Enteral Sedation Review Course

Stages of Anesthesia A Continuum… Stage I Analgesia/sedation 3 planes of CNS depression—initial CNS effects of agent to the clinical endpoint of light to mild sedation and/or relaxation in the conscious patient. Altered perception in time Diminished perception of pain Reduction in anxiety Continually retaining the ability to respond appro. to physical stimulation/verbal commands Any enteral sedation technique must not exceed Stage I of anesthesia

Stages of Anesthesia A Continuum… Stage II Delirium/Excitement Much deeper level of CNS depression Patient is clinically unconscious May be combative or exhibit hyper-active or unusual jerky movements

Stages of Anesthesia A Continuum… Stage III Surgical Anesthesia Most surgical procedures are performed in Stage III Subdivided into 4 planes resulting in: Deepening CNS depression Diminished or loss of protective reflexes Skeletal muscle relaxation Will not respond to physical stimulation or verbal commands May loose ability to maintain airway

Stages of Anesthesia A Continuum… Stage IV Medullary Paralysis/Death Unconscious patient experiences the deepest level of CNS depression Respiratory paralysis Cardiac arrest Clinical death

Conscious Sedation Objectives and Techniques

Enteral vs. Parenteral

Enteral Parenteral Mildly anxious pt Convenient route of administration Pharmacokinetics ADME Level of training Office requirements and staff training Greater anxiety levels Requires injection (IM or IV) Pharmacokinetics ADME Level of training Office requirements and staff training

Single Drug Technique… Advantages Effective at appropriate level of anxiety One drug to be knowledgeable about Decreased incidence of drug interactions Overdose– one drug to consider/reverse Disadvantages Not for the severely anxious patient Less timing flexibility and specificity

Combination Drug Techniques… More than one drug used to match the anticipated pain and anxiety levels of the patient The simpler the combinations the safer the technique What are the intent and the contributions of the various drugs employed?

Intent and Contributions of Agents… Two basic components—sedation/hypnosis and analgesia Sedation/hypnotic agent Sedation vs hypnosis Sedative agent should be regarded as the titratable agent Analgesia Not regarded as titratable Administered in a low fixed dose to enhance analgesia and sedation In a conscious sedation technique analgesia is achieved with effective local anesthesia

Selection of Agents… Should be reversible Relatively short acting Provide minimal respiratory depression Insidious at onset and not easily recognizable without PETCO2 Pulse oximetry is a crude monitor of respiration if patient breathing room air Supplemental O2 obscures the early detection of respiratory depression Role of pulse oximetry with supplemental O2?

Selection of Agents… Goal Find a predictable and beneficial combination of drugs that: Maximize the desirable features of the drugs Minimize the undesirable side effects of the drugs

Oral Techniques… Indications Mildly apprehensive patient prior to appt Pt unable to sleep evening prior to appt. Bolus dose of drug with variable degrees of achieving desired sedation May require additional sedative agents N2O/O2

Intravenous Techniques… Indications Extremely apprehensive Other lesser forms of sedation have failed Perception by patient that the procedure is undesirable, painful or prolonged Advantages Can produce significant levels of amnesia, analgesia and control of secretions Titratable rather than bolus administration

Intramuscular Techniques… Indications: administration of: Sedative agents Analgesics Antiinfectives Emergency drugs Disadvantages Bolus administration based on patients size and weight Variable sedative effects Not recommended for the very young due to small muscle mass

Sites of IM Injections Mid-deltoid Vastus lateralis Gluteal area

IM Technique… 20-22 gauge 1-1½ inch length needle Cleans the skin thoroughly with antiseptic Hold tissue taut and insert needle Aspirate Inject slowly Hold pressure on site to control bleeding and swelling

Injection Site Vastus Lateralis Superior: a hands breadth below the greater trochanter Inferior: a hands breadth above the knee Mid-anterior thigh on the front Mid-lateral thigh on the side

Injections Site Mid-Deltoid Boundaries for injection Superior: acromion Inferior: point that corresponds with the axilla Side: 1/3 of the way around the lateral aspect of the arm

Deltoid Technique

Deltoid Technique

Deltoid Technique

Injection Site Gluteal Region Divide into quadrants Use the upper-outer quadrant Superior border is the posterior superior iliac spine

Other Techniques… Rectal Intra-buccal Sublingual Transmucosal Transdermal Nasal

Inhalation Techniques… Any of the previously mentioned methods can be used with inhalational sedation (N2O/O2) Allows titration of effect without using inappropriate dosages of a single agent