Summary: Regional anesthetic techniques are increasing in popularity because of the improved recovery profiles Intravenous adjuvants can provide patient comfort Titrated infusion of rapid and short acting sedative drugs should enhance patient safety Vigilant monitoring, supplemental oxygen, and the availability ressucitation equipment are strongly recommended

1. SEDATION DURING REGIONAL
ANESTHESIA
Made Wiryana

3. UNCOMFORTABLE SURGICAL PROCEDURE
UNDER LOCAL OR REGIONAL ANESTHESIA
Subcutaneous multiple injection (e.g
cosmetic surgery) of local anesthetic
solution is often painful
Traction on deep structure and immobile
for prolonged periods on narrow operating
table cause significant discomfort
Environment, awake and aware during
surgery extremely anxiety-provoking

4. Local or Regional technique are
supplemented with adjunctive drugs for
Amnesia
Anxiolysis
Sedation
Systemic analgesia
Monitored Anaesthesia Care (MAC)

5. SEDATION CAN BE PROVIDE BY
Preoperative explanation of the procedure
Ongoing verbal communication during the
operation
Low levels of visual and auditory stimuli in
the operating room
Keeping the patient warm
Titrated sedative and analgesic drugs to
avoid compromising patient safety

6. SEDATION IS A BALANCING ACT
RRiisskkss BBeenneeffiittss

7. Supplemental oxygen is strongly
recommended to avoid haemoglobin oxygen
desaturation
Usual monitoring devices and emergency
resuscitation equipment should be
immediately available

8. Emergency equipment
* Oxygen with nasal cannula / mask
* Ambu Bag with mask
* Suction
* Crash Cart
* Airway box
* Reversal Agents
Complications
* Usually related to medications / patient response
* Respiratory Depression
- Patient stimulation may be all that’s needed
- Consider use of above emergency equipment
* Aspiration
- Suction
- May be silent. Watch skin color and SpO2
* Hemodynamic instability
- Consider fluid bolus
* For any complication, consider ACLS guidelines / calling a code (2-4700)

9. • Assistant Responsibilities
– Patient assessment and appropriate
documentation throughout the procedure
– Reassure patient and monitor patient
awareness.
– Provide comfort measures as needed
– Notify clinician of changes / concerns.
– Documentation of required parameters.
The Assistant is not to leave patient bedside for any reason during
the procedure (although may assist the clinician with short,
interruptible tasks) The assistant must be able to drop those
tasks if the patient needs attention)

10. CHOICE OF SEDATIVE AGENTS
Benzodiazepines
Opioid (narcotic)
Non-opioid (NSID) analgesics Sub-anaesthetic
doses of sedative-hypnotics (e.g. barbiturates,
etomidate, propofol, and ketamine
Inhalational technique is avoid for many reasons:
pungent smell and increase PONV, make them
unacceptable

11. BENZODIAZEPINES
Diazepam
Produce anxiolysis, amnesia, and sedation ( CNS depression
is dose dependent), these effects prolonged in elderly, and
undesirable for ambulatory patients
Has long elimination (24-48 hr) and hangover
Midazolam
Produces more profound anxiolysis, amnesia , and sedation
Does not cause pain on injection
Rapid acting, half-life 2-4 hr
Titration is desired to minimized side-effects

14. KETAMIN
Phencyclidine derivative which can produce
dissociative sedative
Subhypnotic doses (0.25-0.75 mg/kg iv) may useful
for sedation and amnesia for local or regional
anesthesia
Supplemental analgesia
Administering with benzodiazepine or other sedative
drugs may reduce the side effects
Low dose ketamin (25 μg/kg/min) combined with
midazolam or propofol is increasing in popularity at
the present time

15. PROPOFOL
Infusion at sub-hypnotic dose (2-5 mg/min)
may produce varying degrees of sedation. This
doses typically equivalent with thiopenton 3-9
mg/min, midazolam 0.06-0.18 mg/min, and
etomidate 0.2-0.6 mg/min
Rapid recovery
Reduce the incidence of over sedation and
side-effects (PONV, respiratory and
cardiovascular variables)

17. ANALGESIC ADJUVANTS
Opioid
Combination these drugs can enhance the
degree of sedation and improve surgical
condition ( prevent discomfort from pressure
and traction )
Combinations of midazolam –alfentanyl and
propofol-fentanyl have been reported to
provide highly satisfactory

18. NSAIDs
Combination of ketorolac-sedative drugs is
becoming increasingly popular as a
supplemental
The quality of analgesia of ketorolac 1
mg/kg was similar with fentanyl 3μg/kg iv
Incidence of pruritus and PONV much
reduced by ketorolac

19. Alpha-2 Agonists
Clonidine and dexmedetomidine have been consderable sedative,
anxiolytic, and analgetic sparing properties
Dexmedetomidine is becoming popular as adjuvant during MAC
in outpatients
Dexmedetomidine has good recovery from sedative-anxiolytic
However dexmedetomidine has been associated with a high
incidence of bradycardia
Further investigations are require in modern anesthetic practice

20. PROCEDURAL SEDATION –
PHARMACOLOGIC CONSIDERATIONS

21. If respiratory depression and/or
hemodynamic instability occurs, consider use
of reversal agents.

23. Patient-Controlled Sedation
• The level of stimulation and discomfort may change
throughout the operative procedure, so levels of
sedation may be required at different times
• The popularity of PCA resulted the idea of the use of
PCS (Zelcer, et al)
• A midazolam-fentanyl mixture reported a higher
degree of intra-operative comfort (Park WY and
Watkins PA)
• Propofol bolus of 0.7 mg/kg and lockout interval of
three minutes was reported as a high level
satisfaction (Grattidge P, Osborne GA, et al)

24. Summary
Regional anesthetic techniques are increasing in
popularity because of the improved recovery profiles
Intravenous adjuvants can provide patient comfort
Titrated infusion of rapid and short acting sedative
drugs should enhance patient safety
Vigilant monitoring, supplemental oxygen, and the
availability ressucitation equipment are strongly
recommended

25. Newer sedative drugs with more specific
action, shorter durations and reduced side-effects
as well as newer techniques like PCS
(Patient Control Sedation) should improve
patient safety and comfort during regional
anesthesia

26. TThhee EEnndd..
TThhaannkk YYoouu!!