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Sedation Complications, Urgencies and Emergencies

Learn to handle sedation complications effectively with key guidelines. Topics include nausea/vomiting, aspiration, paradoxical reactions, oversedation, laryngospasm, and necessary treatments. Be prepared for emergencies!

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Sedation Complications, Urgencies and Emergencies

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  1. Sedation Complications, Urgencies and Emergencies

  2. Medical Emergency Kit

  3. Golden Rule • In cases of trouble • Always verify adequate respirations of your patient • Ventilate • Reverse

  4. Sedation Emergencies • Nausea/Vomiting • Aspiration • Paradoxical reactions • Oversedation • Laryngospasm

  5. Nausea/Vomiting • Most commonly associated with • Opioids • Patient movement will aggravate • Swallowing blood • Anxiety

  6. Treatment of Nausea and Vomiting… • Promethazine (Phenergan) • 25 mg IV, IM, oral or rectal • Additive sedative effect • Trimethylbenzamide (Tigan) • 200-250 mg oral, rectal, IM • Questionable efficacy • Ondansetron (Zofran) • 4 mg IV or IM

  7. Aspiration • Defined • Inhaling of vomit into lungs • Causes • Depression of protective reflexes with depressed level of consciousness • Increased N/V associated with opioids • Swallowing of blood

  8. Aspiration • Damage: • Particles/fluids • Cellular response to lungs (chemical burn) • Respiratory lining breakdown • Surfactant destroyed • Alveoli collapse becoming fluid filled • Large particles • Mechanical airway obstruction • Atalectasis, asphyxia, death

  9. Aspiration • Treatment • Aggressive suctioning • Head down position • Transfer to hospital quickly

  10. Aspiration • Prevention • Identify prone patients • Anxiety • Problems with opioids • NPO solids > 6 hours • NPO clear liquids > 2 hours • Vigilant suctioning of blood • Prophylactics?

  11. Paradoxical Reactions… • Benzodiazepines primary culprit • More common in women and children • Crying • Anger • Agitation • Combativeness • Pruritis • Disorientation • Dysphoria • Tachycardia

  12. Paradoxical Reactions… • Benzo’s remove inhibitions in some patients • Patients with mental disorders more likely • Treatment • Flumazenil

  13. Oversedation… • Any level of sedation or anesthesia can be achieved by any route • Inhalational • Orally • Parenteral

  14. Oversedation… • Your patient is clearly oversedated when they do not… • Maintain their own patent airway • Breath on their own • Respond to verbal commands

  15. Oversedation… • Understand dosing schedules • Understand pharmacokinetics of medications used • Drug—Drug interactions • Increased concentrations of midazolam and triazolam • Erythromycin • Ketoconazole/iatraconazole • Grapefruit juice • Protease inhibitors • Verapamil/diltiazem

  16. Oversedation… • Overuse of opioids often results in… • Respiratory depression • Decreased depth, rate and drive • Decreased skeletal muscle tone

  17. Respiratory Depression… • In the presence of respiratory depression patients may… • Obstruct • Muscle relaxation • Tongue position • Hypoventilation to the point of apnea

  18. Oversedation… • Does not necessarily define a state of emergency, but you must be able to… • Recognize the situation • Be able to get out of it skillfully • Have the courage to ask for help

  19. Oversedation… • Oversedation will generally imply that your patient does not… • Hold his own airway • Breath spontaneously • Both

  20. Oversedation… You absolutely, positively Must Must Must be able to distinguish between the two

  21. Oversedation… • Of the oxygen saturation drops more than 4 points… • Gently shake or shout • Open the airway (jaw thrust maneuver) • Positive pressure ventilation • Administer reversal agent • EMS if no rapid response

  22. Flumazenil Approved use—IV May be given—IM, SL, IN Dose: 0.2 mg (2cc) Pedi: 0.01-0.02 mg/kg Naloxone Intended use—IV May be given—IM, SL, SC Dose: 0.1-0.4 mg Pedi: 0.01 mg/kg Our Savior

  23. Intranasal Flumazenil… • Study performed on 11 kids ages 2-6 yrs. • Dose: 0.04 mg/kg via drops in nose • Adult dose 0.2 mg/70kg • Both resulted in plasma concentrations 5 times that reported to reverse benzo’s • Highest plasma concentrations seen with administration via both nostrils • Peaked in 2 minutes Scheepers et al. Can J Anesth. 2000;47:120

  24. Oversedation… • After the administration of a reversal agent • Must continue to ventilate until spontaneous respirations return • Continue to observe patient for 2 hours to rule out resedation

  25. Laryngospasm • In the event that you cannot ventilate, you must consider the presence of laryngospasm or foreign body airway obstruction • Defined: • Forceful partial or complete adduction of the vocal cords

  26. Laryngospasm • Treatment • Remove any obvious foreign material • Ventilate forcefully with oxygen • Reverse the sedative agent

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