Procedural Sedation Flashcards
What equipment should be easily accessible before starting procedural sedation? (7)
- O2 source (wall, canister) Suction - Airway equipment (mask, NP, oral airway, intubation equipment) - Monitoring equipment (pulse ox, ECG monitor, defib pads, BP cuff, +/- capnography) - IV - Resuscitation drugs - Reversal agents - Adequate staff
What is the starting dose of ketamine?
1 - 2 mg/kg IV - generally has threshold response (vs. additive dose response) so typically don’t need repeat bolus once hit 1-1.5 mg /kg
What is the starting dose of fentanyl?
1 - 2 ug/kg
What is the starting dose of midazolam?
0.05 mg/kg
What is the starting dose of propofol? Subsequent doses? Infusion dosing?
- 0.5 - 1 mg/kg
- titrated aliquots Q1-3 min by 0.25-0.5 mg/k. If procedure lasting > 10min, repeat doses @ 0.5 mg/kg
- infusion typically 3 - 6 mg/kg/hr titrated to sedation level
Starting dose of ketofol?
Essentially about 1/2 of 0.75mg/kg of each agent (e.g. if 10 mg ket diluted in 10 mL, + 10 mg oof prop in 10 mL, then 0.75 mL/kg)
What are the 5 typical depths of dissociation?
1) minimal = anxiolysis
2) moderate = conscious sedation (purposeful respond to commands when stimulated, reflexes, hemodynamics preserved”
3) dissociative sedation = profound analgesia, amnesia w/ protective airway/resp reflexes maintain
4) deep sedation - LOC depression, cannot rouse without very painful stimuli, may require assistance to maintain airway, help with ventilation, but would have reflexes in intubation
5) general anesthesia – LOC no rousability with painful stimuli, full ventilatory and CVS support needed, no airway reflexes
What may be a relative CI to PSA in the (3)ED?
Food is NOT an absolute CI, but may consider delaying PSA if non-urgent if recent ingestion. ASA in general recommends 2h CF, 4 hr BM, 6hrs solids other liquids (however PSA is excluded from these guidelines, and no specific guidelines for PSA).
What are discharge instructions for patients post-procedural sedation? (3)
- must be back to baseline (don’t leave bedside until vocalizing!)
- should NOT drive for 12 - 24 hrs
- should be supervised for 4-8 hrs post-procedure
What are complications of ketamine + how can they be managed/mitigated? (8)
- Hypersalivation/secretions (suction) (10-30%)
- Emesis, ~5-25% (ketofol, give slowly, ?pretreat)
- Laryngospasm ~0.1-0.4%(give SLOWLY!, PPV with BVM + PEEP e.g. CPAP)
- Emergence reactions
- Transient apnea/resp depression (give slowly!, ketofol)
- ?Increased IOP (but not significant increase ICP)
- Worsening psychosis (hallucinogenic effect – dont give in these pts)
- Catecholamine surge (transient increase HR, BP)
- Nystagmus, random purposeless mvmts while sedated
- Evanescent patchy erythematous rash upper torso (5-20%)
When is ketamine contraindicated (absolute indications)? (4)
- larnygospasm concerns (infants < 3, kids with URIs/asthma)
- psychosis (Acute or well controlled)
- globe ruture (increased IOP)
- significant CAD (Catecholamine surge)
What are AE/complications of propofol? (4)
- injection pain
- apnea/resp depression
- loss of airway reflexes
- hypoTN
Dosing for Ketamine in Kids? (IV/IM) How long does it last
1-1.5mg/kg IV , 4-5mg/kg IM
Lasts 10-20 min / 15-30min
What medications might you (traditionally) consider as adjuncts with ketamine in kids?
1) Older kids > 5, prophylactic benzo to reduce emergence (not supported, increased resp complications + emesis)
2) atropine or glycopyrrolate – reduce hypersalivation, glycopyrr may increase airway complications, no benefit found with atropine in this regard
What are the clinical fx of laryngospasm and what drug can induce?
Ketamine. May be preceeded by high pitched stridor or “crowing”, then complete airway obstruction (no CW mvmt, no airway sounds, sudden Co2 waveform loss, inability to BMV)
