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Analgesia and Sedation in Intervention Radiology

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Presentation on theme: "Analgesia and Sedation in Intervention Radiology"— Presentation transcript:

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


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