Procedure - Sedation Flashcards
When you get a patient who might need procedural sedation, one of the first things you should do is _______________.
make them NPO
You don’t want to let them eat and drink only to have them hang out in the ED for several hours longer.
What are UNC’s procedural sedation NPO thresholds?
Adults:
- No solids for 8 hours
- No clears for 2 hours
Review the ASA (American Society of Anesthesiologists) patient classification system.
I: healthy patient (no comorbidities)
II: patient with a mild systemic illness (e.g., UTI)
III: patient with a severe illness that does not limit capacity
IV: patient with a severe illness that is incapacitating and a threat to life
V: patient who is expected to die soon.
Procedural sedation requires _______ people.
at least two
One performing the procedure and one performing sedation.
True or false: the person performing procedural sedation can leave the room during the procedure.
False
In procedural sedation, the provider doing the sedation must have eyes on the patient at all times.
What parameters need to be monitored in procedural sedation?
- Continuous telemetry
- Waveform capnography
- Every five minutes you vitals: BP, HR, SpO2, RR
What resources (materials and personnel) do you need to do procedural sedation?
- Dedicated sedation provider
- Person performing procedure
- SOAPME (suction, oxygen, airway – bag-mask is ok, and EtCO2 monitoring)
- Person capable of establishing IV access
- Reversal agents
- Code cart
Which patients should be given supplemental oxygen prior to and during the procedural sedation?
All patients
The _________ scoring system is used to grade safeness for discharge after anesthesia.
Aldrete
What components go into the Aldrete scoring system?
BP:
+/- 20 of pre-anesthesia level = 2
+/- 20-50 of pre-anesthesia level = 1
+/- 50 of pre-anesthesia level = 0
Consciousness:
- Fully awake = 2
- Arouses on calling = 1
- Doesn’t arouse on stimulation = 0
Color:
- Normal = 2
- Dusky, pale, blotchy = 1
- Cyanotic = 0
Activity:
- 4 extremities moving = 2
- 2 extremities moving = 1
- 0 extremities moving = 0
Respiration:
- Deep breaths without dyspnea = 2
- Dyspneic or shallow breaths = 1
- Apneic = 0
Review the post-anesthesia discharge instructions for patients.
For the next 24 hours:
- Stand up slowly
- Do not perform vigorous activity
- Do not operate heavy machinery
- Do not drink alcohol
- Do not take sedating medicines
What medicines are commonly used for procedural sedation?
In general, you want a short-acting medicine. This can include ketamine (more common for kids), short-acting opioids (fentanyl), and short-acting benzodiazepines (Versed).
What are some contraindications to fentanyl?
Increased ICP
Respiratory distress
What is adult dosing procedural sedation dosing of fentanyl?
0.5 - 1.0 mcg/kg (typical doses 25 mcg - 50 mcg)
The above dose range can be repeated every 5 minutes up to a max of 250 mcg.
How is fentanyl cleared?
Renally
Doses may need to be halved.
How long dose Versed last?
2-6 hours
What are the dosing and administration parameters for Versed?
Adult dosing:
1-2 mg IV pushed over at least 2 minutes. Can repeat for a max of 5 mg.
What are the dosing and administration parameters for Valium (diazepam)?
Adult dosing:
5-10 mg IV pushed over 2-3 minutes. Can repeat for a max of 20 mg.
True or false: ketamine suppresses the respiratory drive.
False
What is one sedation-related side effect of ketamine that is unfortunate?
Sialorrhea
Ketamine cannot be used in what patient population (two answers)?
Alcoholics (it’s hepatically metabolized)
Those with increased ICP
What is adult dosing of ketamine?
0.5 - 1.0 mg/kg IV
Pushed slowly over 2 minutes
Morphine typically lasts ___________.
3-5 hours
What is the dosage of morphine for adults?
2-4 mg IV every five minutes to a max of 20 mg
What is the dosing for Narcan in adults (for apnea)?
0.4 - 2.0 mg IV every 3 minutes to a max of 10 mg
What is the dosing of flumazenil?
0.2 mg IV every minute to a max of 1.0 mg
Patients must be observed until they reach an Aldrete score of _______.
8
What terms have replaced “conscious sedation”?
Minimal sedation (awake anxiolysis) Moderate sedation (sleepy but arousable to light stimulation) Deep sedation (like a deep sleep that's hard to wake someone from)
These are all more mild than general anesthesia.
What are some pediatric-specific diagnoses that may make a child have a difficult airway?
- Airway malacia
- Trisomy 21
- Pierre Robin syndrome
- Prematurity
- Cerebral palsy
- Behavioral patients (can become agitated with sedation)
- Developmental delay
What clinical features do you need to assess before performing conscious sedation?
- PO status (generally prefer 8 hours for solids and 2 hours for clears)
- Physical exam (jaw, neck, mouth, cardiac, and pulmonary systems at the minimum)
- Recent illness
- Recent sedative drug usage (e.g., have they taken opioids or benzodiazepines in the past 24 hours)
- PMH
- Allergies
- Past experiences with sedation/surgery
- ASA class
- Vitals
- Weight
At what Mallampati score is consultation with an anesthesiologist recommended?
III - consider it
IV - absolutely need to do it
No question here, just remember to position the person with neck slightly extended before administering sedation. This can save you from having them lose their airway when you give them the sedative.
..
Because sedation is a procedure, it requires ____________.
a consent form
Review the mnemonic SOBA-PEM-PID.
It’s a mnemonic you can use when you are either intubating a patient or doing procedural sedation:
- Suction
- Oxygen (tank, wall connector)
- Bag-mask
- Airway (laryngoscope, ETT, oropharyngeal airway)
- Pulse-ox
- End-tidal CO2
- Monitor
- Personnel (RT, Nurse)
- IV access
- Drugs (RSI meds, sedation meds, reversal agents, and code drugs)
How full should an O2 tank be for procedural sedation?
At least enough to deliver 15 LPM for 60 minutes.
When should you use an oropharyngeal airway?
Use an OPA when the head tilt, chin lift maneuver fails to relieve their obstruction.
How do you size an OPA?
Just like a nasopharyngeal airway except it’s mouth to angle of the mandible instead of nose to angle of the mandible
Elevated ETCO2 represents _____-ventilation.
hypo
Remember that ETCO2 indicates PaCO2.
What three ID things must be said in a time out?
Name
DOB
MRN
What’s the mnemonic to help you remember the components of the Aldrete scoring?
ARC3
- Activity
- Respiration
- Circulation (BP)
- Color
- Consciousness
In which circumstance can you not discharge a person with an Aldrete score of 8?
When they have received a reversal agent in the previous hour
What is the pediatric sedation dose of ketamine?
2 mg/kg
You can give repeat doses of 0.5 - 1.0 mg/kg every 5 minutes as needed.
How long does a person need to be NPO prior to ketamine for procedural sedation?
None
Because ketamine doesn’t interfere with airway reflexes there is no NPO time needed.
Propofol needs 8 hours for a fatty meal, 6 for a light meal, 4 for formula, 2 for clears
