Procedural Sedation:

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Procedural Sedation
In A Nutshell
Deb Updegraff, R.N., M.S.N. P.N.P. Clinical Nurse
Specialist Pediatric Intensive Care 3S
Intermediate Intensive Care LPCH
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The Players

• MD
• RN
• Patient

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Sedation VS Analgesia
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Levels of Sedation

• Minimal Sedation (anxiolysis)
• Moderate Sedation/Analgesia (formerly called
  conscious sedation)
• Deep Sedation

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American Association of Anesthesiologists ASA
Risk Classification
ASA I - A healthy patient ASA II - A
patient with mild systemic disease ASA III - A
patient with severe systemic disease
(limits activity but not
incapacitating) ASA IV- A patient with an
incapacitating systemic disease that
is a constant threat to life ASA V- A
moribund patient not expected to survive 24
hours with or without surgery
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Pre-sedation Risk AssessmentAmpule

• Allergies
• Medications
• Past Medical History
• Last Meal
• Events leading up to the need for sedation

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Other Risks

• Previous problems with anesthesia or sedation
• Known difficult intubation
• Cranial facial syndromes
• Decreased airway protective reflexes
• Obesity
• GERD or problems with gastric motility

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Equipment (SOAP)

• Suction
• Oxygen
• Airway
• Pharmacy

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Monitoring

• Continuous
• ECG
• O2 Sat
• Blood Pressure
• Q 5 min for moderate to deep sedation
• Q 15 min for others

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Pharmacology Selecting the MedsDepends on the
Procedure and Patient History

• LP
• MRI
• PICC placement
• Central Line Placement
• Bronchoscopy
• Chest tube placement

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Choice of Drugs

• Analgesics
• Narcotics
• Fentanyl
• Morphine
• Ketamine
• Sedation
• Benzodiazepines
• Midazolam
• Lorazepam
• Barbiturates
• -Propofol

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Narcotics

• Fentanyl
• Bolus 0.5-1.0 mcg/kg (MAY REPEAT Qq5-10MIN)
• Rigid Chest Syndrome

• Morphine
• - Bolus0.05-0.1mg/kg (may repeat q5-10min)
• Histamine Release
• Sedative and
• Hypnotic properties

Narcotics have both sedative and analgesic
qualities
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Benzodiazepines

• Midazolam
• Bolus0.05-0.2 mg/kg

• Lorazepam
• Bolus0.05-0.2 mg/kg

Benzodiazepines have both sedative and Amnesic
qualities
NO Analgesic Properties
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Ketamine

• Dissociative anesthetic phencyclidine
  derivative (PCP)
• IV - 0.5 to 2mg/kg
• IM -3-4 mg/kg
• Analgesia/Sedation
• Contraindicated
• Increased Intracranial Pressure
• Increased Intraoccular Pressure
• Onset of action IV 1-2 minute
• IM 3-10 minutes
• Can cause larygospasms and hallucinogenic
  emergent reactions.

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Propofol

• General Anesthetic Agent
• NO Analgesic Properties
• Advantages
• Rapid Onset and Emergence
• Profound Sedation
• Disadvantages
• Metabolic Acidosis
• Severe ? SVR

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Propofol - dosing
Continuous Infusion 5-50 mcg/kg/hr
Induction 2.5 3.5 mg/kg Over 20-30
seconds Repeat as child emerges
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Reversal Agents
Narcan For Narcotic Reversal dose
1-10mcg/kg IV push (1/10th of dose recommended
for full reversal of narcotic poisoning) May
need to repeat. OK IV, IM, endotracheal
Flumazenil For Benzodiazepine Reversal- Can
reverse benzo-induced respiratory depression and
paradoxical excitatory reactions. dose
0.01-0.02 mg/kg. May be repeated.