Pain and Procedural Sedation

Question 1

What are quick solutions to the following sedation complications:
Hypotension
laryngospasm
hypoxemia

Answer 1

Hypotension-fluid bolus
laryngospasm-BVM, reposition
hypoxemia-Give O2

Question 2

What useful properties does ketamine have for procedural sedation?

Answer 2

analgesia, sedation, amnesia

Question 3

What are contraindications to using ketamine?

Answer 3

schizophrenia, age <3mos (increased risk of respiratory deppression), URI, coronary artery disease, HTN, non-communicating hydrocephalus, increased intra-occular pressure

Question 4

What useful properties does propofol have for procedural sedation?

Answer 4

sedative, amnestic

no analgesia

Question 5

• What are agents used for motionless sedation?

- Which agent is useful if you need to preserve the neuro exam?

Answer 5

• pentobarbital and methohexital

- Both have quick onset but methohexital more useful when you don’t want to mask the neuro exam

Question 6

What are situations you would expect to encounter a tough intubation and thus aren’t great candidates for procedural sedation?

Answer 6

• developmental delay=increased risk for aspiration
• prior intubation=potential airway abnormalities
• cardiac anomalies=poor cardiac reserve
• cleft palate/lip/macroglossia/micrognathia=harder to intubate or BVM
• Down’s syndrome-potential for atlantoaxial instability and would need to be intubated in c-collar

Question 7

What side effect of versed should you be aware of?

Answer 7

Paradoxical reactions-increased hyperactivity, usually in kids with baseline high impulsivity, anxiety or younger

Question 8

What side of effect of fentanyl should you be aware of that will not fully be reversed with naloxone?

Answer 8

-Rapid administration of large boluses of fentanyl may cause chest wall rigidity and laryngospasm. These effects may only be partially reversed with naloxone resulting in the need for paralysis and intubation.

Question 9

What side effects/contraindications should you be aware of for methohexital?

Answer 9

• potential to cause vasodilatation and depressed myocardial contractility if infused rapidly, so should not be given to patients who have hypovolemia or cardiovascular instability.
• Methohexital should not be used in patients with temporal lobe epilepsy because the drug can induce seizures in those patients.
• Another potential side effect is apnea and respiratory depression.

Question 10

What is the dosing of ketamine for procedural sedation?

Answer 10

-IV: 1 to 2 mg/kg over 30 to 60 seconds. If initial sedation inadequate or repeated doses are necessary to accomplish a longer procedure, may administer additional doses of 0.5 to 1 mg/kg every 5 to 15 minutes as needed