This document discusses conscious sedation, including why it is used, types of sedation, drugs used, risks, and how to manage complications. The main points are: 1. Sedation is used to relieve anxiety, stress and pain for medical procedures. It can cause relaxation, drowsiness or altered mental states depending on the person. 2. Types of sedation include minimal, moderate and deep sedation. Drugs like benzodiazepines and opioids are commonly used due to their sedative and analgesic effects. 3. Risks include respiratory depression, loss of airway, and vomiting/aspiration. Equipment and drugs like flumazenil and naloxone are needed

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

10. TYPES OF SEDATIONS

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

16. Mallampati Classification

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

32. Difficult Airway Anatomy

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

37. Laryngeal tube
ETT
LMA

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

46. THANK YOU!
QUESTIONS?