1. PROCEDURAL SEDATION INTERN LECTURE SERIES JULY 2003

2. PROCEDURAL SEDATION Procedural sedation and analgesia is a complex interaction between the physician nurse, and patient which allows proper administration of drugs to obtund, dull or reduce the intensity of pain or awareness. Procedural sedation and analgesia is a complex interaction between the physician nurse, and patient which allows proper administration of drugs to obtund, dull or reduce the intensity of pain or awareness.

3. PROCEDURAL SEDATION The administration of drugs by any route is intended to allow the patient to maintain airway control independently and continously, but carries the risk of loss of protective reflexed. The administration of drugs by any route is intended to allow the patient to maintain airway control independently and continously, but carries the risk of loss of protective reflexed. anxiolysis conscious sedation deep sedation general anesthesia

4. PROCEDURAL SEDATION

5. Relevant History and Physical Exam: Relevant History and Physical Exam: 1. Pt age 1. Pt age 2. H/o abnormalities of major organ systems, including heart, lung, kidneys or airway ( sleep apnea, snoring, stridor) 2. H/o abnormalities of major organ systems, including heart, lung, kidneys or airway ( sleep apnea, snoring, stridor) 3. Pregnancy test as needed 3. Pregnancy test as needed 4. Current medications 4. Current medications

6. PROCEDURAL SEDATION Relevant History and Physical Exam: Relevant History and Physical Exam: 5. H/o any adverse or allergic drug reactions with anesthesia or sedation/analgesia 5. H/o any adverse or allergic drug reactions with anesthesia or sedation/analgesia 6. H/o prior sedation/ analgesia, including adequacy of pain control for those procedures 6. H/o prior sedation/ analgesia, including adequacy of pain control for those procedures 7. H/o tobacco, alcohol, or substance abuse or use 7. H/o tobacco, alcohol, or substance abuse or use

7. PROCEDURAL SEDATION Relevant History and Physical Exam: Relevant History and Physical Exam: 8. Vital signs (wt, HR, BP, RR, pulse ox) 8. Vital signs (wt, HR, BP, RR, pulse ox) 9. Cardiopulmonary exam 9. Cardiopulmonary exam 10. Airway exam 10. Airway exam 11. Labs and/or relevant findings that may effect plan for sedation/analgesia 11. Labs and/or relevant findings that may effect plan for sedation/analgesia

8. PROCEDURAL SEDATION Indicators of Potential Problematic Airway Indicators of Potential Problematic Airway Decreased mouth opening Decreased mouth opening Micrognathia Micrognathia Retrognathia Retrognathia Significant malocclusion Significant malocclusion Dentures Dentures Macroglossia Macroglossia

9. PROCEDURAL SEDATION Indicators of Potential Problematic Airway Indicators of Potential Problematic Airway Nonvisible uvula Nonvisible uvula Decreased neck flexibility Decreased neck flexibility Advanced rheumatoid arthritis Advanced rheumatoid arthritis Dysmorphic facial features Dysmorphic facial features Pierre Robin syndrome Pierre Robin syndrome Trisomy 21 Trisomy 21 < 3cm hyoid-mental distance (adult) < 3cm hyoid-mental distance (adult) Tracheal deviation Tracheal deviation

10. PROCEDURAL SEDATION Equipment: Equipment: 2 physicians 2 physicians Pulse oximetry, continuous Pulse oximetry, continuous Cardiac monitoring, continuous Cardiac monitoring, continuous Sedation agents Sedation agents Reversal agents Reversal agents Procedural consent forms Procedural consent forms

11. PROCEDURAL SEDATION Equipment: Equipment: Intubation materials Intubation materials Oxygen delivery equipment Oxygen delivery equipment Nurse, continuous monitoring Nurse, continuous monitoring Age-appropriate resusciation equipment Age-appropriate resusciation equipment Pre-measured doses for pediatric patients Pre-measured doses for pediatric patients

12. PROCEDURAL SEDATION Adult Sedation and Analgesia Drugs And Reversal Agents

13. Adult Sedation and Analgesia Drugs And Reversal Agents Etomidate

14. Etomidate: Etomidate: Recommended dosage: 0.1-0.3 mg/kg Recommended dosage: 0.1-0.3 mg/kg Route: IV over 30-60 secs Route: IV over 30-60 secs Onset: ultra rapid 2-3 min Onset: ultra rapid 2-3 min Duration: 1 hour Duration: 1 hour

15. Adult Sedation and Analgesia Drugs And Reversal Agents Etomidate: Etomidate: Considered a general anesthetic; also sedation and amnestic Considered a general anesthetic; also sedation and amnestic Cardiac, respiratory and BP monitoring required Cardiac, respiratory and BP monitoring required

16. Adult Sedation and Analgesia Drugs And Reversal Agents Etomidate: Etomidate: Contraindications/ Precautions Contraindications/ Precautions Not approved for kids < 12 yo Not approved for kids < 12 yo Avoid if seizure d/o, N/V Avoid if seizure d/o, N/V May cause myoclonic jerks May cause myoclonic jerks Pain at injection site Pain at injection site

17. Adult Sedation and Analgesia Drugs And Reversal Agents Fentanyl Citrate (Sublimaze)

18. Adult Sedation and Analgesia Drugs And Reversal Agents Fentanyl Citrate: Fentanyl Citrate: Dosage: 1-5 mcg/kg induction Dosage: 1-5 mcg/kg induction (50-100 mcg = 1-2 cc) (50-100 mcg = 1-2 cc) Route: IV Route: IV Onset: 1.7 min Onset: 1.7 min Duration: 30-60 mins Duration: 30-60 mins

19. Adult Sedation and Analgesia Drugs And Reversal Agents Fentanyl Citrate: Fentanyl Citrate: Potent narcotic analgesic Potent narcotic analgesic 100 mcg (2cc)=10 mg MSO4 or 75 mg Demerol 100 mcg (2cc)=10 mg MSO4 or 75 mg Demerol Acts as respiratory depressant (5-15 mins after injection) Acts as respiratory depressant (5-15 mins after injection) Reduce dose in elderly and debilitiated pts Reduce dose in elderly and debilitiated pts CNS depressant drugs have additive or potentiating effects with fentanyl CNS depressant drugs have additive or potentiating effects with fentanyl

20. Adult Sedation and Analgesia Drugs And Reversal Agents Fentanyl Citrate: Fentanyl Citrate: Contraindications/Precautions Contraindications/Precautions Large doses produce apnea Large doses produce apnea Chest wall rigidity may occur if pushed too quickly Chest wall rigidity may occur if pushed too quickly Duration of respiratory depressant may be longer than the analgesic effect Duration of respiratory depressant may be longer than the analgesic effect

21. Adult Sedation and Analgesia Drugs And Reversal Agents Fentanyl Citrate: Fentanyl Citrate: Contraindications/Precautions Contraindications/Precautions May produce bradycardia and bronchoconstriction May produce bradycardia and bronchoconstriction Use with caution in pts with COPD, liver disease, kidney dysfunction Use with caution in pts with COPD, liver disease, kidney dysfunction Adverse reactions: hypotension, HTN, emesis, laryngospasm Adverse reactions: hypotension, HTN, emesis, laryngospasm

22. Adult Sedation and Analgesia Drugs And Reversal Agents Lorazepam (Ativan)

23. Adult Sedation and Analgesia Drugs And Reversal Agents Lorazepam: Lorazepam: Dose: 0.02-0.05 mg/kg Dose: 0.02-0.05 mg/kg Route: IV Route: IV Onset: 15 mins Onset: 15 mins Duration: 2 hours Duration: 2 hours

24. Adult Sedation and Analgesia Drugs And Reversal Agents Lorazepam: Lorazepam: Useful as anxiolytic, sedation for radiographic procedures, some minor surgical procedures (burns, FB removal, laceration repair) Useful as anxiolytic, sedation for radiographic procedures, some minor surgical procedures (burns, FB removal, laceration repair)

25. Adult Sedation and Analgesia Drugs And Reversal Agents Lorazepam: Lorazepam: Precautions/ Contraindications Precautions/ Contraindications Severe liver disease Severe liver disease Severe respiratory disease Severe respiratory disease

26. Adult Sedation and Analgesia Drugs and Reveral Agents Meperidine (Demerol)

27. Adult Sedation and Analgesia Drugs And Reversal Agents Meperidine: Meperidine: Dose: 0.3-1.5 mg/kg Dose: 0.3-1.5 mg/kg Route: IV Route: IV Onset: 10-15 min Onset: 10-15 min Duration: 1 ½- 2 hour half-life, effective duration 2-3 hours Duration: 1 ½- 2 hour half-life, effective duration 2-3 hours

28. Adult Sedation and Analgesia Drugs and Reveral Agents Meperidine: Meperidine: Precautions/ Contraindications Precautions/ Contraindications Metabolite normeperidine may cause CNS toxicity, seizures in sickle cell pts or renal- impaired pts Metabolite normeperidine may cause CNS toxicity, seizures in sickle cell pts or renal- impaired pts Contraindicated if pt on MAOI Contraindicated if pt on MAOI

29. Adult Sedation and Analgesia Drugs And Reversal Agents Methohexital (Brevital)

30. Adult Sedation and Analgesia Drugs and Reveral Agents Brevital: Brevital: Dose: 1-3 mg/kg Dose: 1-3 mg/kg Route: IV Route: IV Onset: 1 min Onset: 1 min Duration: 10 mins Duration: 10 mins

31. Adult Sedation and Analgesia Drugs And Reversal Agents Brevital: Brevital: Discontinue immediately if extravasation occurs since tissue necrosis can occur Discontinue immediately if extravasation occurs since tissue necrosis can occur May cause hemodynamic instability and bronchospasm May cause hemodynamic instability and bronchospasm

32. Adult Sedation and Analgesia Drugs and Reveral Agents Brevital: Brevital: Precautions/ Contraindications Precautions/ Contraindications If given intraarterially, thrombosis and gangrene can occur If given intraarterially, thrombosis and gangrene can occur Contraindicated in severe hepatic dysfunction or porphyria Contraindicated in severe hepatic dysfunction or porphyria May cause respiratory depression, hypotension May cause respiratory depression, hypotension

33. Adult Sedation and Analgesia Drugs And Reversal Agents Midazolam (Versed)

34. Adult Sedation and Analgesia Drugs And Reversal Agents Versed: Versed: Dose: 0.05-0.1 mg/kg (1-2 mg) Dose: 0.05-0.1 mg/kg (1-2 mg) (total dose 0.1 mg/kg) (total dose 0.1 mg/kg) Route: IV Route: IV Onset: 3-5 mins Onset: 3-5 mins Duration: 2 hr half-life Duration: 2 hr half-life At total dose 0.1 mg/kg = 60 mins At total dose 0.1 mg/kg = 60 mins

35. Adult Sedation and Analgesia Drugs And Reversal Agents Versed: Versed: Short-acting benzodiazepine CNS depressant Short-acting benzodiazepine CNS depressant Do not give as a bolus dose; administer over at least 2 mins and allow an additional 2 mis to evaluate sedative effect Do not give as a bolus dose; administer over at least 2 mins and allow an additional 2 mis to evaluate sedative effect Reduce dosage in older (>60 yrs) or debilitated pts. Reduce dosage in older (>60 yrs) or debilitated pts. Causes impairment in memory and recall Causes impairment in memory and recall

36. Adult Sedation and Analgesia Drugs and Reveral Agents Versed: Versed: Precautions/ Contraindications Precautions/ Contraindications Associated with respiratory depression and respiratory arrest Associated with respiratory depression and respiratory arrest May cause hypotension from venous pooling May cause hypotension from venous pooling Contraindicated in pts with acute narrow angle glaucoma Contraindicated in pts with acute narrow angle glaucoma

37. Adult Sedation and Analgesia Drugs And Reversal Agents Versed: Versed: Precautions/ Contraindications Precautions/ Contraindications Pts with chronic RF and CHF eliminate versed slowly Pts with chronic RF and CHF eliminate versed slowly Potentiates respiratory depression in acute ETOH intoxication Potentiates respiratory depression in acute ETOH intoxication Reduce dose by 30% in pts > 60 yo or chronic illness Reduce dose by 30% in pts > 60 yo or chronic illness

38. Adult Sedation and Analgesia Drugs And Reversal Agents Morphine Sulfate

39. Adult Sedation and Analgesia Drugs And Reversal Agents Morphine Sulfate: Morphine Sulfate: Dose: 0.03-0.15 mg/kg (2-10mg) Dose: 0.03-0.15 mg/kg (2-10mg) Route: IV Route: IV Onset: 1-3 min; peak effect = 15 min Onset: 1-3 min; peak effect = 15 min Duration: 3-5 hr half-life/ effective duration Duration: 3-5 hr half-life/ effective duration

40. Adult Sedation and Analgesia Drugs And Reversal Agents Morphine Sulfate: Morphine Sulfate: Can be given with hydroxyzine 0.5 mg/kg IM or PO in children Can be given with hydroxyzine 0.5 mg/kg IM or PO in children

41. Adult Sedation and Analgesia Drugs And Reversal Agents Morphine Sulfate: Morphine Sulfate: Precautions/ Contraindications Precautions/ Contraindications Bronchospasm, Bronchospasm, respiratory depression, respiratory depression, histamine release histamine release Hypotension Hypotension bradycardia bradycardia

42. Adult Sedation and Analgesia Drugs And Reversal Agents Morphine Sulfate: Morphine Sulfate: Precautions/ Contraindications Precautions/ Contraindications Prolonged sedation Prolonged sedation GI dysmotility GI dysmotility Chest wall rigidity Chest wall rigidity

43. Adult Sedation and Analgesia Drugs and Reveral Agents Propofol (Diprivan)

44. Adult Sedation and Analgesia Drugs And Reversal Agents Propofol: Propofol: Dose: Dose: 50-200 mcg/kg/min sedation 50-200 mcg/kg/min sedation (2-3 mg/kg induction) (2-3 mg/kg induction) 1-2 mg/kg for orthopedic procedures, joint reduction, burns requiring sedation 1-2 mg/kg for orthopedic procedures, joint reduction, burns requiring sedation (10 mg/cc concentration) (10 mg/cc concentration) May be used as an infusion 100-200 mcg/kg/min May be used as an infusion 100-200 mcg/kg/min (10-20mg/min in a typical adult, titrated for effect) (10-20mg/min in a typical adult, titrated for effect)

45. Adult Sedation and Analgesia Drugs And Reversal Agents Propofol: Propofol: Route: IV Route: IV Onset: 1-2 min Onset: 1-2 min Duration: 5-10 min Duration: 5-10 min Titrate to effect Titrate to effect

46. Adult Sedation and Analgesia Drugs And Reversal Agents Propofol: Propofol: Use with caution in volume-depleted pts (may need fluid bolus prior to giving propofol) Use with caution in volume-depleted pts (may need fluid bolus prior to giving propofol) Causes pain on injection so use larger antecubital vein and/or add lidocaine 0.5-1.0 mg/kg Causes pain on injection so use larger antecubital vein and/or add lidocaine 0.5-1.0 mg/kg Lidocaine may be given w/ propofol drip or as bolus alone Lidocaine may be given w/ propofol drip or as bolus alone

47. Adult Sedation and Analgesia Drugs And Reversal Agents Propofol: Propofol: Precautions/ Contraindications Precautions/ Contraindications Side effects: hypotension, bradycardia, apnea, N/V Side effects: hypotension, bradycardia, apnea, N/V Transient apnea in up to 40% Transient apnea in up to 40% As propofol as no analgesic properties, may need to add 0.1 mcg/kg fentanyl As propofol as no analgesic properties, may need to add 0.1 mcg/kg fentanyl Anaphylaxis with soy and egg allergy Anaphylaxis with soy and egg allergy

48. Adult Sedation and Analgesia Drugs and Reveral Agents Reversal Agents

49. Adult Sedation and Analgesia Drugs And Reversal Agents Reversal Agents Naloxone

50. Adult Sedation and Analgesia Drugs And Reversal Agents Naloxone (Narcan) Naloxone (Narcan) Dose: 5-10 mcg/kg titrated to desired effect Dose: 5-10 mcg/kg titrated to desired effect 0.4 mg-2 mg standard historical dose for OD 0.4 mg-2 mg standard historical dose for OD Route: IV, IM, ET Route: IV, IM, ET Onset: 1-2 min Onset: 1-2 min Duration: dependent upon the dose and route of administration, 30-60 min typical Duration: dependent upon the dose and route of administration, 30-60 min typical

51. Adult Sedation and Analgesia Drugs And Reversal Agents Naloxone (Narcan): Naloxone (Narcan): A narcotic antagonist, preventing or reversing the effects of opoids, including respiratory depression, sedation, and hypotension A narcotic antagonist, preventing or reversing the effects of opoids, including respiratory depression, sedation, and hypotension Titration is preferred to rapid bolus Titration is preferred to rapid bolus Maximum dose = 10 mg Maximum dose = 10 mg Only applies to suspected unknown OD Only applies to suspected unknown OD

52. Adult Sedation and Analgesia Drugs and Reveral Agents Naloxone (Narcan): Naloxone (Narcan): Precautions/ Contraindications Precautions/ Contraindications The pt who has responded satisfactorily to narcan should be kept under continued surveillance; repeated doses may be required as necessary since the duration of action of some narcotics may exceed that of naloxone. The pt who has responded satisfactorily to narcan should be kept under continued surveillance; repeated doses may be required as necessary since the duration of action of some narcotics may exceed that of naloxone.

53. Adult Sedation and Analgesia Drugs And Reversal Agents Reversal Agent Flumazenil (Mazicon)

54. Adult Sedation and Analgesia Drugs And Reversal Agents Flumazenil: Flumazenil: Dose: 0.01 mg/kg Dose: 0.01 mg/kg May repeat 60 secs x 3 (0.2 mg) May repeat 60 secs x 3 (0.2 mg) Max dose = 1 mg Max dose = 1 mg Route: IV Route: IV Onset: 1-2 min Onset: 1-2 min Duration: 20 mins Duration: 20 mins

55. Adult Sedation and Analgesia Drugs And Reversal Agents Flumazenil: Flumazenil: Use for reversal of benzodiazepine- induced sedation Use for reversal of benzodiazepine- induced sedation Administer slowly to avoid the adverse consequences of abrupt awakening such as dysphoria and agitation Administer slowly to avoid the adverse consequences of abrupt awakening such as dysphoria and agitation Repeated doses may be given at 20-min intervals as needed to reverse resedation Repeated doses may be given at 20-min intervals as needed to reverse resedation

56. Adult Sedation and Analgesia Drugs And Reversal Agents Flumazenil: Flumazenil: Maximum dose of 1 mg at any one time; no more than 3 mg in 1 hour. Maximum dose of 1 mg at any one time; no more than 3 mg in 1 hour. A 1 mg dose sustains antagonism for 48 mins A 1 mg dose sustains antagonism for 48 mins

57. Adult Sedation and Analgesia Drugs And Reversal Agents Flumazenil: Flumazenil: Precautions/ Contraindications Precautions/ Contraindications Seizures may occur as reversal of sedative effects performed Seizures may occur as reversal of sedative effects performed Duration of action of flumazenil is shorter than versed and other benzos Duration of action of flumazenil is shorter than versed and other benzos Resedation may occur following initial reversal Resedation may occur following initial reversal

58. Adult Sedation and Analgesia Drugs And Reversal Agents Flumazenil: Flumazenil: Precautions/ Contraindications Precautions/ Contraindications Monitoring must be performed for an appropriate period after initial reversal Monitoring must be performed for an appropriate period after initial reversal Contraindicated in Contraindicated in Status epilepticus Status epilepticus Increased intracranial pressure Increased intracranial pressure TCA od TCA od Chronic benzodiazepine use (> 2 weeks) Chronic benzodiazepine use (> 2 weeks)

59. Adult Sedation and Analgesia Drugs And Reversal Agents Dissociative Agents

60. Adult Sedation and Analgesia Drugs And Reversal Agents Ketamine (Ketalar): Ketamine (Ketalar): Dosage and Route: Dosage and Route: 1 mg/kg sedation (2 mg/kg induction) IV 1 mg/kg sedation (2 mg/kg induction) IV 2-5 mg/kg IM 2-5 mg/kg IM 6 mg/kg intra-nasal 6 mg/kg intra-nasal 6-10 mg/kg PO 6-10 mg/kg PO 10-15 mg/kg PR 10-15 mg/kg PR

61. Adult Sedation and Analgesia Drugs And Reversal Agents Ketamine: Ketamine: Onset: Onset: IV 1-3 mins with 10-20 mins duration IV 1-3 mins with 10-20 mins duration IM 5-20 mins IM 5-20 mins Intra-nasal 15-30 mins Intra-nasal 15-30 mins PO 15-30 mins PO 15-30 mins PR 15-30 mins PR 15-30 mins

62. Adult Sedation and Analgesia Drugs And Reversal Agents Ketamine: Ketamine: Duration: Duration: IV 10-20 mins IV 10-20 mins IM, PO, PR and intra-nasal 30-60 mins IM, PO, PR and intra-nasal 30-60 mins Analgesic duration = 45 mins Analgesic duration = 45 mins Anesthesia duration = 15-20 mins Anesthesia duration = 15-20 mins

63. Adult Sedation and Analgesia Drugs And Reversal Agents Ketamine: Ketamine: Pre-treatment with glycopyrrolate at 0.01 mg/kg (or atropine 0.01 mg/kg) to decrease secretions should be given Pre-treatment with glycopyrrolate at 0.01 mg/kg (or atropine 0.01 mg/kg) to decrease secretions should be given Combine glycopyrrolate with IV, IM or PO dose to give all at once; I.e.,,may combine in syringe for one injection Combine glycopyrrolate with IV, IM or PO dose to give all at once; I.e.,,may combine in syringe for one injection

64. Adult Sedation and Analgesia Drugs And Reversal Agents Ketamine: Ketamine: Precautions/ Contraindications Precautions/ Contraindications Increases intracranial pressure Increases intracranial pressure Positive side effect = bronchodilation (can be used in asthmatics) Positive side effect = bronchodilation (can be used in asthmatics) Hallucinatory emergence reactions are common in adults but uncommon in kids Hallucinatory emergence reactions are common in adults but uncommon in kids

65. Adult Sedation and Analgesia Drugs and Reveral Agents Ketamine: Ketamine: Can treat with versed 0.2 mg/kg concurrently Can treat with versed 0.2 mg/kg concurrently Potential for laryngospasm so avoid if active pulmonary or upper respiratory infection or excessive salivation or bleeding Potential for laryngospasm so avoid if active pulmonary or upper respiratory infection or excessive salivation or bleeding Avoid if coronary artery disease or if pt has elevated intraocular pressure Avoid if coronary artery disease or if pt has elevated intraocular pressure Possible HTN Possible HTN

66. Adult Sedation and Analgesia Drugs And Reversal Agents Adult Drugs For Agitation

67. Adult Sedation and Analgesia Drugs And Reversal Agents Adult Drugs for Agitation Droperidol (Inapsine)

68. Adult Sedation and Analgesia Drugs And Reversal Agents Droperidol (Inapsine): Droperidol (Inapsine): Dose: 1-10 mg Dose: 1-10 mg Route: IV or IM Route: IV or IM Onset: 10 mins Onset: 10 mins Duration: 2 hours Duration: 2 hours

69. Adult Sedation and Analgesia Drugs and Reveral Agents Droperidol: Droperidol: Agitated pts, CT scan or procedures on an uncooperative patient Agitated pts, CT scan or procedures on an uncooperative patient

70. Adult Sedation and Analgesia Drugs and Reveral Agents Droperidol: Droperidol: Precautions/ Contraindications Precautions/ Contraindications Contraindicated if cardiac condution abnormality Contraindicated if cardiac condution abnormality QT prolongation with torsade de pointes QT prolongation with torsade de pointes Rare hypotension Rare hypotension Rare neuroleptic malignant syndrome Rare neuroleptic malignant syndrome

71. Adult Sedation and Analgesia Drugs And Reversal Agents Adult Drugs for Agitation Haloperidol (Haldol)

72. Adult Sedation and Analgesia Drugs and Reveral Agents Haloperidol (Haldol): Haloperidol (Haldol): Dose: 1-10 mg Dose: 1-10 mg Route: IV or IM Route: IV or IM Onset: Onset: IV 10 mins IV 10 mins IM 20 mins IM 20 mins Duration: 2 hours Duration: 2 hours

73. Adult Sedation and Analgesia Drugs and Reveral Agents Haldol: Haldol: Agitated, combative patients Agitated, combative patients Pts requiring rapid sedation Pts requiring rapid sedation

74. Adult Sedation and Analgesia Drugs And Reversal Agents Haldol: Haldol: Precautions/ Contraindications Precautions/ Contraindications Contraindicated if: Contraindicated if: Cardiac conduction abnormality Cardiac conduction abnormality History of dystonic reactions History of dystonic reactions

75. Conscious Sedation Pediatric Sedation and Analgesia Drugs and Reversal Agents

76. Pediatric Sedation and Analgesia Drugs and Reversal Agents Methohexital (Brevital)

77. Pediatric Sedation and Analgesia Drugs and Reversal Agents Brevital: Brevital: Dose and Route: Dose and Route: 1 mg/kg IV 1 mg/kg IV 25 mg/kg PR 25 mg/kg PR Onset: IV within 1 min; PR within 2-5 mins Onset: IV within 1 min; PR within 2-5 mins Duration: Duration: IV lasts 10 mins IV lasts 10 mins PR lasts 45 mins PR lasts 45 mins

78. Pediatric Sedation and Analgesia Drugs and Reversal Agents Brevital: Brevital: Discontinue immediately if extravasation occurs, since tissue necrosis can occur Discontinue immediately if extravasation occurs, since tissue necrosis can occur May cause hemodynamic instability and bronchospasm May cause hemodynamic instability and bronchospasm

79. Pediatric Sedation and Analgesia Drugs and Reversal Agents Brevital: Brevital: Precautions/ Contraindications Precautions/ Contraindications If given intraarterially, thrombosis and gangrene can occur If given intraarterially, thrombosis and gangrene can occur Contraindicated: Contraindicated: Severe hepatic dysfunction Severe hepatic dysfunction porphyria porphyria

80. Pediatric Sedation and Analgesia Drugs and Reversal Agents Midazolam (Versed)

81. Pediatric Sedation and Analgesia Drugs and Reversal Agents Versed: Versed: Dose and Route: Dose and Route: 0.05-0.1 mg/kg IV 0.05-0.1 mg/kg IV 0.1 mg/kg IM 0.1 mg/kg IM 0.2-0.5 mg/kg intra- nasal 0.2-0.5 mg/kg intra- nasal 0.5-1.0 mg/kg PO/PR 0.5-1.0 mg/kg PO/PR Versed: Versed: Onset and Duration: Onset and Duration: 1-3 min for 1 hour 15-30 mins for 1-2 hrs 2-5 mins for 1-2 hrs 10-30 mins for 1-2 hrs

82. Pediatric Sedation and Analgesia Drugs and Reversal Agents Versed: Versed: Suggested Pedi combo: Versed 0.02 mg/kg + 1 mcg/kg fentanyl when used IV Suggested Pedi combo: Versed 0.02 mg/kg + 1 mcg/kg fentanyl when used IV IV : may repeat 0.1 mg/kg by giving increments of 0.05 mg/kg until adequate sedation to a maximum total of 2 mg IV : may repeat 0.1 mg/kg by giving increments of 0.05 mg/kg until adequate sedation to a maximum total of 2 mg IM: use 5 mg/cc concentration to reduce volume. Max total= 2 mg IM: use 5 mg/cc concentration to reduce volume. Max total= 2 mg

83. Pediatric Sedation and Analgesia Drugs and Reversal Agents Versed: Versed: PO: max total = 15-20 mg PO: max total = 15-20 mg Mix w/ small amt juice or w/ tylenol (15mg/kg) Mix w/ small amt juice or w/ tylenol (15mg/kg) Po or intra-nasal, use 5 mg/cc concentration Po or intra-nasal, use 5 mg/cc concentration Syrup (cherry flavored): 0.25-1.0 mg/kg, most effective dose 0.5 mg/kg (up to 20 mg) onset 20 mins; duration 1 hr Syrup (cherry flavored): 0.25-1.0 mg/kg, most effective dose 0.5 mg/kg (up to 20 mg) onset 20 mins; duration 1 hr Excellent amnestic, anxiolytic Excellent amnestic, anxiolytic

84. Pediatric Sedation and Analgesia Drugs and Reversal Agents Fentanyl (Sublimaze)

85. Pediatric Sedation and Analgesia Drugs and Reversal Agents Fentanyl: Fentanyl: Dose and Route: Dose and Route: 1-3 mcg/kg IV 1-3 mcg/kg IV 1-2 mcg/kg IM 1-2 mcg/kg IM 5-10 mcg/kg Oralet 5-10 mcg/kg Oralet 1-2 mcg/kg Nasal 1-2 mcg/kg Nasal Dose can be titrated Dose can be titrated Oralet: 100, 200, 300, 400 mcg Oralet: 100, 200, 300, 400 mcg Fentanyl: Fentanyl: Onset and Duration: Onset and Duration: 1-2 mins ; peak 10 min 7-15 mins; variable 15 mins; 1 ½-2 hrs 10 mins; 1 hr

86. Pediatric Sedation and Analgesia Drugs and Reversal Agents Fentanyl: Fentanyl: Max dose: 5 mcg/kg Max dose: 5 mcg/kg PO: for wt < 40 kg, dose 5-10 mcg/kg up to max of 400 mcg PO: for wt < 40 kg, dose 5-10 mcg/kg up to max of 400 mcg PO: for wt > 40 kg, give adult dose of 400 mcg PO: for wt > 40 kg, give adult dose of 400 mcg Can cause respiratory depression Can cause respiratory depression Oralet may cause N/V Oralet may cause N/V Can cause bradycardia, hypotension, chest wall rigidity Can cause bradycardia, hypotension, chest wall rigidity

87. Pediatric Sedation and Analgesia Drugs and Reversal Agents Reversal Agents

88. Pediatric Sedation and Analgesia Drugs and Reversal Agents Naloxone (Narcan): Naloxone (Narcan): 5-10 mcg/kg titrated to desired effect 5-10 mcg/kg titrated to desired effect IV/IM/ET IV/IM/ET Onset: 1-2 mins Onset: 1-2 mins Duration: 30-60 mins Duration: 30-60 mins Flumazenil (Mazicon): Flumazenil (Mazicon): 0.2 mg/kg IV with onset of 1-2 mins; duration of 20 mins 0.2 mg/kg IV with onset of 1-2 mins; duration of 20 mins Smaller kids= 0.01 mg/kg IV Smaller kids= 0.01 mg/kg IV

89. PROCEDURAL SEDATION Topical Agents: Topical Agents: EMLA Cream (lidocaine 2.5%, prilocaine, 2.5%) EMLA Cream (lidocaine 2.5%, prilocaine, 2.5%) 2.5 gm 2.5 gm Venipuncture and venous cannulation, lumbar puncture, arterial puncture) Venipuncture and venous cannulation, lumbar puncture, arterial puncture) Onset ½-1hr Onset ½-1hr Duration 1 hr after removal of occlusive dressing Duration 1 hr after removal of occlusive dressing

90. PROCEDURAL SEDATION Topical Agents: Topical Agents: EMLA Cream EMLA Cream Apply at least ½ hr prior to procedure Apply at least ½ hr prior to procedure After 1-1 ½ hr, wipe off cream, clean the area with antiseptic and do procedure After 1-1 ½ hr, wipe off cream, clean the area with antiseptic and do procedure Topical Agents: Topical Agents: EMLA Cream EMLA Cream Contraindication: kids < 1 month of age Do not apply to broken skin Conditions associated w/ methemoglobinemia (prilocaine)

91. PROCEDURAL SEDATION Topical Agents: Topical Agents: TAC (tetracaine 0.5%/ adrenaline 0.05% /cocaine 4-11%) TAC (tetracaine 0.5%/ adrenaline 0.05% /cocaine 4-11%) Max dose = 1.5cc/10 kg Max dose = 1.5cc/10 kg Suture of lacerations Suture of lacerations Onset 10-20 mins Onset 10-20 mins Duration 45-60 mins Duration 45-60 mins

92. PROCEDURAL SEDATION TAC TAC Soak gauze pad in soln and place directly over wound for 5-10 mins Soak gauze pad in soln and place directly over wound for 5-10 mins Anesthesia = blanching appearance of wound Anesthesia = blanching appearance of wound TAC TAC Contraindications Mucus membranes Areas w/ end-organ circulation ( ears, fingers, toes, nose, penis)

93. PROCEDURAL SEDATION Topical Agents: Topical Agents: Tetracaine (amethocaine) Cream Tetracaine (amethocaine) Cream 4% cream 4% cream suturing, venipuncture suturing, venipuncture Onset 40 mins Onset 40 mins Duration 4 hrs Duration 4 hrs

94. PROCEDURAL SEDATION Topical Agents: Topical Agents: Tetracaine Cream Tetracaine Cream Apply under occlusion for 40 mins in kids undergoing IV placement Apply under occlusion for 40 mins in kids undergoing IV placement

95. PROCEDURAL SEDATION Topical Agents: Topical Agents: Iontophoresis Iontophoresis 2% lidocaine with epi, 0.6-1 cc 2% lidocaine with epi, 0.6-1 cc Place electrode well over intact skin Place electrode well over intact skin Onset 10 mins Onset 10 mins Duration 10 min without epi, 60 mins w/ epinephrine Duration 10 min without epi, 60 mins w/ epinephrine

96. PROCEDURAL SEDATION Topical Agents: Topical Agents: Iontophoresis Iontophoresis Tingling, burning, itching of skin over both electrodes may occur Tingling, burning, itching of skin over both electrodes may occur Do not use in pts with pacemakers or over metal indwelling catheter ports or end- organs Do not use in pts with pacemakers or over metal indwelling catheter ports or end- organs

97. PROCEDURAL SEDATION Topical Agents: Topical Agents: LET ( lidocaine 5%, epinephrine 0.1%, tetracaine 0.5%) LET ( lidocaine 5%, epinephrine 0.1%, tetracaine 0.5%) Recommended dose = 1-3 cc Recommended dose = 1-3 cc Effective 75-98% of facial & scalp lacerations Effective 75-98% of facial & scalp lacerations Onset 20-30 mins Onset 20-30 mins Duration 45-60 mins Duration 45-60 mins

98. PROCEDURAL SEDATION Topical Agents: Topical Agents: LET LET May need to supplement with injected buffered lidocaine before suturing May need to supplement with injected buffered lidocaine before suturing Only 40-60% effective in extremity wounds Only 40-60% effective in extremity wounds

99. PROCEDURAL SEDATION Ramsey Sedation Scale Ramsey Sedation Scale Awake Awake Level 1: anxious and agitated Level 1: anxious and agitated Level 2: cooperative, oriented, tranquil Level 2: cooperative, oriented, tranquil Level 3: responds to command Level 3: responds to command

100. PROCEDURAL SEDATION Ramsey Sedation Scale Ramsey Sedation Scale Asleep Asleep Level 4: brisk response to light glabellar tap or loud auditory stimulus Level 4: brisk response to light glabellar tap or loud auditory stimulus Level 5: sluggish response to light glabellar tap or loud auditory stimulus Level 5: sluggish response to light glabellar tap or loud auditory stimulus Level 6: no response to light glabellar tap or loud auditory stimulus Level 6: no response to light glabellar tap or loud auditory stimulus

101. PROCEDURAL SEDATION Recommended Fasting Time to Reduce Aspiration Risk: Recommended Fasting Time to Reduce Aspiration Risk: Clear liquids2 hrs Clear liquids2 hrs Breast milk4 hrs Breast milk4 hrs Infant formula6 hrs Infant formula6 hrs Non-human milk6 hrs Non-human milk6 hrs Light meal6 hrs Light meal6 hrs Regular meal8 hrs Regular meal8 hrs

102. PROCEDURAL SEDATION