Your SlideShare is downloading. ×
Procedural sedation and analgesia
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Procedural sedation and analgesia

1,026
views

Published on


0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,026
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
44
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. Procedural Sedationand Analgesia Paleerat Jariyakanjana, MD Faculty of Medicine Naresuan University 31 Jan 2013
  • 2. Procedural sedation  administration of sedatives or dissociative anesthetics  induce depressed level of consciousness  maintaining cardiorespiratory function  little or no patient reaction or memoryProcedural sedation and analgesia (PSA)  addition of agents to reduce or eliminate pain
  • 3. Sedation Level
  • 4. Sedation LevelMinimal sedationprocedures that require patient cooperation and those in which pain is controlled by local or regional anesthesiaProcedures: lumbar puncture, sexual assault examinations, simple fracture reductions, abscess I&DAgents: nitrous oxide, midazolam, fentanyl, pentobarbital, low- dose ketamine
  • 5. Sedation LevelModerate sedationprocedures in which detailed patient cooperation is not necessary, and diminished pain reaction and muscular relaxation is desiredProcedures: reduction of shoulder dislocation, thoracostomy tube insertion, synchronized cardioversionAgents: propofol, etomidate, ketamine, methohexital, an d combination of fentanyl and midazolam
  • 6. Sedation LevelDeep sedationprocedures that are painful and require muscular relaxation with minimal patient reactionProcedures: reduction of dislocated hipAgents: same as moderate sedation, but with larger doses
  • 7. PATIENT EVALUATION
  • 8. History and Comorbidities: ASAPatient AssessmentProcedural Urgency
  • 9. Patient AssessmentHx: fasting state, prior experiences with PSA or anesthesia, current medications, and allergiesPE: potentially difficult airway or cardiorespiratory problems
  • 10. Patient AssessmentRoutine laboratory studies: not necessaryDirected ancillary testing  airway abnormalities, infections, advanced age, hepatic or renal disease, dehydration, fever, or hypovolemia
  • 11. RISKS AND PRECAUTIONS
  • 12. Fasting State
  • 13. Number of Physicians Needed2 physicians 1. perform sedation and monitor patient 2. perform procedureminimal & moderate levels of sedation  1 emergency physician  administering sedation and performing procedure
  • 14. Equipmentequipment for airway management and resuscitationdefibrillatorreversal agentsIV access  not required for minimal sedation  equipment for IV access should be immediately available
  • 15. PROCEDURAL SEDATIONMONITORING
  • 16. Interactive Monitoring: by dedicated observersMechanical Monitoring
  • 17. Mechanical Monitoring
  • 18. STEP-BY-STEPTECHNIQUE
  • 19. Preprocedure Pain ManagementThe administration of morphine or fentanyl for pain control before the start of PSA will provide the patient with analgesia during PSA.
  • 20. Preprocedure Pain ManagementPSA should begin after last dose of analgesic has been given and has reached its peak affect  3-5 minutes for IV morphine  2-3 minutes for IV fentanyl
  • 21. Supplemental Oxygen during Procedural Sedation and Analgesiaadministration of supplemental oxygen can delay recognition of hypoventilation
  • 22. Sedation Management1. patient has been evaluated2. appropriate sedation target level is selected3. monitoring modalities are applied4. preparations are made for possible adverse events5. PSA
  • 23. Sedation ManagementOnce the patient has achieved the target sedation level, the actual procedure may begin.
  • 24. SEDATION AGENTS
  • 25. Nitrous Oxidecan be used alone for minimal sedation or as adjunct with IV medications for moderate sedation
  • 26. Midazolamsole agent for minimal sedationcan be combined with opioid for moderate or deep PSAAdverse side effectsmild cardiovascular depression, and hypotension can arise when this agent is given to patients who are hypovolemicparadoxical agitation
  • 27. Fentanyleasily titratable when used alone for minimal sedationcan be used in combination with midazolam for moderate and deep PSA
  • 28. Methohexitalbest used for brief moderate and deep sedation  joint dislocation reductionAdverse side effectsrespiratory depression
  • 29. Pentobarbitalexcellent agent for minimal sedation for neuroimaging in children
  • 30. Ketaminestate of dissociation  profound analgesia, sedation, and amnesiaboth analgesic and anxiolytic propertiesonly sedative agent that typically preserves patients ventilatory effort and has minimal effect on blood pressure
  • 31. KetamineAdverse side effectshypersalivationlaryngospasm, vomitingemergence reactions  mild agitation to recurrent nightmares and hallucinationsincreases intracranial pressure  avoid in patients with head injuriesincrease intraocular pressure  avoided in patients with eye injuries or glaucoma
  • 32. Etomidaterapid onset and short duration of effectAdverse side effectsless cardiovascular depression but similar respiratory depressionmyoclonic jerkingsuppression of adrenal-cortical axis
  • 33. Propofolfrequently used for moderate and deep PSA
  • 34. PropofolAdverse side effectsassociated with fewer complications than etomidate or methohexital in patients who received multiple doses and is much easier to titratemost serious adverse effect: sudden respiratory depression and apneahypotensionC/I: allergic to eggs or soy protein
  • 35. Follow-Up and Patient InstructionsAt the completion of the PSA procedure, patients are monitored until a return to baseline mental status.Return to a preprocedure baseline score or a score of at least 18 indicates the patient is safe for discharge.
  • 36. ANY QUESTIONS?

×