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Conscious sedation2
- 2. Conscious sedation by: dr. osama elnabarawy anesthesia consultant
- 3. Why we give sedations to the patients?
- 4. Sedation is one of Anasthesia Magic
- 5. It releases patient’s feelings Sedation effects differ from person to person. The most common feelings are drowsiness and relaxation. Once the sedative takes effect, negative emotions, stress, or anxiety may also gradually disappear.
- 6. Patient may feel as she is flying over the clouds
- 7. OR falling in a deeeeeeeeeep well.
- 8. IT CAN BE A HAPPY DREAM OR NIGHT MARE
- 9. Indications for the use of sedative drugs Premedication 'Sedo-analgesia'. This term describes the use of a combination of a sedative drug with local anaesthesia Radiological procedures. Some patients, particularly children and anxious individuals, are unable to tolerate long and uncomfortable imaging procedures without sedation Endoscopy. Intensive therapy. Most patients require sedation to facilitate mechanical ventilation and other therapeutic interventions Supplementation of general anaesthesia
- 11. Minimal Sedation Does not mandate implementation of Conscious Sedation Policy Patient maintains – Normal respiration – Normal eye movement – Normal response to command, and – Normal or baseline mental orientation
- 12. Moderate Sedation Protective reflexes are intact • Airway remains patent • Spontaneous ventilation is adequate • Patient responds to physical stimulation or verbal command • No adverse effect on cardiorespiratory function
- 13. Deep Sedation Use of medication to induce a level of depressed consciousness from which the patient is not easily aroused • Can result in partial or complete loss of protective airway reflexes • Need for airway support • Beyond the scope of this policy
- 15. Airway Assessment • Mallampati class • Difficult airway anatomy • History of difficult intubation • Disease states associated with a difficult airway
- 17. Difficult Airway Anatomy • Short/fat neck • Decreased mobility of the airway joints • Dental overbite or small mandible • Large tongue • Distortion in the airway (extrinsic or intrinsic) Difficult anatomy may make mask/bag ventilation difficult or impossible
- 18. NPO Guidelines
- 20. What drugs are used? The drugs used in conscious sedation vary based on delivery method: Oral: You’ll swallow a tablet containing a drug like diazepam (Valium) or triazolam (Halcion). Intramuscular: You’ll get a shot of benzodiazepine, such as midazolam (Versed), into a muscle, most likely in your upper arm or your butt. Intravenous: You’ll receive a line in an arm vein containing a benzodiazepine, such as midazolam (Versed) or Propofol (Diprivan). Inhalation: You’ll wear a facial mask to breathe in nitrous oxide.
- 24. Drugs used for Sedation Benzodiazepines • Produce amnesia, sedation, anxiolysis • Anticonvulsants • Minimal effects on circulation • Diazepam (Valium) – T1/2 is 25 – 30 hours • Lorazepam (Ativan) – T1/2 is 10 – 20 hours • Midazolam (Versed) – T1/2 is 1 – 4 hours
- 25. Midazolam administration A suitable administration regimen is 2mg injected over 30 seconds, followed by a pause for 90 seconds before giving further increments of 1mg every 30 seconds until sedation is judged to be adequate. The correct dose has been given when there is slurring of speech and/or a slowed response to commands, and the patient exhibits a relaxed behavior.
- 26. Propofol (Diprivan) is a potent, short-acting intravenous anaesthetic agent. it is a reliable and safe drug for intravenous sedation. In comparison with midazolam, recovery appears to be rapid and ‘clear-headed’, but amnesia is often less profound. It is particularly useful for short (5–10 minute) cases very short distribution half-life (2–4 minutes) and an elimination half-life of 30–60 minutes. Intravenous propofol by infusion
- 27. Administration Diprivan 1% is presented in 20ml glass ampoules containing 200mg of propofol emulsion (10mg/ml). A dose of 30mg (3ml) of propofol is given slowly, followed immediately by an infusion at an (initial) rate of 300mg (30ml) per hour. Propofol sedation should be used only by those trained in anaesthesia
- 28. • Drugs that bind to opioid receptors and produce – Analgesia – desired effect – Euphoria – clinically useful but potentially dangerous – Respiratory depression – depresses medullary ventilation centers. – Other side effects: Nausea, pruritis, orthostatic hypotension. Opioids
- 29. Opioids : Some I.V. Dosing Guidelines • Morphine : 0.025 – 0.05 mg/kg, max of 0.1 mg / kg – 70 kg patient : 1.75 – 3.5 mg, Max of 7 mg • pethidine 0.5 – 1.0 mg / kg, max of 50 – 100 mg • Fentanyl : 1 – 2 mcg / kg, max of 3 mcg / kg Opioids
- 30. • Benzodiapines (i.e. Midazolam) and narcotics (i.e. fentanyl) together with have a synergistic effect on sedation and respiratory depression. Use extreme caution when using these two drug families together !!!!! Opioids with Benzodiazepines
- 31. Moderate Sedation Risks • Respiratory depression • Loss of airway • Vomiting/aspiration • Arrhythmias
- 33. Airway Obstruction: Recognition Respirations • Paradoxical chest movement • Tachypnea • Inspiratory stridor • Snoring (partial), • No breath sounds (complete) • Decreased O2 sats
- 34. Airway Obstruction: Recognition Neuro - Restlessness, -decreased mental status, -unconscious - Skin: cyanosis -Vitals: Tachycardia, bradycardia, hypertension
- 35. How can we relive Airway Obstruction
- 39. How to reverse effect of Benzodiazepines and Opioids?
- 40. Reverse of Benzodiazepines Flumazenil • A benzodiazepine receptor antagonist • Treat overdoses of benzodiazepines with 0.2 mg IV per minute (maximum single dose is 1 mg) • Rapid reversal with large boluses may result in arrhythmias, hypertension, aggitation or seizures
- 41. Reverse of opioids Naloxone • A pure narcotic agonist that reverses the respiratory depression caused by narcotics • Reverses respiratory depression AND analgesic effects of opioids • Rapid reversal with a large bolus is undesirable • Titrate 0.05 mg – 0.1 mg to effect • Half-life about 30 min • Pulmonary edema, narcotic withdrawal symptoms, and pain crisis (if on chronic opioids) are possible
- 42. Equipment needed • Pulse oximeter • Oxygen source • Ambu-bag with mask and oral airway • Laryngoscopes with Miller and Mac blades • Endotracheal tubes with stylet • Functioning suction with Yankauer tip • ECG monitor
- 43. Equipment needed Emergency “Code Alpha” Cart w/ defibrillator • Standard resuscitative drugs • Anesthesia emergency drugs –Narcan (naloxone) -flumazenil –Succinylcholine
- 44. Intra-procedure monitoring • SaO2 (via pulse oximetry) • Blood pressure • EKG monitor (rhythm & rate) • Respirations • Level of consciousness
- 45. Intra-procedure Patient should be responsive to physical and verbal stimuli at all times • If unresponsive, patient has become deeply sedated • Stop procedure • Initiate appropriate airway management • Defer further administration of sedatives until patient returns to moderate sedation