Pharm2 9 Anesthesia & Sedation pt2

Question 1

Define Deep Sedation (key words)

Answer 1

A controlled state of depressed consciousness, accompanied by PARTIAL LOSS OF PROTECTIVE REFLEXES including inability to respond purposefully to VERBAL command, produced by a pharmacological or non-pharmacological method, or combination thereof

Question 2

What’s the difference btwn procedural sedationa nd other forms of sedation? (2)

Answer 2

you never lose gag reflex – no “puke in dah lungs”, never lose ability to purposefully respond

Question 3

2 other names for Procedural Sedation

Answer 3

“Conscious” or “Light” Sedation

Question 4

Who am I?

Utilized conscious sedation for a painful procedure in 1844
With Dr. William T.G. Morton, founded concepts that eventually became modern day anesthesia

Answer 4

Horace Wells (1815-1848)

Question 5

____ was the most common anesthetic, frequently used pre-operatively pre-1840.
Perhaps still used today by many ☺

Answer 5

Alcohol

Question 6

Presently we have a variety of medications making conscious sedation much easier

Clearly, which agent is best?

Answer 6

no single agent is best.

None is best otherwise we wouldn’t be having this class. Darn it.

Question 7

5 indications for Conscious Sedation (aka for procedural/light sedation)

Answer 7

To control pain, apprehension or anxiety
For complex or long surgical procedures
To facilitate the treatment of medically compromised patients
To induce amnesia in selected cases (ex: for kids who had traumatic incident with a dog will have retrograde amnesia)
To minimize use of physical restraints in technically complex or precise cases

Question 8

Conscious Sedation Risks (2)
This has the potential to bring your patient to, and perhaps over, the brink of:
What else?

Answer 8

Respiratory arrest

If you give too much they lose the gag reflex and need to be intubated. So if you do this you need to be skilled w/ intubation, and have that equipment right there at the bedside.

Question 9

What’s the goal of procedural sedation?

Answer 9

Short time – use potent drugs that push the patient right to the edge of resp arrest, and holds them there for the precise time you want them there, and then recover them as rapidly as possible afterwards. And have all the precautions in place just in case.

Question 10

NYS law: How many ppl/who is needed for procedural sedation procedure?

Answer 10

*3 ppl needed: person for anesthesia, monitor patient, to do the procedure.

Question 11

ASA Classification: estimating patient risk for receiving anesthesia & surgery

This is (or is similar to) ___ criteria.

Answer 11

Class I - Normal healthy patient
Class II - Patient w/ mild systemic disease
Class III - Patient w/ severe systemic disease
Class IV - Patient w/ incapacitating disease that is a constant threat to life
Class V - Moribund patient who is not expected to last 24 hours with or without surgery
E – any Emergency Surgery

Similar to Goldman’s Criteria of pre-op patient risk

Question 12

3 considerations for choosing an anesthetic in a patient with a pre-existing disease.

Answer 12

Choose anesthetic agents that will not worsen patient’s chronic medical conditions
Will not result in prolonged post-op observation or sequelae related to anesthetic
Allows patients to pick up right where they left off, resume pre-op medications and be on their way

Question 13

Ketamine – first studies came out of

Answer 13

vetinary medicine

Question 14

How does ketamine work based on doses? (2)

Answer 14

Low doses: Low 1 mg/kg/IV. Works local
High dose: 4mg/kg IV – anesthetic
so if I screw up and give too much it’s an anesthetic

Question 15

Ketamine increases ___

Answer 15

ICP

Question 16

What’s the problem with dentists using Chlorylhydrate? What’s it used for? And what’s its route of admin?

Answer 16

of long recovery: a drug used for procedural sedation in dentistry for kids: Chlorylhydrate (PR). But the problem is the avg recovery time was 18 hours. Typically 1 nurse is doing this PACU – post anesthesia care unit. Think of all the ppl that can be recovered in a 12 hour shift, maybe 6-8 with 1.5 go recover each patient and get them to a regular bed when anesthesia wears off.

Question 17

How do clinicians define “best” drug for a procedure? (3)

Answer 17

The drug provides a safe, predictable response, with a wide therapeutic range
it is inexpensive (huh?) - unrelated drug to the topic, but LMWH’s fewer associated costs make it less expensive than Heparin, despite being more expensive on the market.
there is an early recovery to “turn the bed”

Question 18

“I’m going to give you a little shot that is going to relax you.” before operation – what drug is this?

Answer 18

Midazolam

Question 19

Anesthetic agents terminate their effect by:

Answer 19

Redistribution.

Constantly redistribution back and forth thru adipose, BBB, central, and peripheral…

Question 20

Benefit of IV administration of titrating anesthetics/sedatives

Answer 20

rapid distribution of agent to central compartment with predictable peak effect and clinical response. Must more predictable.

Question 21

When is Midazolam’s onset of action? What do you do until then?

If they respond in that amount of time, what do you do next?

Answer 21

2-3 min, in that time you’re monitoring & assessing them to see if they’re responding
If you wait the 2-3 minutes and they have responded, continue with the sedating drug, w/e that is. 50% dose of what patient needs of the follow up drug, whatever it is.

Question 22

How to convince parents that IV meds are better than PO meds with sedation on their kids.

Answer 22

PO is least predicable b/c it depends on what type of food is in your stomach. Tell parents IV is better, b/c if anything goes wrong with PO, you then would have to insert an IV. So this initial IV access has additional safety, b/c if things go downhill you already have IV access.

Question 23

Define stacking

Answer 23

giving more injections when you’re not waiting long enough for the drug’s onset of action to actually occur (waiting only 30 sec b4 injecting more, when the drug’s onset is 2 minutes)

Question 24

Kids getting a CT scan need to have a __ and __…or you’ll have to flee the country!

Answer 24

Pulse-ox and EKG

Question 25

5 monitoring equipment you need with procedural sedation

also need a defibrillator in the room

Answer 25

Automatic B/P
Heart rate Monitor
Lead II ECG
Oxygen saturation
Patient’s level of awareness

Question 26

What type of monitoring is not useful in kids under 5 years? Why?

Answer 26

Automatic B/P – not used for kids under 5 years. Not useful to measure these kids’ blood pressure. Bc if something goes wrong, the first thing that changes in these kids is tachycardia. Blood pressure may remain the same though, so it’s not a good judge. Also if a kid falls asleep w/ minimal sedation, but the cuff on their arm blows up, waking them up. Now you need to use more sedation, and this happens again. It’s counterproductive and the least important of their vital signs. This is what Prof Herman believes, but “it’s up to you.”

Question 27

Evaluating patient for ventilations: What’s the best way?

Answer 27

Collapsing and filling of their nonrebreather bag

this is better than pulse-ox b/c The pulse ox will normally read 95-100. If she stopped breathing, it’d take ~5 min for pulse ox to fall below 90. If you hook them up to 100% o2 nonrebreather their pulse ox will read 100%.

Question 28

Who would you not put 100% oxygen nonrebreather on for procedural sedation?

Answer 28

COPD pt who might be put into resp distress if you did this.

Question 29

If they stop breathing, 9 time out of 10 ___ resolves the issue.

Answer 29

suctioning

Question 30

When monitoring, the patient’s skin should feel (2)

They should be able to respond to ___

Answer 30

Warm & dry

Patient should always be able to respond to command if performing conscious sedation