Procedural Sedation: Deb Updegraff, R.N., M.S.N. P.N.P. Clinical Nurse Specialist Pediatric Intensive Care 3S Intermediate Intensive Care LPCH

The Players MD RN Patient

Sedation VS Analgesia

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

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

Pre-sedation Risk Assessment Ampule Allergies Medications Past Medical History Last Meal Events leading up to the need for sedation

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

Equipment (SOAP ) Suction Oxygen Airway Pharmacy

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

Pharmacology: Selecting the Meds Depends on the Procedure and Patient History LP MRI PICC placement Central Line Placement Bronchoscopy Chest tube placement

Choice of Drugs Analgesics –Narcotics Fentanyl Morphine –Ketamine Sedation –Benzodiazepines Midazolam Lorazepam –Barbiturates -Propofol

Narcotics Fentanyl –Bolus= mcg/kg ( MAY REPEAT Qq5-10MIN ) –Rigid Chest Syndrome Morphine - Bolus= mg/kg (may repeat q5-10min ) –Histamine Release –+ Sedative and Hypnotic properties Narcotics have both sedative and analgesic qualities

Benzodiazepines Midazolam –Bolus= mg/kg Lorazepam –Bolus= mg/kg Benzodiazepines have both sedative and Amnesic qualities NO Analgesic Properties

Ketamine Dissociative anesthetic: phencyclidine derivative (PCP) IV 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.

Propofol General Anesthetic Agent NO Analgesic Properties Advantages: –Rapid Onset and Emergence –Profound Sedation Disadvantages: –Metabolic Acidosis –Severe  SVR

Propofol - dosing Induction 2.5 – 3.5 mg/kg Over seconds Repeat as child emerges Continuous Infusion 5-50 mcg/kg/hr

Reversal Agents Narcan: For Narcotic Reversal dose: 1-10mcg/kg IV push (1/10 th 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: mg/kg. May be repeated.