Procedural Sedation & Analgesia
Procedural Sedation and Analgesia
Airway Assessment: Predicting difficulty
| Difficult Airway (LEMON) | Difficult Ventilation (MOANS) |
|---|---|
| L ook externally: syndromic, obese, gestalt | M ask seal (beard, trauma, prone) |
| E valuate 3-3-2 rule (mouth opening, thyromental, hyomental) |
O besity (redundant upper airway, OSA, poor reserve) |
M allampati
|
A ge > 55 (Loss of airway tone) |
| O bstruction: OSA, PTA, epiglottis, mass | N o teeth |
| N eck mobility: Rheum. arthritis, c-collar | S tiffness (asthma, COPD, pregnant) |
Preparation
Assemble appropriate staffing and equipment (SOAPME):
- S uction
- O xygen
- A irway adjuncts
- P ersonnel
- M edications
- E quipment
Select sedative AND analgesic if both are required. Match duration of procedure to duration of drug.
Medications
SEDATION medications
| Medication / Initial IV dose | Advantage | Side Effects |
|---|---|---|
| Midazolam 0.05 mg/kg | Shortest benzodiazepine | |
| Lorazepam 0.05 mg/kg | Short benzodiazepine | |
| Diazepam 0.1 mg/kg | Muscle relaxation | |
| Etomidate 0.15 mg/kg | Short duration | Myoclonus |
| Propofol 1-2 mg/kg | Short duration | Transient hypotension |
| Ketofol 0.5 mg/kg 1:1 ratio of ketamine:propofol |
CV stable, amnesia, analgesia |
ANALGESIC medications
| Medication / Initial IV dose | Advantage | Side Effects |
|---|---|---|
| Fentanyl 1-2 mcg/kg | Short duration | Decreased respiratory rate |
| Hydromorphone 0.02 mg/kg | | Decreased respiratory rate and blood pressure | |
| Morphine 0.1-0.2 mg/kg | | Decreased respiratory rate and blood pressure |
DISSOCIATIVE medications
| Medication / Initial IV dose | Advantage |
|---|---|
| Ketamine 1-2 mg/kg | |
| Dexamedetomidine 0.5-1 mcg/kg over 10 min |
No respiratory depression |
References
- Cravero JP, Beach ML, Blike GT, Gallagher SM, Hertzog JH; Pediatric Sedation Research Consortium.The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg. 2009 Mar;108(3):795-804. doi: 10.1213/ane.0b013e31818fc334. [PubMed]
- Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M .A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425-33.e2. doi: 10.1016/j.annemergmed.2010.08.032. Epub 2010 Oct 13. [PubMed]
- Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, Willman E.,Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial.Ann Emerg Med. 2012 Jun;59(6):504-12.e1-2. doi: 10.1016/j.annemergmed.2012.01.017. Epub 2012 Mar 7. [PubMed]
- Drayna PC, Estrada C, Wang W, Saville BR, Arnold DH, Ketamine sedation is not associated with clinically meaningful elevation of intraocular pressure. Am J Emerg Med. 2012 Sep;30(7):1215-8. doi: 10.1016/j.ajem.2011.06.001. Epub 2011 Dec 12. [PubMed]
- Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of emergency medicine. 2011 [PubMed]
