Procedural sedation and analgesia


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Procedural sedation and analgesia

  1. 1. Procedural Sedationand Analgesia Paleerat Jariyakanjana, MD Faculty of Medicine Naresuan University 31 Jan 2013
  2. 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. 3. Sedation Level
  4. 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. 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. 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
  8. 8. History and Comorbidities: ASAPatient AssessmentProcedural Urgency
  9. 9. Patient AssessmentHx: fasting state, prior experiences with PSA or anesthesia, current medications, and allergiesPE: potentially difficult airway or cardiorespiratory problems
  10. 10. Patient AssessmentRoutine laboratory studies: not necessaryDirected ancillary testing  airway abnormalities, infections, advanced age, hepatic or renal disease, dehydration, fever, or hypovolemia
  12. 12. Fasting State
  13. 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. 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
  16. 16. Interactive Monitoring: by dedicated observersMechanical Monitoring
  17. 17. Mechanical Monitoring
  19. 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. 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. 21. Supplemental Oxygen during Procedural Sedation and Analgesiaadministration of supplemental oxygen can delay recognition of hypoventilation
  22. 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. 23. Sedation ManagementOnce the patient has achieved the target sedation level, the actual procedure may begin.
  25. 25. Nitrous Oxidecan be used alone for minimal sedation or as adjunct with IV medications for moderate sedation
  26. 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. 27. Fentanyleasily titratable when used alone for minimal sedationcan be used in combination with midazolam for moderate and deep PSA
  28. 28. Methohexitalbest used for brief moderate and deep sedation  joint dislocation reductionAdverse side effectsrespiratory depression
  29. 29. Pentobarbitalexcellent agent for minimal sedation for neuroimaging in children
  30. 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. 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. 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. 33. Propofolfrequently used for moderate and deep PSA
  34. 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. 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. 36. ANY QUESTIONS?