1. Analgesia and Sedation in Intervention Radiology
Assoc. Prof.
Somchai Amornyotin
Department of Anesthesiology
and Siriraj GI Endoscopy Center, Faculty of Medicine
Siriraj Hospital, Mahidol University, Thailand

2. Objectives Definitions of Sedation Depth of Sedation Monitoring
Medications Used
Reversal Drugs

3. Definitions Procedural Sedation = Moderate or Deep sedation/Analgesia
Conscious Sedation = Moderate Sedation
MAC (Monitored Anesthesia Care) = A continuum that can range widely and is not always predictable

4. Definition of Total IntraVenous Anesthesia (TIVA)
A general method of producing general anesthesia by injecting intravenous drugs excluding simultaneous administration of any inhalation agent

5. Monitored Anesthesia Care (MAC)
Anesthetic personnel
Monitored anesthesia care may include varying levels of sedation, analgesia and anxiolysis as necessary
“If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required”

6. Why do We Use Analgesics and Sedatives?
1. Analgesia
2. Amnesia
3. Increase patient’s comfort
4. Improve procedural performance
5. Increase patient satisfaction
6. Increase radiologist satisfaction

7. Rational for Using Analgesics/Sedatives
Less operating room pollution
Quick induction and reversal
Superior recovery profile
Portable delivery system beneficial for remote areas
Easy to titrate drugs

8. Ideal Drug Consistent action Rapid onset, offset
Analgesia, amnesia, anxiolytic effects
Reversible
Minimal risks or adverse events
Low cost?

9. What is Important to Know Before Giving Analgesics/Sedatives?
Patient Characteristics
Procedure Specifications
Pharmacokinetic
Pharmacodynamic
Basic Pharmacologic Actions and Interaction of Drugs Used
Cost Effectiveness?

10. Importance of Sedation
Relief of anxiety and fear
Relief of discomfort
Increase patient compliance with screening/ surveillance guidelines
Enhance quality of the examination
Minimize risks and physical injury to the patients
Improve over experience and satisfaction

11. Risk Factors Associated with Sedation-Related Complications
Depth of sedation
Skill and training of practitioner
Age of the patient
ASA physical status
Monitoring used
Drugs used

12. ASA Physical Status Classification
ASA Classification
Definition
ASA I
A normal healthy patient
ASA II
A patient with mild systemic disease
ASA III
A patient with severe systemic disease
ASA IV
A patient with severe systemic disease that is a constant threat to life
ASA V
A moribund patient who is not expected to survive without the operation
ASA VI
A declared brain-dead patient whose organs are being removed for donor purposes

13. Patient-Related Risk Factors
Significant medical conditions such as extremes of age, severe pulmonary, cardiac, renal or hepatic disease, pregnancy
Abuse of drugs or alcohol
Uncooperative patients
Potentially difficult airway management

14. Depth of Sedation Minimal Moderate (Conscious) Deep General Anesthesia
Responsiveness
Normal response to verbal stimulation
Purposeful response to verbal or tactile stimulation
Purposeful response to repeated or painful stimulation
Unarousable even with painful stimulus
Airway
Unaffected
No intervention required
Intervention may be required
Intervention often required
Spontaneous ventilation
Adequate
Ventilation may be inadequate
Frequently inadequate
Cardiovascular function
Usually maintained
May be impaired
BIS (0-100)

15. Depth of Sedation
Clinical Assessment

16. Modified Ramsay Scale Score Response State 1 2 3 4 5 6
Anxious, agitated or restless
Awake 2
Cooperative, oriented, tranquil 3
Asleep, brisk response to loud auditory stimulus 4
Asleep, sluggish response to loud auditory stimulus
Sleep 5
No response to loud auditory stimulus, but response to painful stimulus 6
No response to painful stimulus

17. Observer’s Assessment of Alertness/Sedation Scale (OAA/S)
Scores
Descriptions 5
Responds readily to name spoken in normal tone 4
Lethargic response to name spoken in normal tone 3
Responds only after name is called loudly and/or repeatedly 2
Responds only after mild prodding or shaking 1
Responds only after painful trapezius squeeze
No response after painful trapezius squeeze

18. Sedation Depth Monitors
Depth of Sedation
Sedation Depth Monitors

19. Sedation Depth Monitors
Bispectral Index (BIS) Narcotrend Patient State Index Danmeter Entropy

20. Monitoring 1. Clinical monitoring
2. Ventilation (ETCO2, Visual, Precordial)
3. Oxygenation (Pulse Oximetry)
4. CVS status (BP, HR, EKG)

21. Analgesic Drugs

22. Opioids Opioids Potency Dose (mg) Peak effect (min) Duration (hr)
Morphine 1 10
15-30
3-4
Meperidine
0.1
100
5-7
2-3
Fentanyl
75-125
3-5
0.5-1
Sufentanil
Alfentanil
10-20
1.5-2

23. Fentanyl Potent narcotic Adult: 0.5 mcg/kg IV up to 2 mcg/kg
Onset 1-2 min
Duration min
Respiratory depression
Synergistic effect with sedatives

24. Pethidine (Meperidine)
Adult: 1-2 mg/kg IV
Duration 2-3 hr
Post-operative shivering: mg IV
Atropine-like effects
Synergistic effect with sedatives
Drug interaction with Monoamine Oxidase Inhibitors

25. Morphine Adult: 0.1-0.2 mg/kg IV Duration 3-4 hr
Respiratory depression
Histamine release
Synergistic effect with sedatives

26. Naloxone Opioid antagonist 0.1-0.8 mg IV (1-4 mcg/kg) Duration 30 min
Cardiovascular stimulation

27. Sedative Drugs

28. Midazolam Amnesia Titrate 0.5-1.0 mg IV, Max 5 mg
Onset 2-4 min, Max effect 5 min
Duration min
Clearance reduced in Elderly, Obese, Hepatic or Renal Impairment

29. Diazepam Amnesia Titrate 2-5 mg IV, Max 20 mg Onset 1-5 min
Duration 3 hr
Half life of hr
Clearance reduced in Elderly, Obese, Hepatic or Renal Impairment

30. Flumazenil Benzodiazepine antagonist 0.2 mg IV over 15 sec
Repeat every 60 sec – Max 1 mg
Caution in chronic benzodiazepine users
Watch for re-sedation

31. Post-Procedural Care Routine Post-Procedural Care Monitoring
Discharge Scores
Post-op pain management

32. Non-Anesthesiologist Administered Sedation
Recommendations
ASA Physical Status I, II
III (Stable and Controllable)
Non-Extreme Aged Patients
Minimal or Moderate (Conscious) Sedation

33. Anesthesiologist Consultation
Sedation-related risk factors
Depth of sedation
Urgency
Type of procedure

34. Anesthesiologist Consultation
Patient-related risk factors
Patient with cardiorespiratory instabilities
Patient with significant medical conditions

35. Thank You For Your Attention