Procedural Sedation

Procedural Sedation

• The phrase “procedural sedation” refers to techniques of managing a patient’s pain and anxiety to facilitate appropriate medical care in a safe, effective and humane fashion.

Chloral Hydrate

Chloral Hydrate

• Usually given to Outpatients due to relative low risk profile. For non-painful procedures only.

• EEGs
• MRI/CT Scans
• Echocardiograms

Chloral Hydrate

• PO/Rectal

• Dose: 50mg/kg give 30-60 minutes prior to procedure.

• Can repeat x1 25mg/kg

• Not to exceed 100mg/kg in a 24 hour period

Chloral Hydrate

• Expect a moderate decrease in heart rate and blood pressure in patients ASA I-II

• For infants < 6 months there is ↑ risk for apnea and hypoxia.

• Age a limiting factor. High failure rate in children > 4 years.

Pentobarbital : Nembutal®

Nembutal

• PO/Rectal/IM/IV

• Dose for procedural sedation:

• 4mg/kg , may repeat 2mg/kg, max 100mg

Nembutal: precautions

• Rapid IV injection ie, can cause respiratory depression, apnea, laryngospasm, bronchospasm and hypotension

• Recommended to infuse IV dose over 10-30 minutes.

• Can significantly decrease cardiac output and should be avoided with CHF

Benzodiazepines

• Midazolam- Versed®

• Lorazepam - Ativan®

• Induce anterograde amnesia (not retrograde)

• May have some opioid sparing effect by ↓ anticipatory pain response

Midazolam -® Versed

• Most commonly used Benzo for preoperative and pre-procedural sedation.

• Undergoes hepatic metabolism and renal excretion and prolonged effects seen with dysfunction of either system

• Sedative, amnestic and anxiolytic with no analgesic properties

• Commonly used with an opioid analgesic such as Fentanly®

Versed®

• Onset in 1 to 2 minutes

• Duration 30 min

• Caution for respiratory depression and hypotension

Fentanyl- Sublimaze®

• Used in combination with Versed for many years due to rapid onset and effectiveness

• Synthetic opioid

• Metabolized by the liver

• Short duration of effect

• Pure analgesic (should not be

• used alone)

• Least histamine release of opiates

Fentanyl

• Dosage for Pediatrics:

• -IM or IV 0.5-1.0 mcg/kg/dose

• -onset 1-2 min

• -lasts 30 minutes

Ketamine-Ketalar®

• Classified as a general anesthetic

• Rapid acting dissociative anesthetic that produces a profound analgesic effect

• Gaining favor in children due to reliable effects and strong safety profile

Ketamine

• IV 1-2 mg/kg/dose

• -Onset is 1 minute

• -Duration 10-20 minutes

• IM 2-4 mg

• -onset 5 minutes

• -duration 15-45 minutes

Propofol-

• Classified as a general anesthetic

• -Lower doses

• sedation

• hypnosis

• Anmestic, anxiolytic, antiemetic, and

• antiepileptic properties

• No Analgesic effects

Propofol

• Dosing 2.5 -3.5 mg/kg/ dose over 20-30 seconds

• Onset 10-30 seconds

• Duration 10-20 minutes

• For prolonged procedures may require continuous infusion 125-300mcg/kg/minute. (smaller children may require smaller infusion rates.

Propofol Caution

• Profound Respiratory Depression

• Profound Irreversible bradycardia

• Profound Hypotension

• Avoid with Soy or Egg allergies