Pharm2 9 Anesthesia & Sedation pt3 DOSES

Question 1

Emergency Equipment to have in the room when you’re doing sedation, just in case. (8)

Answer 1

Pharyngeal suction
Positive pressure ventilation
Oxygen
Appropriate size face mask, ambu
Laryngoscope:  blades, batteries, bulb
Airways:  nasal and oral 
ET tubes, Cricothyrotomy set up
Defibrillator and emergency ACLS meds

Question 2

Diazepam (Valium) -
Class
Dose (2)
Onset
Duration
Risks (2)

Answer 2

Class: Benzodiazepine
Dose: 0.1 mg/kg IV, 0.5 mg/kg PR
Onset: < 1 minute
Duration: 1-2 hours
Risks: decreased respiratory drive, decreases B/P

Question 3

What conclusions are made from Diazepam, based on its duration?

Answer 3

There aren’t too many ER surgeries that last 2 hours. So for that time that follows someone needs to be with the patient.
Or you wouldn’t choose this if the surgery won’t last anywhere as long as this drug.

Question 4

Midazolam (Versed)
Class
Dose (2)
Onset (2)
Duration
Risks

Answer 4

Class: Benzodiazepine
Dose: 0.15 mg/kg IV/IM
Onset: 2 minutes IV, 10-15 minutes IM
Duration: 30 minutes IV
Risks: decreased respiratory drive, decrease B/P

Question 5

With Midazolam, it stops in __ minutes, so they can…

Answer 5

Now this one stops in 30 minutes. Then they can sit up, take sips of liquid or ice chips. Then they don’t necessarily need to be monitored one on one (you won’t leave ‘em alone though)

Question 6

Which Benzo is much more realistic in the ER?

Answer 6

Midazolam (30 min duration vs 2 hours with Diazepam)

Question 7

*All benzo’s cause a degree of what? Which one specifically has the greatest of this effect?

Answer 7

*All benzo’s cause a degree of amnesia, depending on what receptors they hit, but *Midazolam has the greatest amnestic properties INCLUDING retrograde amnesia (a couple hours).

Question 8

___ has the greatest amnestic properties INCLUDING retrograde amnesia (a couple hours).

Answer 8

Midazolam

Question 9

Meperidine (Demerol)
Class
Dose (2)
Onset (2)
Duration (2)
Risks (4)

Answer 9

Class: Opioid agonist
Dose: 1 mg/kg IV, 1-2 mg/kg IM
Onset: < 1 minute IV, 15 minutes IM
Duration: 30-60 minutes IV, 2-3 hours IM
Risks: cardiac arrhythmias,decreased respiratory drive, really bad pruritis, and vomiting

This drug is listed here b/c it’s occasionally used, but it’s so infrequent he won’t focus on this.

Question 10

Morphine Sulfate
Class
Dose
Onset
Duration
Risks (2)

Answer 10

Class: Opioid agonist
Dose: 0.1 mg/kg IV
Onset: < 5 minutes
Duration: 3-4 hours
Risks: cardiac arrhythmias,	decreased respiratory drive

Question 11

What is Morphine a gold standard for?

Answer 11

It’s used for pain that will last a long time: Fractured femurs, MI for chest pain, burns.
Pilonidal cyst

Question 12

Fentanyl (Sublimaze)
Class
Dose
Onset
Duration
Risks (4)

Answer 12

Class: Opioid agonist
Dose: 2-3 µg/kg IV
Onset: 2 minutes
Duration: 30 minutes
Risks: decreased respiratory drive, decreased BP, bradycardia, rarely chest wall rigidity

Question 13

This is the drug that most use for procedural sedation. “very clean” a synthetic morphine equivalent, that’s ~100x more potent.
While morphine gets a nl syringe, this is in an insulin syringe (mcg).

Answer 13

Fentanyl

No nausea/vomiting “I promise you, in 99/100 patients.”

Question 14

Effect of 5 mg of morphine = ___ of this other drug.

Answer 14

75 mcg of Fentanyl.

Question 15

*the only drug that can cause rigid chest wall syndrome – the chest wall can’t expand. These pts can only breathe by moving their diaphragm.

Answer 15

Fentanyl

Question 16

If someone develops rigid chest wall syndrome while on ___, how do you treat it? (can’t use narcam b/c it works on diff receptors to stop the euphoria)

Answer 16

Fentanyl

You need to paralyze chest muscles so they can’t contract. Rapid sequence induction – give fasiculating or nonfasiculating general anesthetic (rocuronium, vecuronium) so they are paralyzed to overcome this analgesic Fentanyl. Now this patient has lost their protective gag reflex, can’t breathe at all b/c muscles are paralyzed. Now this pt needs to be intubated and monitored overnight.

Question 17

Colonoscopies, get __ then __. this is the very popular combination

Answer 17

midazolam, then fentanyl

Question 18

Ketamine (Ketalar)
Class
Dose (2)
Onset (2)
Duration (2)
Risks (4)

Answer 18

Class: Dissociative agent
Dose: 1-2 mg/kg IV, 4 mg/kg IM
Onset: < 1 minute IV, ~ 5 minutes IM
Duration: 15 minutes IV, 30-60 minutes IM
Risks: increases BP/intracranial/intraoccular pressures, rare emersion reaction laryngeospasm,`

Question 19

12kg little girl fell of the monkey bars, their forearm is bent at a 45º angle. They are splinted and brought in by EMS. Start IV, hook up to EKG, pulse ox, o2, first drug you give is _____. Why? What dose?

now you wanna give the kid some ______. What dose?
Stop, wait, and watch. 30 sec after this, she will develop ___ for ~10 seconds. Then that’ll stop.

Next she will start gazing around (seeing Barney come out of the ceiling). Now I’ll take her both of the forearm fracture and put them back into place, the kid won’t even notice/care. Then put a splint on her, sling her, and the nurse & her will wait.

Which drug wears off first? Then what happens?

Answer 19

Midazolam (calm ‘em down) .15 mg/kg IV*.

ketamine 1mg/kg push (she weighs 12 kg), give her 12mg of ketamine.

horizontal nystagmus

Ketamine wears off first, she goes to x-ray for repeat film, and if it’s good after 30 minutes when Midazolam wears off.

Question 20

Emersion reaction – very rare (he’s never seen, but heard of it happening) –

What drug is it associated with? what is it? Who does it happen to? What do you do about it?

Answer 20

kid wakes up seeing the delusions. They’re biting, kicking, screaming, etc until you give a Benzo (Valium) and they snooze for 4-5 hours, and they wake up & it’s gone. Rarely happens in anyone under age 10. So due to this, Ketamine is not used in anyone >10.

Question 21

A child has a side effect from sedation. They look like they’re trying to scream, but they can’t.
What going on?
Which drug is this an adverse effect to?
How do you tx?

Answer 21

Laryngeal spasm, Ketamine

Take a bag valve mask that’s normally used to ventilate patient, and use this for ~10 minutes until this wears off, and it’s fine.

You can’t tx this by intubating b/c the laryngeal spasm doesn’t allow it

Question 22

Milk of Amnesia’s actual name is

Answer 22

Propofol

“this is everyone’s favorite”
Looks like skim milk leaking into veins

Question 23

Propofol (Diprovan)
Class
Dose
Onset
Duration
Risks

Answer 23

Class: Intravenous anesthetic-sedative-hypnotic
Dose: 0.5 - 1.0 mg/kg IV
Onset: 1 “arm-brain circulation”
Duration: < 5 minutes
Risks: not FDA approved for peds use, cardiac arrhythmias, decreased respiratory drive

Question 24

How do you talk the patient through use of Propofol?

Answer 24

There’s a small burning sensation when it’s injected. “when you feel the burning in your arm count backwards from 100.” they won’t’ even make it to 99 before they’re out.

Question 25

What happens to virtually everyone who is put on Propofol? What do you do about it?

Answer 25

Virtually everyone stops breathing when this drug is given. “but only for ~90 seconds.” So this person is ALWAYS on 100% O2 with a pulse-ox. Pre-oxygenate for 5 minutes with NRB, and it prevents this from being an issue.

Question 26

When is Propofol particularly valuable?

Answer 26

emergency medicine. such as Putting a dislocated shoulder back in place

Question 27

Chloral Hydrate - a terrible drug. Why?
Class
Dose
Onset
Duration
Risks

Answer 27

Mean time to discharge kids to CT scan was 18 hours b/c of sedation. Do not use this drug.

Class: Hypnotic-Sedative
Dose: 50-75 mg/kg PO/PR
Onset: 30 minutes
Duration: 3-4 hours
Risks: not FDA approved in peds,  cardiac arrhythmias, decreased respiratory drive, prolonged recovery