3.2 Procedural Sedation Flashcards
How do you assess level of sedation for procedural sedation?
Modified Ramsay Sedation Scale (aim for 4-6, mod to deep). Richmond Agitation and Sedation Scale (aim for -1 to -4)
NPO status for procedural sedation?
Ideal to fast, but recomendation is do not delay procedure based on NPO status, bc no demonstration of risk reduction of emesis/aspiration
Describe the ASA Physical Status Classification System, and how it relates to whether you will perform procedural sedation
Determines severity of comborbidity for patient undergoing procedural sedation.
ASA I - normal.
ASA II - mild systemic dz, including pregnant, obese, mild diabetes, drinker, smoker.
ASA III - COPD, heavy drinker, pacemaker, dialysis. Can still do procedural sedation, but may need med adjustment or monitoring.
ASA IV, V, VI - sedation at bedside should not be done, needs anesthesiologist, resuscitation team, etc.
What is the Mallampati Score? What are Class I - IV?
Judges how easy intubation will be.
Class I - complete visualization soft palate
Class IV - soft palate not visible at all
What is needed for pre-procedure preparation re: sedation?
- ) Informed written consent.
- ) Gather equipment: cardiac monitor with pulse ox, capnography, IV access with crystalloid, airway mgmt and resuscitative equipment.
- ) Staff: RN for continuous monitoring, provider credentialed to perform sedation/airway mgmt, provider to perform procedure.
What is required for intra-procedure monitoring re: sedation?
Baseline vitals, continuous ECG, capnopgrahy and pulse ox, Q5 min BP, HR, RR/depth, O2 sat, ETCO2, sedation/pain level.
Titrate sedation meds according to these parameters.
What is involved in post-procedure recovery re: sedation?
Q15m VS until stable for 30m.
Monitor for 90m if rescue agent was used.
Criteria for recovery: return to baseline verbal, motor, mental status; no major discomfort; no active bleeding; vital signs WNL or within 20% of pre-procedure; adequate resps and > 92%; tolerate oral intake
What are potential complications from procedural sedation?
Death, arrest, airway compromise, prolonged sedation, hypoxemia, aspiration, hotn, bradycardia, tachycardia, hospital admission
What goes into selecting an agent for procedural sedation?
Safety of med, patient comorbidites (asthma, head injury, CNS-depressants, shock state, resp status), prior adverse rxns
What are your choices for procedural sedation?
Bzd plus/minus opioid
You choose midazolam for procedural sedation. Describe
Rapid onset, shorter half-life compared to other bzds.
Adverse effects: respiratory depression/apnea - exacerbated with other CNS depressants.
Dose: 0.5-1mg Q2min, max dose 10mg IV.
Onset: 3minutes.
Duration: 60 minutes.
You add on fentanyl to midaz for procedural sedation. Describe
Synthetic opioid, rapid onset, short duration of action. Adverse effects: respiratory depression, bradycardia, hotn, chest-wall rigidity in high doses 5mcg/kg rapid IV.
Dose: 0.5-2mcg/kg IV.
Describe use of ketamine as procedural sedation
Dissociative sedative with analgesic and amnestic effects.
Benefits: analgesic, no cardiopulmonary depression, can use alone, IM or IV.
Sympathomimetic: can cause HTN, tachycardia, bronchodilation.
AEs: transient increased in ICP, HTN, emergence phenomenon, disequilibrium, ataxia.
Dose: 1-2mg IV, 4mg IM.
Onset: 1-5m. Duration: 15-30m.
Describe use of propofol in procedural sedation
Sedative hypnotic with amnestic effect, NO analgesic effect.
Benefits: rapid onset/short duration, no dose adjustment for renal/liver dz, rapid recovery.
AE: resp depression, bradycardia, hotn, seizure-like activity.
CI: egg/soy/EDTA allergy.
Dose: 0.5-1.5mg/kg IV, repeat doses in 0.5mg/kg increments.
Onset: under 1m. Duration: 5-15m.
Describe etomidate in procedural sedation
Sedative hypnotic with amnestic effect. NO analgesia.
Benefits: rapid onset/short duration, limited resp and CV depression, decreased ICP.
AE: myoclonus, N/V.
Dose: 0.1-0.3mg/kg IV, max dose 0.6 mg/kg.
Onset: under 1m. Duration: 3-10m.
