Sedation & Analgesia Flashcards
ASA Grades
Classification Definition
ASA I A normal healthy patient
ASA II A patient with mild systemic disease
ASA III A patient with severe systemic disease
ASA IV A pt w/ severe systemic disease that is a constant threat to life
ASA V Moribund pt w/ multi organ failure or haemodynamic compromise
ASA VI A Pt declare brain dead, awaiting organ harvesting
Procedural sedation indications
- Orthopaedic procedures
- DC Cardioversion
- Any procedure that the patient may find painful or unpleasant
Reversal agent for Opioid overdose
Flumazenil
Morphine dose / Onset time / Peak time / Duration
- 0.1 - 0.2 mg/kg
- 5-10 min onset
- 10-15 minute peak
- 2-4 hour duration
Fentanyl dose / Onset time / Peak time / Duration
- 1-2 mcg/kg
- 1-2 min Onset
- 2-5 min peak
- 30 min duration
Propofol properties
- Sedative
- Amnesic
- No analgesic properties
- 30-60s onset
- Peak 1-2 mins
- Decreased muscular tone
- Resp / CVS depression
- Vasodilation
- Anti-Ionotropic
- Hypotension
- Dose = 0.5 - 1mg/kg
Midazolam properties
- Sedation
- Amnesic
- No analgesic properties
- Decreased muscle tone
- Onset 1-2 mins
- Peak 3-4 mins
- Duration 30 mins
- CVS/Resp depression
- Risk of hypotension but less than propofol
- Dose = 1-2mg
- Top up 0.5mg
Ketamine properties
- Dissociative sedative
- Analgesic
- Amnesic
- CVS/Resp preservation
- Sympathetic response (Tachy, Hypertension, Laryngospasm, Emergence phenomena)
- 1mg/kg
- 1/4 - 1/2 dose top up
- Onset 1min
- Peak 2min
- Duration 30min
What monitoring does ASA advise for a moderate sedation?
- ECG
- NIBP (on 3 min cycles)
- SPO2
- Waveform ETCO2*
- Recommended for moderate sedation
- Mandatory for deep sedation
What does RCEM list as a never event for procedural sedation?
Overdose of Midazolam due to the selection of a higher dose preparation, instead of the 1mg/ml presentation
Clinical assessment and minimum monitoring standards for the anaesthetised patient
Clinical assessment:
- Respiratory rate
- Pulse rate and strength
- CRT / peripheral perfusion
- pupillary size and reactivity
- lacrimation and sweating
- evidence of respiratory effort or limb movement
Minimum standards of monitoring:
- SPO2
- Waveform capnography
- 3-lead ECG
- NIBP
Objectives of analgesia
- To relieve suffering
- To improve assessment
- To reduce physiological stress and prevent deterioration
- To facilitate treatment that would otherwise cause significant distress
Practice recommendations on prehospital pain management from the National Association of EMS Physicians and endorsed by the UK military
- Mandatory assessment of both presence and severty of pain
- Use of reliable tools for the assessment of pain
- indications and contraindications for prehospital pain therapy
- non-pharmacological interventions for pain management
- pharmacological interventions for pain management
- Mandatory patient monitoring and documentation before and after
analgesic administration - Appropriate handover and transfer of care to hospital
- Quality improvement and management structure to ensure appropriate use of prehospital analgesia
Non-Pharmalogical analgesic interventions
- Distraction
- Reassurance
- Immobilisation
- Cold water & dressing in burns
Entonox separates into its components at what temperature?
-6 degrees Celsius
Fascia Iliaca plane block - Indication & Nerves affected
NoF or Midshaft femur
Femoral and Lateral femoral cutaneous
Serratus Anterior plane block - Indication & Nerves affected
Rib fractures
Intercostobrachial
Long thoracic
Thoracodorsal
Digital Ring block indication and nerves
Finger dislocations, fractures and lacerations
Digital nerves
WHO analgesic ladder 5 key principles
1) Oral administration of analgesics should be used whenever possible
2) Analgesics should be given at regular intervals with the duration and dose of medication supporting the patient’s level of pain
3) Analgesics should be prescribed according to the pain intensity characterised by the patient (this should be free from judgement from the clinician)
4) Dosing of pain medication should be adapted to the individual, starting at the lowest dose and duration possible but titrating accordingly to response
5) Consistent administration of analgesics is vital for effective pain management
