{"id":5366,"date":"2011-07-14T20:25:52","date_gmt":"2011-07-14T20:25:52","guid":{"rendered":"http:\/\/crashtext.org\/misc\/5366.htm\/"},"modified":"2015-02-07T19:25:04","modified_gmt":"2015-02-08T00:25:04","slug":"procedural-sedation","status":"publish","type":"post","link":"https:\/\/crashingpatient.com\/resuscitation\/sedation\/procedural-sedation.htm\/","title":{"rendered":"Procedural Sedation"},"content":{"rendered":"
(Anesthesiology: November 1998 – Volume 89 – Issue 5 – p 1293\u20131294)<\/p>\n
Annals recs for credentialing, privileges, and practice (Ann Emerg Med 2011;58(4):365)<\/p>\n
Who owns deep sedation editiorial (by Steve Green Ann Emerg Med 2011)<\/p>\n
<\/a><\/p>\n <\/p>\n <\/a><\/p>\n Deep sedation by EPs is safe (W J EM 2011;12(4):399)<\/p>\n <\/a><\/p>\n review states only one case of aspiration in all of the literature (Emerg Med J 2010;27:254e261)<\/p>\n Fasting not necessary (Annals EM 42:5, November 2003)<\/p>\n <\/p>\n In healthy patients, midazolam had no effects<\/p>\n dex > propofol in BP reductions<\/p>\n Dex also reduced HR<\/p>\n (J Clin Anesth 2011;23:218)<\/p>\n Precedex<\/p>\n <\/p>\n First case report (Eur J Emerg Med 2010;17(1):60)<\/p>\n New Annals Guidelines by Green & Krauss (Ann Emerg Med 2011; )<\/p>\n best article (Anaesthesia 2007;62(Sup 1):48-53<\/p>\n Ketamine Review from Pharm Journal<\/a><\/p>\n Green’s study of overdose show a remarkable degree of safety (ANNALS OF EMERGENCY MEDICINE 1999;34(4):492)<\/p>\n neck\/face rash common, not IgE mediated<\/p>\n 1 pass drugs (propofol, etomidate, ketamine, sux, brevitol, thiopental, adenosine)<\/p>\n If pt has diplopia, ask them to close 1 eye<\/p>\n How Krauss gives ketamine to kids<\/strong><\/p>\n 0.5 mg\/kg q 5 minutes x 3, maybe 4 doses for longer procedures<\/p>\n when the pt is >50 kg he doses lower. He gives 25 mg aliquots until the pt is where he wants.<\/p>\n IM Dosing: sub-disassoc 2mg\/kg; disassoc 4-5 mg\/kg<\/p>\n <\/p>\n <\/p>\n <\/p>\n Is lamotrigine the antidote to the hallucinations (from ScanCrit<\/a>\u00a0 pdf<\/a>)<\/p>\n For perioperative pain (Anesth 2005;102:211) 0.5 mg\/kg bolus and then same per hour<\/p>\n Ketamine Activates Breathing and Abolishes the Coupling between Loss of Consciousness and Upper Preserves Laryngeal Reflexes (Anesthesiology 1973; 38:128 \u201333) Case of laryngospasm (no actual spasm visualized) from prehospital ketamine (Burnett AM, PREHOSPITAL EMERGENCY CARE 2012;Early Online:1\u20133)<\/p>\n <\/p>\n <\/p>\n Review of pharm (Current Drug Targets, <\/em>2005, 6, <\/em>789-794)<\/strong><\/p>\n alpha of 45 minutes<\/p>\n terminated by redistrib from cns and hepatic p450<\/p>\n increases CBF, so may increase CBV<\/p>\n <\/p>\n <\/p>\n <\/p>\n A low dose infusion gives analgesia<\/p>\n Injections give analgesia and anxiolysis<\/p>\n High Doses give amnesia and disassociation<\/p>\n Cautions<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Central adrenergic release, premedication with depressants (benzos) or fentanyl will probably blunt this response.<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 MAP increased ~25 mmHg<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Probably has neuroprotective effect by NDMA antagonism, so probably will be allowed to be used in stroke and head injury in the future.<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 True laryngospasm is exceedingly rare, probably just tongue obstruction.\u00a0 Inevitably resolves with airway positioning.<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 The intraocular pressure increase has only been reported in animals<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Avoid in hyperthyroid states due to catecholamine release<\/p>\n Premedication<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Glycopyrolate .01 mg\/kg, not to exceed .2 mg or atropine .01 mg\/kg not to exceed .5 mg (can go in same syringe as ketamine, though usually better to give 10-20 minutes beforehand)<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Benzos totally unnecessary in kids, probably not to be used for routine in adults as will prolong recovery times.\u00a0 Use when\/if emergence reaction.\u00a0 Recovery period must be quiet, take off BP cuff, keep in calm environment.<\/p>\n Dosing<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 IM 4 mg\/kg (4-10) or for just analgesia 1 mg\/kg<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Booster Doses 2-5 mg\/kg q 10 minutes<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Use 100 mg\/cc formulation<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Infusion is probably best route for adults<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Mix up bag 1 mg\/cc<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 .15 mg\/kg\/min until sedation then drop down to half that dose<\/p>\n \u00b7\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Injection 1 mg\/kg (ETOH 3 mg\/kg)<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 .5-1 mg\/kg booster doses q 10 minutes<\/p>\n o\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Give slowly to prevent apnea from blunted hypercapnia reflexes<\/p>\n <\/p>\n Ketamine 1-2 mg\/kg IV, give atropine beforehand (can go in same syringe), .5-1 mg\/kg\/hr infusion<\/p>\n Safety of sedation with ketamine and versed in severe head injury patients: comparison with sufentanil. No increases in ICP, comparable to the fentanyl derivative 25 patients (Crit Care Med. 2003 Mar;31(3):711-7)<\/p>\n and (Crit Care Med 2005;33(5):1109)<\/p>\n and (Ann Emerg Med 2015;65:43)<\/p>\n (Emergency Medicine Journal 2007;24:794-795) Cerebral blood flow (CBF) is critically dependant on cerebral perfusion pressure (CPP) and oxygenation in acute head injuries. Optimal CPP is achieved by maintaining a normal mean arterial pressure (MAP) and limiting iatrogenic increases in intracranial pressure (ICP).1 Brain tissue has high oxygen consumption and no reserves; hypoxia therefore has rapid and profound effects. Early tracheal intubation and ventilation can help prevent hypoxia and aspiration. Hypoxia and hypotension in traumatic brain injury are associated with a 75% mortality rate.2 End tidal carbon dioxide should be maintained around 5 kPa, as hypercapnia causes cerebral vasodilation and increased ICP.3 Ketamine, a potent analgesic, can be used for dissociative anaesthesia in higher doses (2 mg\/kg), or sedation in lower doses. It has a rapid onset and relatively short duration of action (5\u009610 min). Unlike other commonly used induction agents, ketamine does not suppress respiratory activity or airway reflexes; it also has a positive effect on gut motility, and vomiting after administration is uncommon. These properties make it the ideal agent when profound analgesia and sedation are required without a definitive airway in place.3 Ketamine causes increased catecholamine release and decreased norepinephrine (noradrenaline) re-uptake which results in increased heart rate, arterial pressure, and MAP. This makes it a useful analgesic for trauma patients who may already be haemodynamically compromised. A single episode of hypotension is associated with a worse outcome.2 Ketamine is an N-methyl-D-aspartate (NMDA) receptor antagonist. Head injury increases concentrations of glutamate, which induces neuronal apoptosis. Ketamine blocks the actions of glutamate on the NMDA receptor, which may protect against cellular neurotoxicity, but this has yet to be demonstrated in human studies.1 3 4 Despite these benefits, the use of ketamine in patients with head injuries remains controversial. Early studies suggested that the use of ketamine may have resulted in a transient increase in ICP in a small number of patients.3 CPP was compromised only in the patients with pre-existing intracranial hypertension and obstruction to the flow of cerebral spinal fluid. This has, however, led to the persistent belief that ketamine is contraindicated in patients with traumatic head injuries. Studies done subsequently have shown, however, that the effects of ketamine on cerebral haemodynamics and ICP are in fact variable and depend on both the presence of additional anaesthetic agents and PaCO2 values.5 This patient was sedated with midazolam 10 mg iv, which prevents the emergence phenomenon, and ventilation was controlled artificially en route to hospital. When ketamine is used in the presence of controlled ventilation, in conjunction with anaesthetics which reduce cerebral metabolism such as {gamma}-aminobutyric acid (GABA) receptor agonists, ICP is not increased.1 4 1. Alban\u00e8se J, Arnaud S, Rey M, et al. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology 1997; 87: 1328\u009634.[CrossRef][Medline] 2. Anon. Prehospital Trauma Life Support Committee of the National Association of Emergency Medical Technicians in Cooperation with The Committee on Trauma of The American College of Surgeons. PHTLS , 6th ed, 2007: 194\u0096221. 3. Sehdev RS, Symmons DAD, Kindl K. Ketamine for rapid sequence induction in patients with head injury in the emergency department. Emerg Med Australas 2006; 18: 37\u009644.[CrossRef][Medline] 4. Himmelseher S, Durieux ME. Revising a dogma: ketamine for patients with neurological injury? Anesth Analg 2005; 101: 524\u009634.[Abstract\/Free Full Text] 5. Mayberg TS, Lam AM, Matta BF et al. Ketamine does not increase cerebral blood flow velocity or intracranial pressure during isoflurane\/nitrous oxide anaesthesia in patients undergoing craniotomy. Anesth Analg 1995; 81: 84\u00969.[Abstract]<\/p>\n <\/p>\n <\/p>\n J Neurosurg Pediatr. 2009 Jul;4(1):40-6.LinksEffectiveness of ketamine in decreasing intracranial pressure in children with intracranial hypertension. Bar-Joseph G, Guilburd Y, Tamir A, Guilburd JN.Paediatric Critical Care and.Object Deepening sedation is often needed in patients with intracranial hypertension. All widely used sedative and anesthetic agents (opioids, benzodiazepines, propofol, and barbiturates) decrease blood pressure and may therefore decrease cerebral perfusion pressure (CPP). Ketamine is a potent, safe, rapid-onset anesthetic agent that does not decrease blood pressure. However, ketamine’s use in patients with traumatic brain injury and intracranial hypertension is precluded because it is widely stated that it increases intracranial pressure (ICP). Based on anecdotal clinical experience, the authors hypothesized that ketamine does not increase-but may rather decrease-ICP. Methods The authors conducted a prospective, controlled, clinical trial of data obtained in a pediatric intensive care unit of a regional trauma center. All patients were sedated and mechanically ventilated prior to inclusion in the study. Children with sustained, elevated ICP (> 18 mm Hg) resistant to first-tier therapies received a single ketamine dose (1-1.5 mg\/kg) either to prevent further ICP increase during a potentially distressing intervention (Group 1) or as an additional measure to lower ICP (Group 2). Hemodynamic, ICP, and CPP values were recorded before ketamine administration, and repeated-measures analysis of variance was used to compare these values with those recorded every minute for 10 minutes following ketamine administration. Results The results of 82 ketamine administrations in 30 patients were analyzed. Overall, following ketamine administration, ICP decreased by 30% (from 25.8 +\/- 8.4 to 18.0 +\/- 8.5 mm Hg) (p < 0.001) and CPP increased from 54.4 +\/- 11.7 to 58.3 +\/- 13.4 mm Hg (p < 0.005). In Group 1, ICP decreased significantly following ketamine administration and increased by > 2 mm Hg during the distressing intervention in only 1 of 17 events. In Group 2, when ketamine was administered to lower persistent intracranial hypertension, ICP decreased by 33% (from 26.0 +\/- 9.1 to 17.5 +\/- 9.1 mm Hg) (p < 0.0001) following ketamine administration. Conclusions In ventilation-treated patients with intracranial hypertension, ketamine effectively decreased ICP and prevented untoward ICP elevations during potentially distressing interventions, without lowering blood pressure and CPP. These results refute the notion that ketamine increases ICP. Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations.<\/p>\n <\/p>\n <\/p>\n Clinical guidelines in Peds (Ann Emerg Med. 2004;44:460-471)<\/p>\n <\/p>\n Probably no difference with or without antisalagogue (Acad Emerg Med. 2003;10:482-483.)<\/p>\n <\/p>\n Case series of use in mentally disabled adults (Acad Emerg Med 1999 6(1):86)<\/p>\n <\/p>\n <\/p>\n Purpose To define the guidelines for patient selection, administration, monitoring, and recovery for ED dissociative sedation. Definition of Dissociative Sedation d A trancelike cataleptic state induced by the dissociative agent ketamine, characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability. Characteristics of the Ketamine \u0091\u0091Dissociative State\u0092\u0092 d Dissociation: After administration of ketamine, the patient passes into a fugue state or trance. The eyes may remain open, but the patient does not respond. d Catalepsy: Normal or slightly enhanced muscle tone is maintained. On occasion, the patient may move or be moved into a position that is selfmaintaining. Occasional muscular clonus may be noted. d Analgesia: Analgesia is typically substantial or complete. d Amnesia: Total amnesia is typical. d Maintenance of airway reflexes: Upper airway reflexes remain intact and may be slightly exaggerated. Intubation is unnecessary, but occasional repositioning of the head may be necessary for optimal airway patency. Suctioning of hypersalivation may occasionally be necessary. d Cardiovascular stability: Blood pressure and pulse rate are not decreased and typically are mildly increased. d Nystagmus: Nystagmus is typical. Indications d Short, painful procedures, especially those requiring immobilization (eg, facial laceration, burn debridement, fracture reduction, abscess incision and drainage, central line placement, tube thoracostomy). d Examinations judged likely to produce excessive emotional disturbance (eg, pediatric sexual assault examination). Contraindications: Absolute (Risks Essentially Always Outweigh Benefits) d Age younger than 3 months (higher risk of airway complications) d Known or suspected psychosis, even if currently stable or controlled with medications (can exacerbate condition) Contraindications: Relative (Risks May Outweigh Benefits) d Aged 3 to 12 months (higher risk of airway complications) d Procedures involving stimulation of the posterior pharynx (higher risk of laryngospasm) d History of airway instability, tracheal surgery, or tracheal stenosis (presumed higher risk of airway complications) d Active pulmonary infection or disease, including upper respiratory infection or asthma (higher risk of laryngospasm) d Known or suspected cardiovascular disease, including angina, heart failure, or hypertension (exacerbation due to sympathomimetic properties of ketamine). Avoid ketamine in patients who are already hypertensive and in older adults with risk factors for coronary artery disease. d Head injury associated with loss of consciousness, altered mental status, or emesis (elevated intracranial pressure with ketamine) d Central nervous system masses, abnormalities, or hydrocephalus (elevated intracranial pressure with ketamine) d Glaucoma or acute globe injury (elevated intraocular pressure with ketamine) d Porphyria, thyroid disorder, or thyroid medication (enhanced sympathomimetic effect) Personnel d Dissociative sedation is a 2-person procedure, 1 (eg, nurse) to monitor the patient and 1 (eg, physician) to perform the procedure. Both must be knowledgeable about the unique characteristics of ketamine. d Avoid dissociative sedation when personnel are not experienced with ketamine or may not have time to perform such sedation properly. Presedation d Perform a standard presedation assessment d Educate accompanying family about the unique characteristics of the dissociative state, especially if they will be present during the procedure or recovery.<\/p>\n <\/p>\n Atropine and Glycopyrrolate <\/strong> glycopyrrolate 0.2 mg both pregnancy class B<\/p>\n Hatzskorzian R, Li Pi Shan W, C\u00f4t\u00e9 AV, Schricker T, Backman SB. The management of severe emergence agitation using droperidol. Anaesthesia 2006; 61: 1112\u00965. 2 Malviya S, Voepel-Lewis T, Ramamurthi R, Burke C, Tait AR. Clonidine for the prevention of emergence agitation in young children: efficacy and recovery profile. Pediatric Anesthesia 2006; 16: 554\u00969.<\/p>\n <\/p>\n <\/p>\n <\/p>\n Study results were published in the August issue of the Archives of General Psychiatry.<\/strong> “The public health implications of being able to treat major depression this quickly would be enormous,” said NIH Director Elias A. Zerhouni, M.D. “These new findings demonstrate the importance of developing new classes of antidepressants that are not simply variations of existing medications.” For this study 18 treatment-resistant, depressed patients were randomly assigned to receive either a single intravenous dose of ketamine or a placebo (inactive compound). Depression improved within one day in 71 percent of all those who received ketamine, and 29 percent of these patients became nearly symptom-free within one day. Thirty-five percent of patients who received ketamine still showed benefits seven days later. Participants receiving a placebo infusion showed no improvement. One week later, participants were given the opposite treatment, unless the beneficial effects of the first treatment were still evident. This “crossover” study design strengthens the validity of the results.<\/p>\n <\/p>\n<\/span>Fasting<\/span><\/h2>\n
<\/span>Peds<\/span><\/h3>\n
<\/span>Hemodynamic Characteristics<\/span><\/h2>\n
<\/span>Dexmedetomidine<\/span><\/h2>\n
<\/span>Ketamine<\/span><\/h2>\n
Krauss Free Emergency Lecture<\/a><\/h4>\n
\nAirway Dilator Muscle Dysfunction in rats (ANESTHESIOLOGY 2012; 116:6\u20138.)<\/p>\n
\nsuggestion actually works to prevent ketamine bad trips (Anesthesia & Analgesia 2011;112(5):1082)<\/p>\nHead Injury<\/h4>\n
<\/span>Emergence Reaction<\/span><\/h3>\n