1. Enteral Sedation Review Course

2. 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

3. 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

4. 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

5. 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

6. Conscious Sedation Objectives and Techniques

7. Enteral vs. Parenteral

8. 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

9. 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

10. 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?

11. 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

12. 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?

13. 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

14. 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

15. 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

17. 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

19. Sites of IM Injections
Mid-deltoid
Vastus lateralis
Gluteal area

20. 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

21. 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

23. 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

24. Deltoid Technique

25. Deltoid Technique

26. Deltoid Technique

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

30. Other Techniques… Rectal Intra-buccal Sublingual Transmucosal
Transdermal
Nasal

31. 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