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Procedural Sedation

  1. Definitions

    1. Conscious sedation: a state of depressed consciousness that allows the protective reflexes to be maintained; allows the patient to respond to physical stimulation or verbal commands
    2. Deep sedation: patient is not easily aroused; may be accompanied by a partial or complete loss of protective reflexes
    3. Procedural sedation: administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function
    4. In our department, if we are giving a medication to make the patient more able to tolerate a procedure, then this is procedural sedation (formerly known as conscious sedation). Therefore, consent must be obtained, and both nurses and physicians must fill out the sedation form. This includes a variety of medications, including Versed (midazolam), ketamine, pentobarbital, and combinations such as morphine/versed. It also includes different routes of administration, including oral, intranasal, intravenous, intramuscular, and rectal. On the other hand, the administration of medications given for pain only, such as morphine given to a sickle cell patient with pain crisis, or oral or IV narcotics given to a patient with a fracture for pain control alone, is not procedural sedation and requires no separate consent.
  2. Uses

    1. fracture reduction
    2. burn debridement
    3. laceration repair
    4. imaging studies
    5. abscess incision and drainage
    6. sexual abuse examination
    7. foreign body extraction
  3. Dietary precautions (these are ASA recommendations, not policy)

    1. "Pre-procedure fasting: Because sedatives and analgesics tend to impair airway reflexes in proportion to the degree of sedation/analgesia achieved, members of the Task Force support the concept of pre-procedure fasting before sedation/analgesia for elective procedures. However, the literature provides insufficient data to test the hypothesis that pre-procedure fasting results in a decreased incidence of adverse outcomes in patients undergoing sedation/analgesia (as distinct from patients undergoing general anesthesia)." Anesthesiology 1996:84:459-71.
    2. elective sedation:
      0-5 months: NPO x 4 hours
      5-36 months: NPO x 6 hours
      >36 months: NPO x 8 hours
    3. emergency sedation: This is nearly always what we provide in the emergency department. It is very important to measure risk vs. benefit in deciding when to sedate a patient and how long to require they have NPO status. Please discuss this issue with your attending in the Peds ED in order to decide on the best timing for each individual patient.
  4. Monitoring during sedation

    1. continuous monitoring of O2 saturation, heart rate, mental status, and ventilatory effort
    2. intermittent monitoring of BP, RR
    3. during deep sedation, suction should be on and immediately available, along with airway equipment and any applicable reversal agents
    4. continue until discharge criteria are met
  5. Routes of administration

    1. oral: advantages: ease of administration. disadvantages: may be inadequate for painful or prolonged procedures, GI absorption, emptying, first-pass metabolism
    2. IV: advantages: reliable, controllable, titratable, multiple dosing, rapid onset. disadvantages: requires IV placement
    3. IM: advantages: simple, single dose, consistent (over time) effects. disadvantages: painful, inconsistent absorption, additional doses require additional stick
    4. transmucosal (intranasal, rectal): advantages: hepatic metabolism and local gastric effects are avoided, faster in onset than oral. disadvantages: erratic absorption
  6. Medications (see chart for doses, onset of action, peak and duration)

    1. midazolam (Versed): Anxiolytic, sedative benzodiazepine. Provides no analgesia. May be given po, IV, IN, IM. Use lower doses when given in combination with other sedating agents, e.g. opiates. Dose: po or IN: 0.5-0.7mg/kg, onset 15-30min¸ duration 60-90min, IV 0.05-0.1mg/kg, max 4mg¸ onset 1-3min, duration 0.5-3hrs
    2. ketamine: Dissociative anesthetic, provides deep sedation. May be given IV, IM, po, IN. Very rapid in onset and short in duration. Can cause laryngospasm. Usually given with an antisialagogue, such as glycopyrrolate or atropine. Contraindicated in head injury and eye injury. Dose IV:1-2mg/kg; titrate to effect; onset 30-60sec, duration 5-15min
    3. morphine: Opiate analgesic with some sedative side effect. May be given IV, IM, SQ. Used in combination with other agents when analgesia and sedation are required. Dose IV: 0.05-0.15mg/kg, onset 5-10min, duration 2-4hrs
    4. pentobarbital: Barbiturate; provides no analgesia. Given IV, is rapid in onset and short in duration. Well suited for brief, nonpainful procedures (e.g. CT)
    5. fentanyl: Potent, fast acting opiate. Provides good analgesia, but little sedation at low doses. Can cause facial itching. Give lower doses when in combination with other sedating agents. Dose IV: 1-3mcg/kg, onset 0.5-3sec, duration 30-60min
    6. codeine: Oral opiate analgesic. Good for pain control, but relatively non-sedating. Dose po: 0.5-1mg/kg, onset 30-60min, duration 4-8hrs
    7. propofol: Very rapid, very short acting IV anesthetic. No analgesia. Dose IV: 1.0mg/kg initially followed by 0.5mg/kg as needed
    8. nitrous oxide: Inhaled only. Very safe, quick in onset and very short-acting. Not currently available in our emergency department
    9. reversal agents: Narcan: to reverse opioids. Dose 0.01mg/kg IV; may repeat every 2-3min IV prn; Flumazenil: to reverse benzodiazepines. Dose IV:< 20kg:0.01mg.kg, >20kg: 0.2mg/dose; may repeat every 1 min IV prn
  7. Criteria for discharge (note, there is no specific length of time to discharge)

    1. Cardiovascular function and airway patency are satisfactory and stable.
    2. The patient is easily arousable, and protective reflexes are intact.
    3. The patient can talk and ambulate (if age appropriate).
    4. For a very young or handicapped child, incapable of the usually expected responses, the presedation level of responsiveness or a level as close as possible to the normal level for that child should be achieved.
    5. The state of hydration is adequate.

See article: Krauss B, Green SM. Procedural Sedation and Analgesia in Children. Lancet, 2006; 367:766-780.

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