Sedation Analgesia Dr. Daniels

DON DANIELS COL MC 1 Sedation and Analgesia Objectives • Discuss assesment & preparation of patients prior to sedation and analgesia • Discuss medications available by class, mechanism of action, onset, duration and side effects • Discuss sedation techniques • Discuss monitoring, equipment, & documentation • Discuss inappropriate drugs & techniques DON DANIELS COL MC 2 Sedation and Analgesia Definitions • Sedation & Analgesia: a state that allows pts to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and/or tactile stimulation. Drugs may be given po, pr, IV, IM, IN or by inhalation. DON DANIELS COL MC 3 Sedation and Analgesia Definitions • Conscious Sedation: an inappropriate phrase because sedated pts often have altered mental status. Replaced by Sedation and Analgesia • Amnesia: Forget what happens • Anxiolysis: Relieves nervousness, flight instinct • Hypnosis: Decreased level of consciousness • Analgesia: Pain reduction DON DANIELS COL MC 4 Sedation and Analgesia Definitions • Levels of Sedation or Analgesia: Depth of sedation or analgesia is based on response to stimulus, presence of protective airway reflexes, and patency of the airway. Important to think of this as a continuum. – Light: All present – Deep: Response only to vigorous stimuli; may intermittently lose protective reflexes; intermittent airway obstruction – General Anesthesia: No response to stimuli. Protective reflexes absent DON DANIELS COL MC 5 Sedation and Analgesia Goals • • • • Titrate the sedation The patient is responsive and cooperative Spontaneous ventilation is maintained Airway reflexes are maintained (Avoid general anesthesia or aspiration) • Autonomic reflexes are maintained • Since all levels represent a continuum, you must be prepared if the patient becomes deeper than you anticipate DON DANIELS COL MC 6 Sedation and Analgesia Pre Procedure Assessment • Assess the physical condition (JCAHO) – Stability, optimization, can he wait – Age, weight, medication allergies, current medications, recreational drug use, alcohol usage/abuse, tobacco and past anesthesia history – Airway assessment – Cardiovascular, Pulmonary, Gastrointestinal, hepatic and renal assessment, Diabetes, Obesity, & Pregnancy status – Pertinent labs DON DANIELS COL MC 7 Sedation and Analgesia Pre Procedure Assessment • Assign a Physical Status JCAHO requires providers document a risk assessment summary in the preprocedure note and state whether the patient is an acceptable candidate for sedation/analgesia • Immediately prior to sedation, also need to reassess & document change in physical status • Easy method is to assign ASA physical status • ASA I: healthy • ASA II: mild to moderate systemic disturbance • ASA III: severe systemic disturbance that limits normal activities • ASA IV: severe, life threatening disturbance • ASA V: Moribund pt with little chance of survival 8 DON DANIELS COL MC Sedation and Analgesia Pre Procedure Assessment • Example of summary statement in progress note • “2 May 01, 1000 hrs. 70 y/o male ASA 2 for HTN and NIDDM for MRI with sedation(per pt request). Pt is an acceptable candidate for sedation.” • “4 May 01, 0800 hrs. No change in physical status. Patient has signed consent for sedation and MRI. Risk, benefits and alternatives of sedation explained, all questions answered.” DON DANIELS COL MC 9 Sedation and Analgesia NPO guidelines • NPO after midnight – There has been a relaxation in this standard during the late 90’s. NPO to solids after midnight. NPO to liquids 2-3 hrs prior to sedation – Clear liquids: apple juice, water, pedialyte. Black coffee without sugar, milk or cream DON DANIELS COL MC 10 Sedation and Analgesia Pre Procedure Preparation • Monitors: SpO2, NIBP, EKG • Airway equipment: O2, Bag and mask, nasal and oral airways, nasal cannula, non rebreather mask • Emergency Drugs: Atropine, Epinephrine • Other: IV, Suction, Crash Cart • Personnel: BCLS, ACLS, PALS certified DON DANIELS COL MC 11 Sedation and Analgesia Titration Guidelines • Desired goal – Calm, comfortable patient – Slightly sleepy – Can verbally arouse sleepy patient – Slurred speech – Regular respirations no less than 10/min • Undesirable goal – – – – Agitation, confusion Disorientation Hypoxia, resp <10 Deep sleep, unable to arouse – Loss of protective reflexes – Dyrrhythmias 12 DON DANIELS COL MC Sedation and Analgesia Titration Guidelines • Slow titration ( 1/2 , 1/4 ,1/4) • Additional doses based on pt response • Appropriate drug for procedure (narcotics for invasive, benzo’s for imaging) • Calc dose based on weight, age and physical condition • Decrease when combining narc w benz DON DANIELS COL MC 13 Sedation and Analgesia Benzodiazepines • Mechanism of Action – Enhance function of GABA binding to its receptor causing cell membrane hyperpolarization making the cell more resistant to neuronal excitation • Pharmacologic Properties – Anxiolytic, hypnotic, anticonvulsant, skeletal muscle relaxant and amnestic. They have no analgesia properties DON DANIELS COL MC 14 Sedation and Analgesia Benzodiazepines • Diazepam (Valium) – Onset < 2min IV, < 10 min rectal, 15 min 1h PO – Peaks in 3-4 min – Last 4-6 hrs – Dose 0.02-0.15 mg/kg IV, IM, PO, rectal. Titrate at 1-2 mg increments IV • Midazolam (Versed) – – – – Onset 30 sec-1 min IV Peak 3-5 min IV Last 15-120 min IV Dose 0.01-0.15 mg/kg IV. 1 mg increments. Rarely need more than 5 mg. DON DANIELS COL MC 15 Sedation and Analgesia Benzodiazepines • Diazepam – Contraindications: known hypersensitivity, Untreated glaucoma, pregnancy, shock, coma, resp depression – Side effects: bradycardia, hypotension, resp depression, drowsiness, ataxia, paradoxical excitement, venous thrombosis, phebitis @ injection site • Midazolam – Contraindications: Same as Diazepam – Side effects: tachycardia, vasovagal episodes, PVC’s, hypotension, bronchospasm, laryngospasm, apnea, hypoventilation, euphoria, disinhibition, tonic clonic movements, agitation, hyperactivity 16 DON DANIELS COL MC Sedation and Analgesia Opioids • Mechanism of Action: mimic the action of endorphins by binding to opioid receptors resulting in activation of the pain modulation system. Provides analgesia or pain relief • Although there are 5 receptors the Mu receptor is responsible for analgesia • Do not provide amnesia DON DANIELS COL MC 17 Sedation and Analgesia Meperidine (Demerol) • Dose range: – 0.10 - 1 mg/kg IV slow titrate – 50-150 mg (1-3 mg/kg) IM q 3-4 hrs • Healthy <40 y/o 75-100 mg IM • Elderly/debilitated 20-50 mg IM • Onset – IV: < 1 min – IM: 1-5 min DON DANIELS COL MC 18 Sedation and Analgesia Meperidine (Demerol) • Peak – IV: 5-20 minutes – IM: 30-50 minutes • Duration – IV/IM: 2-4 hours • Contraindications: – Known hypersensitivity – MAO inhibitors (fatal HTN, tachycardia) – History of seizures DON DANIELS COL MC 19 Sedation and Analgesia Meperidine (Demerol) • Side Effects – CV: hypotension, cardiac arrest, tachycardia – PULM: resp depression, arrest, laryngospasm – CNS: euphoria, dysphoria, sedation, seizures, dependence, dizziness – GI: constipation, biliary tract spasm, N&V – MS: chest wall rigidity – DERM: urticaria, pruritis DON DANIELS COL MC 20 Sedation and Analgesia Morphine • Dosage – IV: 0.01-0.1 mg/kg (max 15 mg) titrate slowly – IM: 2.5-15 mg • Onset – IV < 1 minute – IM 1-5 minute • Peak – IV: 5-20 minutes – IM: 30-60 minutes DON DANIELS COL MC 21 Sedation and Analgesia Morphine • Duration – IV/IM: 4-5 hours • Contraindications – Known hypersensitivity – Caution in asthmatics DON DANIELS COL MC 22 Sedation and Analgesia Morphine • Side effects: Morphine releases histamine and is known to decrease peripheral vascular resistance – CV: hypotension, tachycardia, bradycardia, arrhythmias – PULM: bronchospasm, laryngospasm, resp dep, chest wall rigidity – CNS: blurred vision, syncope, euphoria – GU: urinary retention – GI: biliary tract spasm – DERM: uticaria, pruritis DON DANIELS COL MC 23 Sedation and Analgesia Fentanyl • DOSAGE – IV: 0.5-3 mcg/kg, – Supplied in micrograms @ 50 mcg/ml. It is potent. – Titrate 25-50 mcg (0.5 - 1 ml) slowly • ONSET – IV: < 30 seconds • PEAK – IV: 5-15 minutes • DURATION – IV: 30-60 minutes DON DANIELS COL MC 24 Sedation and Analgesia Fentanyl • SIDE EFFECTS – – – – CV: hypotension, bradycardia Pulm: respiratory depression, apnea CNS: dizziness, blurred vision GI: n/v, delayed gastric emptying, biliary tract spasm – MS: chest wall rigidity DON DANIELS COL MC 25 Sedation and Analgesia Fentanyl • PRECAUTIONS – 100 x’s more potent than morphine (100 mcg fentanyl = 10 mg Morphine) – Greater respiratory depression than demerol or morphine – Greater incidence of chest wall rigidity DON DANIELS COL MC 26 Sedation and Analgesia Opioid Precautions • If chest wall rigidity, cannot ventilate, use narcan. If you need to use neuromuscular blockade to break rigidity call anesthesia stat • If you need narcan to reverse remember the reversal is usually shorter than the opioid duration • Decrease opioid dosage in elderly, debilitated, hypovolemic, or pts with hepatic failure • Decrease opioid dosage if using together with sedatives DON DANIELS COL MC 27 Sedation and Analgesia Opioid Comparison Potency Duration Caution histamine release tachycardi a, MAO inhibitors >er chest wall rigidity 28 Morphine Gold 4-5 hrs standard Demerol 1/10 2-4 hrs potency of morphine Fentanyl 100 x's > 1/2-1 hr Morphine DON DANIELS COL MC Sedation and Analgesia Dissociative analgesia (ketamine) • Indication: Academy Pediatrics recommends using ketamine instead of DPT. Ketamine causes intense analgesia and amnesia • Mechanism of Action: – Causes dissociation of nerve impulses from thalamocortical and limbic systems. DON DANIELS COL MC 29 Sedation and Analgesia Ketamine • Dose – IV: 0.25 - 1mg/kg – IM: 2.5-5 mg/kg • Onset – IV: <30 seconds – IM: 3-4 minutes • Peak – IV: 1 minute – IM: 5-20 minutes • Duration – IV: 5-15 minutes – IM: 12-25 minutes • Contraindications – Increased ICP – Preterm infants – Severe, uncontrolled HTN, tachycardia, CAD – Acute cocaine intoxication DON DANIELS COL MC 30 Sedation and Analgesia Ketamine • Side Effects – CV: HTN, tachycardia, arrhythmias, bradycardia, cardiovascular collapse in cathecolamine depleted patient – PULM: respiratory depression, apnea, laryngospasm – CNS: tonic-clonic movements, emergence delirium, nystagmus, diplopia, increased ocular tension – GI: hypersalivation, N/V DON DANIELS COL MC 31 Sedation and Analgesia Chloral Hydrate • • • • A sedative/hypnotic. Not an analgesic Good for use with small children Oral or rectal route, absorption irregular Minimal effect on respiration, but will be additive to resp depression when combined with other agents • Delayed onset > 60 min • Dose: 20-100 mg/kg. Max 1500 mg. DON DANIELS COL MC 32 Sedation and Analgesia Pentobarbital • • • • • • • Sedative hypnotic, long acting barbiturate Non analgesic (hyperalgesic) Popular for noninvasive radiologic procedures PO, PR, IM, IV Rapid onset Dose 5mg/kg IM or 1-2 mg/kg IV Max 100 mg Hypersensitivity reactions, hypoventilation, apnea. When combined with narcotics, apnea, airway obstruction increased. Contraindicated in porpyria. DON DANIELS COL MC 33 Sedation and Analgesia Reversal Agents: Naloxone • Opioid antagonist • Inhibits opioid agonist at Mu receptor sites • Can cause withdrawal symptoms in pts with opioid physical dependence • Onset: IV 1-2 minutes • Peak: IV 5-15 minutes • Duration: IV 1-4 hrs COL MC DON DANIELS 34 Sedation and Analgesia Reversal Agents: Naloxone • Dosage: Mix 0.4 mg with 9 ml NS. Slowly titrate 1 ml diluted soln to desired response. Do not just “push” the amp of Narcan. • Side effects: – – – – CV: tachycardia, hypertension, arrhythmias Pulm: pulmonary edema CNS: tremulousness DON DANIELS 35 GI: nausea, vomiting COL MC Sedation and Analgesia Reversal Agents: Romazicon • Benzodiazepine antagonist • Competively inhibits the activity of benzodiazepine receptor site on the GABA/BZ complex in the CNS. • Reverses sedation, respiratory depression, amnesia, & psychomotor effects of benzodiazepines DON DANIELS COL MC 36 Sedation and Analgesia Reversal Agents: Romazicon • Dosage: 0.2 - 1 mg IV, titrated @ a rate of 0.2 mg/min. May repeat q 20 min. Max single dose 1 mg. • Onset: 1-2 min IV • Peak: 2-10 min IV • Duration: 45-90 min DON DANIELS COL MC 37 Sedation and Analgesia Reversal Agents: Romazicon • Contraindications: tricyclic antidepressant poisioning, may cause panic attack in pts w panic disorder, pts on BZ for epilepsy • After flumazenil therapy, monitor patient for at least 2 hrs for resedation or respiratory depression. DON DANIELS COL MC 38 Sedation and Analgesia Inappropriate Agents • Propofol – – – – IV hypnotic agent May cause apnea and hypotension even at low doses Often results in general anesthesia at low doses Quick onset and short duration requires expert control, vigilance and continuous infusion – Pain on injection often leads to unwanted patient movement – Cause paradoxical excitement in a small percentage of patients DON DANIELS COL MC 39 Sedation and Analgesia Inappropriate Agents • Sufentanil – Opioid: 1000 times more potent than morphine – Profound respiratory depression @ low doses – Bradycardia • Alfentanil – Ultra short acting opioid – Greater incidence of N/V, bradycardia and chest wall rigidity DON DANIELS COL MC 40 Sedation and Analgesia Inappropriate Agents • Nitrous Oxide – Colorless gas; potent analgesic, weak anesthestic – Depresses airway reflexes – High risk of diffusion hypoxia – MAC level requires removal of oxygen – May cause birth defects, premature abortion in health care workers, requires scavenging DON DANIELS COL MC 41 Sedation and Analgesia Inappropriate Agents • Neuromuscular Blocking agents – Used to cause skeletal muscle paralysis for ventilated patients under general anesthesia or in critical care setting – There is no place for these agents in patients receiving sedation and analgesia – Succinylcholine is only used to emergently secure an airway & by personnel trained in advanced airway management. ACLS training is not enough. DON DANIELS COL MC 42 Sedation and Analgesia Monitoring and Documentation • Pulse ox is required, however as sedation levels change, NIBP and EKG use is highly recommended • IV access is required except for peds receiving chloral hydrate • At least one person should be monitoring the patient at all times. This person should not have additional duties • Vital signs should be documented q 5 min DON DANIELS COL MC 43 Sedation and Analgesia Recovery & Discharge • All pts recovered until reaching PARS 8-10 • One trained person must be present in recovery area • Vital signs monitoring and documented periodically • For discharge all patients will have a responsible adult accompany the patient home. The patient should not be allowed to drive. DON DANIELS COL MC 44 Sedation and Analgesia Summary • Sedation is a continuum that requires caution and vigilance to ensure patient comfort while maximizing safety • Drugs used to sedate or provide analgesia can be your friend and your enemy. To obtain a cooperative comfortable patient slowly titrate to achieve your endpoint to avoid oversedation. • Know the pharmacology of the drugs you use and match them to the desired goal. It may prevent a death. • Don’t use inappropriate drugs. Leave their use to the experts. • Monitoring & documentation is essential for patient safety and to satisfy requirements of accreditation organizations. DON DANIELS COL MC 45