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Procedural Sedation Pharmacology

Procedural Sedation Pharmacology. Deb Updegraff R.N., P.N.P, C.N.S. Clinical Nurse Specialist LPCH Pediatric Intensive Care Unit. Procedural Sedation.

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Procedural Sedation Pharmacology

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  1. Procedural Sedation Pharmacology Deb Updegraff R.N., P.N.P, C.N.S. Clinical Nurse Specialist LPCH Pediatric Intensive Care Unit

  2. Procedural Sedation • The phrase “procedural sedation” refers to techniques of managing a patient’s pain and anxiety to facilitate appropriate medical care in a safe, effective and humane fashion.

  3. Sedation Pharmacolgy Individual responses are dependant on: • Age • Concurrent disease states • Concurrent drug therapy

  4. Chloral Hydrate Hypnotic- “Short term sedative and hypnotic given prior to nonpainful procedures

  5. Chloral Hydrate • Usually given to Outpatients due to relative low risk profile. For non-painful procedures only. EEGs MRI/CT Scans Echocardiograms

  6. Chloral Hydrate PO/Rectal Dose: 50mg/kg give 30-60 minutes prior to procedure. Can repeat x1 25mg/kg Not to exceed 100mg/kg in a 24 hour period

  7. Chloral Hydrate • Expect a moderate decrease in heart rate and blood pressure in patients ASA I-II • For infants < 6 months there is ↑ risk for apnea and hypoxia. • Age a limiting factor. High failure rate in children > 4 years.

  8. Pentobarbital : Nembutal® Barbituate- Non elective central nervous system depressants primarily used as Hypnotic sedative for non painful procedures.

  9. Nembutal • PO/Rectal/IM/IV • Dose for procedural sedation: 4mg/kg , may repeat 2mg/kg, max 100mg

  10. Nembutal: precautions • Rapid IV injection ie, can cause respiratory depression, apnea, laryngospasm, bronchospasm and hypotension • Recommended to infuse IV dose over 10-30 minutes. • Can significantly decrease cardiac output and should be avoided with CHF

  11. Benzodiazepines • Midazolam- Versed® • Lorazepam - Ativan® Induce anterograde amnesia (not retrograde) May have some opioid sparing effect by ↓ anticipatory pain response

  12. Midazolam -® Versed • Most commonly used Benzo for preoperative and pre-procedural sedation. • Undergoes hepatic metabolism and renal excretion and prolonged effects seen with dysfunction of either system • Sedative, amnestic and anxiolytic with no analgesic properties • Commonly used with an opioid analgesic such as Fentanly®

  13. Versed® • Onset in 1 to 2 minutes • Duration 30 min • Caution for respiratory depression and hypotension

  14. Dosage for children having procedures: PO; 0.5 mg/kg/dose may repeat once with 0.25mg/kg/dose. Max dose: 20mg. IV: 0.05-0.1 mg/kg dose. May repeat over several minutes to a max dose of 0.1-0.2 mg/kg. Intranasal: 0.2-0.3 mg/kg. May repeat in 15 min Adults: 0.5 mg to 2mg slow push over at least 2 min. Usual dose needed is 2.5 – 5 mg . > 5mg generally not needed.

  15. Fentanyl- Sublimaze® • Used in combination with Versed for many years due to rapid onset and effectiveness • Synthetic opioid • Metabolized by the liver • Short duration of effect • Pure analgesic (should not be used alone) • Least histamine release of opiates

  16. Caution: Chest rigidity with rapid infusion and hypotension

  17. Fentanyl • Dosage for Pediatrics: -IM or IV 0.5-1.0 mcg/kg/dose -onset 1-2 min -lasts 30 minutes

  18. Etomidate Classified as a General Anesthetic Ultra short acting nonbarbiturate hypnotic used for the induction of Anesthesia Used for Sedation in Adults 0.2mg/kg IV given over 30-60 seconds Onset <1minutes Duration 3-5 minutes Limited data, Action too short for some procedures

  19. Ketamine-Ketalar® • Classified as a general anesthetic • Rapid acting dissociative anesthetic that produces a profound analgesic effect • Gaining favor in children due to reliable effects and strong safety profile

  20. Ketamine When patients are on ketamine they may appear awake. Eyes may remain open, they may have nystagmus. Ketamine is a potent phencyclidine deriviative Produces potent analgesia and rapid sedation while it preserves respiratory drive and airway protective reflexes

  21. Ketamine • IV 1-2 mg/kg/dose -Onset is 1 minute -Duration 10-20 minutes • IM 2-4 mg -onset 5 minutes -duration 15-45 minutes

  22. Ketamine Caution: Nystagmus can occur along with hypersecretions, agitation Delirium, vomiting , myoclonus and laryngospasm

  23. Propofol- • Classified as a general anesthetic -Lower doses sedation hypnosis • Anmestic, anxiolytic, antiemetic, and antiepileptic properties • No Analgesic effects

  24. Propofol • Dosing 2.5 -3.5 mg/kg/ dose over 20-30 seconds • Onset 10-30 seconds • Duration 10-20 minutes • For prolonged procedures may require continuous infusion 125-300mcg/kg/minute. (smaller children may require smaller infusion rates.

  25. Propofol Caution • Profound Respiratory Depression • Profound Irreversible bradycardia • Profound Hypotension • Avoid with Soy or Egg allergies

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