Procedural Sedation And Analgesia

Question 1

What is the definition of procedural sedation and analgesia (PSA)

Answer 1

Administration of sedative or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintains cardiorespiratory function

Question 2

What does procedural sedation and analgesia result in?

Answer 2

1. Depressed level of consciousness
2. Maintain oxygenation and independent airway control

Question 3

What is required for procedural sedation?

Answer 3

Monitoring
*patients may or may not remember the procedure depends on type of medication used, dosages, patients physiology

Question 4

What is monitored anesthesia care (MAC) or local anesthesia with standby

Answer 4

Sedation and analgesia can be provided as needed
*ideal for patients in frail health
*can convert to general anesthesia
*”standby” is the anesthesia provider monitoring the patient while the procedure is performed under local / regional anesthesia

Question 5

What are indications to complete procedural sedation?

Answer 5

1. Alleviate anxiety
2. Minimize physical pain and discomfort
3. Minimi se negative physiological repsonse to treatment
4. Maximize amnesia
5. Control behavior to expedite performance of procedures

Question 6

What are CI of procedural sedation

Answer 6

1. allergies
2. Last meal
   *food within <6 hours
   *fluids within <2 hours
3. Commodities
   *inability to intubate or manually ventilate
4. ASA classification
   *Class IV or V

Question 7

What are CI of procedural sedation relating to airway exam

Answer 7

1. Inability to open mouth >3cm
2. Thyromental distance <6cm
3. Mallampati classification
   *based on size of tongue and the visibility of pharyngeal structures
4. ROM of cervical spine
5. Presence of a beard

Question 8

What is class I of Mallampati

Answer 8

Soft palate, anterior and posterior Tonsillar pillar, uvula are visible

Question 9

What is class II of Mallampati

Answer 9

Tonsillar pillars and part of the uvula obscured by the tongue

Question 10

What is class III of Mallampati

Answer 10

Only soft and hard palate visible

Question 11

What is class IV of Mallampati

Answer 11

Only the hard palpate is visible

Question 12

What to monitor and document for procedural sedation and analgesia

Answer 12

Document mental status before and after procedure
Document ADE
Always have supplemental O2, ACLS meds, reversals agents
1. Cardiac monitor
2. Pulse oximetry
3. Blood pressure
4. End-tidal CO2 (ETCO2) = normal 35-4mmHG

Question 13

What are the ideal procedural sedation and analgesia agents

Answer 13

Provide rapid onset, maximal comfort, quick resolution, minimal after effects
1. Analgesia - narcotics
2. Amnesia - sedative (benzo)
3. Dissociative provides analgesic, amnestied, and sedative effects

Question 14

What is fentanyl and what is the dosage, onset, and duration

Answer 14

Strong synthetic opiate, Analgesic (no amnestic properties)
Dosage: 0.5-2ug/kg IV over 2 mins
Onset: 1-2 min
Duration: 30-60 mins

Question 15

What are the AE and reversal agent of fentanyl

Answer 15

Reversal agent: Naloxone
AE: bradycardia, hypotension, increased intracranial pressure, chest wall rigidity (large doses)

Question 16

What is morphine and what is the dosage, onset, and duration

Answer 16

Strong opiate, analgesic (no amnesiac properties)
Dosage: 3-4mg over 2 minutes
Onset: 2-5 mins
Peak: 20 mins
Duration: 4-5 hours

Question 17

What is the reversal agent and AE of morphine

Answer 17

Reversal agent: Naloxone
AE: respiratory depression, hypotension possible

Question 18

What is midazolam (versed) and what is the dosage, onset, and duration

Answer 18

Benzo, sedation, anxiolytic, amnestic (no analgesia)
Onset: 1-3 mins
Peak: 3-5mins
Duration: 20-60 mins

Question 19

What is the reversal agent and AE of Midazolam (versed)

Answer 19

Reversal agent: flumazenil (romazicon)
*caution if on chronic benzo can cause refractory seizures
AE: respiratory depression, HTN, prolonged sedation possible in elderly