acute withdrawal and Status Epilepticus)
- Preparation: Resource Limited Environments (e.g. low and middle income countries)
- See Resource Limited Environment
- Consider alternatives to Conscious Sedation
- Defer non-emergent procedures to the most appropriate available local options
- Local or Regional Anesthesia is preferred
- Consider non-intravenous options as listed below
- Preparation
- Familiarize yourself with locally available medications
- Follow a pre-procedure checklist
- Prepare the evironment
- Adequate lighting
- Clean, organized work area
- Disrobe patient for adequate access
- Alert all staff to remain vigilant throughout procedure
- Assign one person dedicated solely to monitoring during the procedure
- Obtain IV Access
- Infuse crystalloid (NS or LR)
- Consider initial 500 cc or 10-20 cc/kg bolus
- Monitoring equipment as available
- Emergency airway and breathing equipment prepared and ready for use (ideally as above)
- Airway Monitoring
- Maintain airway with Jaw Thrust
- Monitor for airway obstruction
- Nasopharyngeal Airway, suction and intubation equipment should be ready
- Breathing monitoring
- Pulse Oximeter (preferred if available)
- If not available, continuously auscultate Respiratory Rate, volume, rhythm and observe chest rise
- Supplemental Oxygen
- If not available, use bag-valve mask to improve oxygenation by preventing Atelectasis
- Circulation monitoring
- Obtain Blood Pressure every 5 minutes
- Continuous Pulse Oximetry
- If not available, palpate pulse or auscultate heart sounds continuously
- References
- Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
- Preparation: BiPAP
- Indications
- Sleep Apnea patient with risk of airway compromise during procedure
- Elderly
- Starting setting
- Inspiratory pressure: 10 cm H2O
- Expiratory pressure: 5 cm H2O
- Protocol: Two phase Approach (Hennepin protocol, per Jim Miner, MD)
- Obtain adequate analgesia with Opioids 20 minutes prior to Procedural Sedation
- Administer Procedural Sedation (e.g. Propofol) without analgesia (e.g. Fentanyl)
- Analgesia persists through procedure, while not complicating respiratory status
- Protocol: Difficult IV Access options
- Intranasal medications
- Fentanyl
- Midazolam (Versed)
- Lidocaine
- Dexmedetomidine (Precedex)
- Intramuscular Medications
- Ketamine
- Midazolam (Versed)
- Hydromorphone (Dilaudid)
- Rectal Medications
- Methohexital (Brevital)
- Diazepam (Valium)
- Midazolam (Versed)
- Precautions
- Monitor patient response (grimace, whimper, withdrawal from pain) to procedure
- Maintain awareness of inadequate Anesthesia and analgesia, in addition to standard monitoring
- Pregnancy
- See Trauma in Pregnancy
- Pregnant patients are higher risk for cardiopulmonary compromise
- Decreased Functional Residual Capacity
- Increased oxygen demand and resting Respiratory Rate
- Baseline relative Hypotension
- Avoid Hypoxia, hypercapnia and Hypotension
- Risk of adverse fetal effects
- Measures to consider
- Supplemental Oxygen
- Intravenous crystalloid fluid (LR) infusion (and consider bolus)
- Vomiting and pulmonary aspiration prophylaxis (e.g. Metoclopramide or H2 Blocker)
- Left lateral decubitus position
- Increases uteroplacental flow and venous return
- Reduce aspiration risk
- Safer Anesthetics and Analgesics in pregnancy
- See Analgesic Medications in Pregnancy
- Avoid Benzodiazepines (e.g. Midazolam)
- Ketamine
- Avoid in maternal Hypertension
- Propofol
- Significant risk of Hypotension
- Other agents to consider
- Nitrous Oxide
- Remifentanil
- Preparations: Sedatives - Ketamine
- Indications
- Preferred Sedative in children (do not use for age <3 months)
- Sedation in a patient with a potentially difficult airway
- Sedation in critically ill patient (where Hypotension risk with Propofol)
- ASA Physical Status Score 2 and 3
- Effects
- Analgesic and Anesthetic properties
- IV
- Onset in 1 min, peaks at 1-3 min, dissociation for 15 min, and recovery over 60 min
- Initial
- Adult: 1.0 mg/kg slow IV over 1-2 min
- Child: 1.5 mg/kg slow IV over 1-2 min
- Next
- Administer 1/2 of intial dose every 10 minutes as needed
- IM
- Onset in 3-5 min, peaks at 5-20 min, dissociation for 15-30 min, and recovery over 90-150 min
- Initial: 2-5 mg/kg IM (adult and child)
- Repeat 2 mg/kg IM after 10 min for one dose if needed
- Intranasal
- Analgesia: 1-1.5 mg/kg intranasally
- Onset of action in 10 min
- Graudins (2015) Ann Emerg Med 65(3): 248-54 +PMID:25447557 [PubMed]
- Sedation
- Not recommended intranasally for sedation
- Amount delivered intranasally is too low for Anesthesia dosing and onset varies widely
- Adverse effects
- Peri-procedure Vomiting may occur in up to 28% of children
- Least adverse effects in children of the procedural Sedatives
- Bhatt (2017) Pediatr 171(10): 957-64 +PMID:28828486 [PubMed]
- Laryngospasm (0.3 to 0.4% of cases, especially children)
- See Laryngospasm on Induction
- See Laryngospasm Notch Maneuver
- Typically transient, but risk of airway obstruction
- Risk of emergence reaction in up to 10-20% (e.g. Agitation)
- Consider concurrent Midazolam in adults (0.03 mg/kg) to counter emergence reaction
- Sener (2011) Ann Emerg Med 57(2):109-114 [PubMed]
- Older data recommends avoiding in Closed Head Injury (risk of Increased Intracranial Pressure)
- Newer data suggests safe in Head Injury
- Hypersalivation
- Anticholinergics (Atropine, glycopyrrolate) are not recommended to dry secretions
- Green (2009) Ann Emerg Med 54(2): 171-80 +PMID:19501426 [PubMed]
- Respiratory drive is typically preserved
- However, transient apnea (10-20 s) may occur with rapid infusion
- Infuse Ketamine slowly (over 1-2 minutes)
- Preparations: Sedatives - Propofol
- Indications
- Preferred procedural Sedative in adults for brief procedures
- Indicated for ASA Physical Status Score 2 (non-hypotensive, stable)
- Use Ketamine or Etomidate instead in patients at risk of Hypotension
- Adverse Effects
- Hypotension
- Respiratory depression
- Appears safe in pregnancy and Lactation (limited data)
- Effects
- Propofol is primarily Anesthetic
- Peak effect reached in 30-60 seconds with 5-6 minute duration
- Administer concurrent Analgesics (e.g Fentanyl 50 mcg increments)
- Adult
- Initial: 1 mg/kg IV over 20-30 seconds (typically given as smaller increments)
- Obese patients: Consider 0.7 to 0.8 mg/kg for starting dose
- Thin young patients: Consider 1.5 mg/kg for starting dose (risk of respiratory depression)
- Frail elderly patients: Consider 20-30 mg IV for starting dose
- Next: 0.5 mg/kg IV as needed
- Next: 0.25 to 0.5 mg/kg IV every 3 minutes
- Decrease dose in older patients (cummulative required total dose decreases with age)
- Age 18-40 years old: 2 mg/kg total dose
- Age 41-64 years old: 1.7 mg/kg total dose
- Age >64 years old: 1.2 mg/kg total dose
- Patanwala (2013) J Emerg Med 44(4): 823-8 +PMID:23333181 [PubMed]
- Child
- Initial: 1 mg/kg IV (up to 40 mg) over 20-30 seconds (typically given as smaller increments)
- Next: 0.5 mg/kg IV (up to 20 mg) as needed
- Typically no respiratory depression at 1 mg/kg dose
- Amnesia occurs at this dose
- However, apnea may occur when Propofol is combined with Opioids
- Perform painful procedures immediately following infusion
- Amnestic effect wears off prior to sedation
- Preparations: Sedatives - Etomidate
- Indications
- Indicated for ASA Physical Status Score 2 and 3
- Consider for sedation in hypotensive adult patient (or Ketamine)
- Otherwise Propofol is preferred adult Sedative with greater efficacy, less Myoclonus than Etomidate
- Miner (2007) Ann Emerg Med 49(1): 15-22 [PubMed]
- Adverse Effects
- Myoclonus (20-40% of cases)
- Administer Etomidate slowly over 90 seconds
- Pretreatment
- Fentanyl (or Alfentanil or Sufentanil)
- Alternatively, Magnesium Sulfate or Midazolam may be used as pretreatment
- Adrenal suppression
- Adrenal suppression is typically associated with continuous infusion
- Appears safe for single dose
- Avoid in Sepsis
- Respiratory depression (10% of cases)
- Nausea and Vomiting (at emergence)
- Seizure threshold lowered (avoid in Seizure disorder)
- Pharmacokinetics
- Onset: 15-30 seconds
- Duration: 3-8 min (up to 15 min)
- Dosing: IV
- Initial: 0.1 to 0.2 mg/kg IV
- Repeat 0.05 mg/kg IV every 3-5 minutes as needed
- Preparations: Sedatives - Pentobarbital
- Indicated in brief sedation
- Ideal for CT Head (brief action, Seizure Prophylaxis)
- May be accompanied to CT with RN (low risk of respiratory depression, or other serious adverse effects)
- Observe for Hypotension
- Dose: 2.5 mg/kg IV (may repeat additional 1.25 mg/kg as needed twice)
- Preparations: Sedatives - Methohexital (Brevital)
- Indications
- Propofol is preferred over Methohexital
- Consider methohexital where unable to obtain Intravenous Access (can be given rectally)
- Safe in pregnancy
- Pharmacokinetics
- Barbiturate with rapid onset of action, and with IV dosing same as IM dosing
- Onset within 30-60 minutes
- Duration 3-5 minutes
- Adverse Effects
- Cardiopulmonary depression
- Follow same precautions as for Propofol
- Respiratory depression (10-22%)
- Hypotension (1-3%)
- Paradoxically lowers Seizure threshold (avoid in Seizure disorder)
- Contrast to other barbiturates which are used to a abort Seizures
- Laryngospasm
- Give a full dose (additional Methohexital) to fully supersaturate GABA receptors
- Otherwise similar management to Ketamine laryngospasm
- See Laryngospasm on Induction
- Other adverse effects
- Vomiting
- Cough
- Hiccups
- Preparations: Sedatives - Ketaphol or Ketafol (Ketamine with Propofol)
- Postulated to reduce risk of Hypotension and apnea of Propofol by cutting dose with Ketamine
- Initial studies recommended ratio of 4:1 Propofol to Ketamine for adequate effect
- Some protocols start 1:1 ratio Propofol to Ketamine 0.5 then add Propofol to effect
- Most studies show no significant benefit over Propofol alone (similar efficacy and safety)
- Andolfatto (2012) Ann Emerg Med 59(6): 504-12 [PubMed]
- Nejati (2011) Acad Emerg Med 18(8): 800 [PubMed]
- Ferguson (2016) Ann Emerg Med 86(5): 574-82 [PubMed]
- Typical protocol
- Start: Administer mix of Propofol 0.5 mg/kg AND Ketamine 0.5 mg/kg
- Next: Administer additional Propofol 0.5 mg/kg every 90 seconds as needed to adequate effect
- Effects
- Peak onset at 20-60 min with a 15 min duration
- Preparations: Sedatives - Midazolam (Versed)
- Indications
- Other sedation agents are preferred in most cases
- Intranasal Versed in children may allow for imaging, Intravenous Access, Laceration Repair
- Intravenous (onset 2-3 min and lasts 20-30 min, up to 60 min)
- Age 6 months to 5 years
- Initial: 0.05 to 0.1 mg/kg IV
- Titrate: Up to 1 mg increments IV every 3 min to max of 0.6 mg/kg
- Age 6 to 12 years
- Initial: 0.025 to 0.05 mg/kg IV
- Titrate: Up to 1 mg increments IV every 3 min to max of 0.4 mg/kg
- Adults (and over age 12 years)
- Initial: 0.02 mg/kg IV (1-2 mg IV)
- Titrate: 1 mg increments IV every 3 min
- IM (onset 10-20 min and lasts 60-120 min)
- Child: 0.1 to 0.15 mg/kg
- Adult: 0.07 mg/kg up to 5 mg
- Other routes
- Oral: 0.5 to 0.75 mg/kg
- Peaks at 15-30 min, duration 60-90 min
- Nasal: 0.2 to 0.5 mg/kg intranasal (1/2 in each nostril) using 5 mg/ml up to 10 mg
- Peaks at 10-15 min, duration 45-60 min
- May cause burning sensation on spraying into nose
- Rectal 0.25 to 0.5 mg/kg per Rectum
- Contraindicated in pregnancy (Category D), and wait at least 4 hours for Breast Feeding
- Commonly used in combination with Fentanyl
- When combined with Opioids (e.g. Fentanyl), use lower Midazolam dose
- Risk of Deep Sedation with cardiopulmonary depression
- Unpredictable at increased doses (risk of respiratory and cardiovascular depression)
- Unreliable sedation for painful procedures
- Best delivered in incremental doses (e.g. 1 mg increments)
- Exercise extra caution in elderly, debilitated, children, hepatic insufficiency, Dementia
- Reversal: Flumazenil 0.01 mg/kg up to 2 mg over 15 seconds
- Do not use if on longterm Benzodiazepines
- Preparations: Sedatives - Nitrous Oxide
- Mixed with 40% oxygen (pre-set)
- Dose is self administered by patient breathing through demand valve mask
- Onset within 5 minutes and duration <5 minutes after discontinuing
- Activity is similar to Opioids
- Consider for IV Access start
- Preparations: Sedatives - Dexmedotomidine (Precedex)
- Selective alpha-2 agonist with strong Sedative properties but no Analgesic properties (See Dexmedotomidine)
- Typically used for IV sedation in the Intensive Care unit (e.g. Mechanical Ventilation, severe Alcohol Withdrawal)
- Intranasal: 2-3 mcg/kg
- Onset in 13-25 minutes and duration for 85 minutes (longer in adults)
- Intranasal use rarely causes Bradycardia or Syncope
- Oriby (2019) Anesth Pain Med 9(1): e85227 +PMID:30881910 [PubMed]
- Preparations: Analgesics - Fentanyl
- Nasal: 2 mcg/kg intranasal (1/2 in each nostril) up to a maximum of 100 mcg
- Onset of analgesia within 10 minutes and duration of 30 minutes
- 2 mcg/kg is equivalent to 0.1 mg/kg Morphine
- Bioavailability: 70%
- Nebulized: 4 mcg/kg in breath activated neb
- As effective as IV Morphine using ultrasonic nebulizer with tight fitting mask
- Farahmand (2014) Am J Emerg Med 32(9):1011-5 +PMID:25027194 [PubMed]
- IV (onset in 1-3 min, lasting 30-60 min)
- Adult: 50 mcg/dose every 3 minutes, titrating to effect
- Child: 1 mcg/kg/dose IV every 3 minutes, titrating to effect
- Age 1-3 years old: 2-3 mcg/kg/dose every 30-60 minutes as needed
- Age 3-12 years old: 1-2 mcg/kg/dose every 30-60 minutes as needed
- Age >12 years old: 0.5-1 mcg/kg/dose every 30-60 minutes as needed
- Reversal: Naloxone
- Adverse effects
- Less histamine release than with Morphine
- Respiratory depression
- Supplemental Oxygen, Jaw Thrust maneuver, bag-valve mask
- Use lower doses in combination with Midazolam (Versed)
- Preparations: Analgesics - Morphine
- 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)
- Intramuscular onset of activity may be delayed as long as 30 minutes
- Adverse Effects
- Nausea or Vomiting
- Consider pretreatment with Antiemetic (e.g. Ondansetron)
- Hypotension
- Consider pretreatment bolus of crystalloid (500 cc or 10-20 cc/kg NS)
- Pruritus and/or rash
- Typically not Allergic Reaction
- Morphine may result in histamine release
- Reversal: Naloxone
- Preparations: Analgesics - Miscellaneous Agents
- Oxycodone (immediate release)
- Oral route (better than IM opiods, without significant delay)
- Adults (and over age 12 years) 5-10 mg every 4-6 hours as needed
- Child: 0.05 to 0.3 mg/kg/dose (up to 10 mg) every 4-6 hours as needed
- Reversal: Naloxone
- Hydrocodone-Acetaminophen (Vicodin or Lortab) 2.5 mg/5 ml elixir
- 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)
- Reversal: Naloxone
- Ketorolac (Toradol)
- IV/IM: 0.5 mg/kg (up to 30 mg)
- Preparations: Older agents to avoid (replaced by other agents above)
- Chloral Hydrate
- Older oral sedation agent similar to Ethanol with GABA-receptor mediated effects
- Rapidly metabolized to the active form, trichloroethanol
- Agitation and Nausea are common
- Common use among pediatric dentists (with case reports of outpatient pediatric deaths)
- Ketamine or oral/intranasal Midazolam are far preferred over oral Chloral Hydrate
- Management: Disposition
- Continue monitoring until no risk of respiratory depression
- Observe for at least 2 hours if any reversal agent used (e.g. Naloxone, Flumazenil)
- Discharge after patient is alert and back to baseline mental status
- Give Discharge Instructions
- Family or friend should observe the patient for several hours after discharge
- Patients may expect Nausea, Fatigue or light headedness for up to 24 hours after discharge
- Complications: Common
- Hypoxia (40.2 per 1000 sedations)
- Highest risk with Profol or with combined Midazolam with Opiate
- Open airway with Jaw Thrust
- Supplemental Oxygen
- Tactile and verbal stimulation
- Vomiting (16.4 per 1000 sedations)
- Highest risk with Ketamine
- Consider prophylactic Antiemetic in those at higher risk but evidence is lacking (see above)
- Suction airway
- Place patient in left lateral decubitus position
- Maintain airway management and consider definitive airway (i.e. Endotracheal Intubation)
- Administer Antiemetic (e.g. Ondansetron)
- Hypotension (15.2 per 1000 sedations)
- Highest risk with Propofol or combined Midazolam with an Opiate
- Typically resolves spontaneously
- Consider crystalloid fluid (NS or LR) bolus of 500 ml (or 10-20 ml/kg)
- Consider Push Dose Pressor (e.g. Phenylephrine) for refractory Hypotension
- Apnea (12.4 per 1000 sedations)
- Highest risk with Midazolam with or without an Opiate
- Capnography allows for earlier recognition (contrast with delayed recognition with Oxygen Saturation)
- Supplemental Oxygen
- Bag-Valve-Mask Ventilation
- Consider Endotracheal Intubation
- Consider reversal agents (e.g. Naloxone or Flumazenil)
- References
- Bellolio (2016) Acad Emerg Med 23(2): 119-34 [PubMed]
- Complications: Uncommon
- Pulmonary aspiration (1.2 per 1000 sedations)
- Suction airway
- Supplemental Oxygen
- Maintain airway management and consider definitive airway (i.e. Endotracheal Intubation)
- Consider antibiotic coverage for Aspiration Pneumonia
- Agitation
- More common with Ketamine-related emergence reactions
- Also Agitation occurs paradoxically in children with Benzodiazepines (up to 15% of cases)
- Consider Benzodiazepine (e.g. Versed), unless of course the Benzodiazepine was causative
- Calm redirection can help patients more calmly emerge
- Sinus Bradycardia
- Typically resolves spontaneously
- Atropine may be dosed if needed
- Laryngospasm (3-4 per 1000 sedations with Ketamine)
- More common with Ketamine (esp. if comorbid Asthma or acute URI)
- May respond to Laryngospasm Notch Maneuver
- Deliver High Flow Oxygen
- Attempt bag valve ventilation
- Consider Paralytic Agent (e.g. Succinylcholine or Rocuronium) and intubation
- References
- Bellolio (2016) Acad Emerg Med 23(2): 119-34 [PubMed]
- References
- Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
- Braude in Herbert (2013) EM:Rap 13(11): 14
- Claudius and Behar in Herbert (2019) EM:Rap 19(12): 15-6
- Kay (2015) Crit Dec Emerg Med 29(8): 11-17
- Lester and Braude in Herbert (2014) EM:Rap 14(5): 5-6
- Weingart in Majoewsky (2012) EM:RAP 12(2): 8
- Miner (2012) APLS Lecture, HCMC, Minneapolis
- Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
- Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
- Shahbaz and Kivlehan (2018) Crit Dec Emerg Med 32(8): 19-28
- Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208
- Strayer in Herbert (2017) EM:Rap 17(12): 17-9
- University Minnesota Childrens - Pediatric Emergency Drug Card
- Becker (2012) Anesth Prog 59:28-42 [PubMed]
- Brown (2005) Am Fam Physician 71:85-90 [PubMed]
- Godwin (2014) Ann Emerg Med 63(2): 247-58 [PubMed]