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BDS4 Sedation Symposium > IV sedation techniques > Flashcards

IV sedation techniques Flashcards

1
Q

What would be the features of the ideal IV sedation agent?

A

Anxiolysis (main aim of sedation)

Sedation

Easy to administer

Non-irritant

Quick Onset

Quick recovery

No adverse side efffects

Amnesia

Low cost

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2
Q

How do Benzodiazepines act?

A

Acts on receptors in the CNS:

Enhance effect of GABA (inhibitory neurotransmitter) in cerebral cortex and motor circuits- prolongs time for receptor repolarisation

Mimics effect of glycine (inhibitory) on receptors in brainstem and spinal cord

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3
Q

What component of benzos allow attachment to receptors?

A

Benzine ring

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4
Q

What are the respiratory effects of benzodiazepines

A

Respiratory depression via:

CNS depression and muscle relaxation

Decrease in cerebral response to increased CO2 (drives breathing)

Synergistic relationship with other CNS depressants

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5
Q

When is the respiratory depression effects of Benzos increased?

A

If patient’s respiratory system already compromised

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6
Q

What are the cardiovascular effects of benzos?

A

Decreased BP- muscle relaxation decreases vascular resistance

Increased HR- baroreceptor reflex compensates for BP fall

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7
Q

Which drugs to benzos interact with

A

Other CNS depressants

Erythromycin

Antihistamines

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8
Q

How are issues with tolerance and dependence in patients taking benzos combatted?

A

Only given in 2 week prescriptions

-> One off sedation appointments will not cause this (but may be seen in patients who already abuse benzos)

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9
Q

What is the issues with patients disclosing sexual fantasies while sedated, how is the practitioner protected?

A

Higher dose increase chance

-> Sedationist must never be alone with patient

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10
Q

What are the advantageous properties of midazolam?

A

Water soluble (at pH <4)

Lipid soluble at physiological pH- allows crossing of BBB

Painless injection

Rapid onset (2-3 times more potent that diazepam)

Elimination half life of 90-150mins (quicker recovery than diazepam)

Metabolised in liver

Additional extra-hepatic metabolism in bowel (better for those with liver disease)

More reliable

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11
Q

What caused pain on injection when using diazepam preparations in past?

A

propylene glycol (this is because diazepam is water insoluble and requires another liquid)

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12
Q

What pH is Midazolam

A

3.5

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13
Q

What quantity do midazolam preparations come in?

A

5mg/5ml

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14
Q

Who are the members of the sedation team?

A

Operator/Sedationist

Second trained person- nurse

Runner

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15
Q

What are the requirements of the sedation team?

A

All must have appropriate sedation training

Must be able to manage sedation related complication and emergencies

Annual ILS training and sedation scenario training

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16
Q

What type of cannula is used in sedation?

A

In-dwelling

-> Butterfly is not recommended (easily dislodged, issues with clotting and obstruction)

17
Q

What are the advantages of the in-dwelling cannula

A

More secure

Made of teflon (preferred to metal)

Rarely blocks

18
Q

What sites can be used for cannulation?

A

Dorsum of hand

Antecubital Fossa

19
Q

What are the advantages of using the dorsal of the hand for cannulation?

A

Easily accessible- patient likely to be clothed

Superficial and Visible

20
Q

What are the disadvantages of using the dorsum of the hand?

A

Poorly tethered- vessels move around

Affected by peripheral vasoconstriction- may need to warm hand up

21
Q

When is the antecubital fossa used?

A

As a second choice to dorsum of the hand if you cannot find a vein there (bigger vessels)

-> Less stable, be careful to stay lateral to brachial artery and median nerve

22
Q

What can be used as a topical anaesthetic prior to cannulation?

A

Ametop gel or EMLA

-> used less now as patient would need to apply before appointment

23
Q

What monitoring equipment is used by staff in sedation?

A

Pulse oximeter

Non-invasive blood pressure device- measures every 5-10 mins

-> acts as early warning system to allow intervention before an emergency can develop and minimise risk

24
Q

What is used to reverse patient in an emergency situation?

A

Stop if values get worrying

Administer flumazenil (antagonist for benzos) and provide means of ventilation

25
Q

How is midazolam administered

A

0.5-1mg bolus- then 1 mg ever 60 seconds until suitably sedated (max of 7.5mg)

26
Q

What are the signs of the end point for sedation

A

Slurring and slowing of speech

Relaxation

Delayed response

Willingness to accept treatment

Verrill’s sign- ptosis

Eve’s sign- loss of motor coordination

-> Patient should NOT lose verbal communication

27
Q

How can Eve’s sign be checked

A

Ask patient if they can place finger on nose with eyes closed

28
Q

What factors can affect dose of midazolam required to achieve sedation (therapeutic dose)

A

Sleep

Alcohol

Stress

Other drugs

age

29
Q

How long should sedation last

A

30-45mins

30
Q

What do you do if you notice patient oxygen saturation is dropping?

A

Ask them to take deep breaths and see if it improves

31
Q

What happens in the recovery phase of sedation?

A

Escort can be with patient (can act as second person)

Patient can leave 60 mins after first increment- so long as they can walk unaided

Cannula must be removed before leaving (infection risk)

Escort is given post-op instructions

32
Q

What are the steps in dealing with respiratory depression

A

1.Talk, shake, hurt
2. Place in head tilt, chin lift, jaw thrust position
3. Administer oxygen via nasal cannulae (2L/min)
4. If this fails administer oxygen via Hudson mask (5L/min)
5. Administer Flumazenil
6. Use BVM and check airways

33
Q

What quantity does the preparation of flumazenil come in?

A

500 micrograms in 5ml

34
Q

How is flumazenil administered? What are the issues with it?

A

200mcg then 100mcg every 60 seconds until response

-> has shorter half-life than midazolam so patient could re-sedate (keep for longer)

BDS4 Sedation Symposium (8 decks)

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