Sedation - meds and airway management Flashcards
(20 cards)
Explain the difference between sedation and paralysis
Sedation: a temporary depression of consciousness to reduce responsiveness to the environment.
Paralysis: Renders the muscles unable to move ‘neuromuscular blocking agents’
Describe Delayed Sequence Intubation (DSI)
Essentially procedural sedation for pre-oxygenation.
Useful for patients fighting pre-oxygenation and decreasing concentration on intubation preparation (ETOH/hypoxic/drugs etc)
DSI:
Ketamine 1mg/kg
–>
Preoxygenate 2-3 minutes
–>
Administer paralytic, wait 1 minute
–>
Intubate
Describe Rapid Sequence Intubation (RSI)
Airway management technique that produces inducing immediate unresponsiveness (induction agent) and muscular relaxation (neuromuscular blocking agent) and is the fastest/most effective means of controlling the emergency airway.
Nine steps:
- Plan/prepare (airway equiptment, monitoring, meds, team, pt, PPE, ETT)
- Protect the cspine (if required)
- Pre oxygenate (100% hi flow O2 for 3 mins, can use nasal canula at 15L/min)
- Positioning (can use pillow under neck) - Pre treatment (prep aramine etc)
- Cricoid pressure (optional)
- Paralysis with induction (depolarising eg sux, or polarising eg roc)
- Placement with proof
- Post intubation management (cuff pressure, secure ETT, ongoing sedation, ventilation)
Typical male and female ETT size
Female: 7-7.5mm
Male: 7.5-8.5mm
Induction agents for sedation
- Fentanyl
- Ketamine
- Midazolam
- Propofol
- Thiopental
Induction agents for sedation
- Fentanyl
- Ketamine
- Midazolam
- Propofol
- Thiopental
Paralytic agent
- Rocuronium (non-depolarising)
- Pancuronium (non-depolarising)
- Cistacurium besylate (non-depolarising)
- Suxamethonium (depolarising)
- Vecuronium
Fentanyl - indication, dose, onset time, duration, side effect, contraindication
Indication:
Opioid analgesic. Short acting, conscious sedation. Induction dose: 50-100mcg
Onset time:
<60seconds Duration: Dose dependent (30 min for 1-2mcg/kg, 6 hours for 100mcg/kg)
Side effect:
Resp depression, apnoea, circulatory depression, myoclonic jerks, bronchospasm
Contraindication:
Obstructive lung disease, severe resp depression, opioid hypersensitivity, raised ICP
Ketamine - indication, dose, onset time, duration, side effect, contraindication
Indication:
Non-barbituate rapid acting general anaesthetic.
RSI, especially if heamodynamically unstable.
Good for TBI as does not raise ICP.
Good for reactive airway disease as causes bronchodialation.
Induction dose:
2mg/kg Onset time: 30 seconds
Side effects:
Emergence syndrome, increased myocardial oxygen consumption, increased secretions
Contraindication:
Condition that a significant raise in BP would be hazardous
Ketamine - indication, dose, onset time, duration, side effect, contraindication
Indication:
Non-barbituate rapid acting general anaesthetic.
RSI, especially if heamodynamically unstable.
Good for TBI as does not raise ICP.
Good for reactive airway disease as causes bronchodialation.
Induction dose:
2mg/kg
Onset time:
30 seconds
Side effects:
Emergence syndrome, increased myocardial oxygen consumption, increased secretions
Contraindication:
Condition that a significant raise in BP would be hazardous
Midazolam - indication, dose, onset time, duration, side effect, contraindication
Indication:
Short acting benzodiazepine - used for conscious sedation.
Not recommended for RSI but can be used for RSI of shocked patients.
Conscious sedation dose:
1-2.5mg over 2 min
Induction dose:
0.02mg/kg (10-15mg)
Onset time:
15-30 minutes
Side effects:
Respiratory depression, apnoea, hypotension, paradoxical agitation
Contraindication:
Myasthenia Gravis
Propofol - indication, dose, onset time, duration, side effect, contraindication
Indication:
Short acting general anaesthetic.
Induction of anaesthesia/sedation
First line sedation for RSI.
Useful for pt’s with reactive airway disease and status epilepticus.
Induction dose:
2-2.5mg/kg
Maintenance dose:
1-3mg/kg/hr
Onset time: 15-45 seconds
Duration: 5 - 10 minutes
Side effects:
Hypotension and bradycardia. Myocardial depression, reduced cerebral perfusion
Contraindication: Egg allergy. Children <16. Heamodynamically unstable
Propofol - indication, dose, onset time, duration, side effect, contraindication
Indication:
Short acting general anaesthetic.
Induction of anaesthesia/sedation
First line sedation for RSI.
Useful for pt’s with reactive airway disease and status epilepticus.
Induction dose:
2-2.5mg/kg
Maintenance dose:
1-3mg/kg/hr
Onset time:
15-45 seconds
Duration:
5 - 10 minutes
Side effects: Hypotension and bradycardia. Myocardial depression, reduced cerebral perfusion
Contraindication: Egg allergy. Children <16. Heamodynamically unstable
Thiopental - indication, dose, onset time, duration, side effect, contraindication
Indication:
Barbituate, general anaesthetic.
Used for RSI.
Induction dose:
3-5mg/kg
Duration:
5-10 minutes
Side effects:
Laryngospasm, hypotension, hypokalaemia, vasodilation
Contraindications:
Heamodynamically unstable. Status asthmaticus.
Thiopental - indication, dose, onset time, duration, side effect, contraindication
Indication:
Barbituate, general anaesthetic.
Used for RSI.
Induction dose:
3-5mg/kg
Duration:
5-10 minutes
Side effects:
Laryngospasm, hypotension, hypokalaemia, vasodilation
Contraindications:
Heamodynamically unstable. Status asthmaticus.
Define a depolarizing neuromuscular blocker
eg: rocuronium
Acts as acetylcholine (ACh) (neurotransmitter) receptor antagonists by binding to the ACh receptor and stopping any action potentials. This stops the transmission of sodium and therefore conduction of the nervous system, causing relaxation.
Suxamethonium - indication, dose, onset time, duration, side effect, contraindication
Indication:
Short acting depolarizing neuromuscular blocker.
Facilitated ETT intubation.
Dose: 0.6-1.1mg/kg
Onset time:
30-60 seconds
Duration:
6-10 minutes
Side effects:
Hyperkalaemia, malignant hyperthermia, increased intraocular pressure
Contraindications:
Major burns, crush and spinal injuries, hyperkalaemia, open eye injury, hx of malignant hyperthermia
Suxamethonium - indication, dose, onset time, duration, side effect, contraindication
Indication:
Short acting depolarizing neuromuscular blocker.
Facilitated ETT intubation.
Dose:
0.6-1.1mg/kg
Onset time:
30-60 seconds
Duration:
6-10 minutes
Side effects:
Hyperkalaemia, malignant hyperthermia, increased intraocular pressure
Contraindications:
Major burns, crush and spinal injuries, hyperkalaemia, open eye injury, hx of malignant hyperthermia
Rocuronium - indication, dose, onset time, duration, side effect, contraindication
Indication:
Non-depolarising neuromuscular blocker.
Facilitate ETT intubation.
Provide muscle relaxation during mechanical ventilation.
Can be used for RSI unless rapid recovery is required - eg elective surgery or neuro assessment
Induction dose:
0.6mg/kg
RSI dose:
1-2mg/kg
Onset time:
60-90 seconds
Duration:
30-40 minutes
Side effects:
Allergy - rare
