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Procedural Sedation:

Procedural Sedation:. In A Nutshell. Deb Updegraff, R.N., M.S.N. P.N.P. Clinical Nurse Specialist Pediatric Intensive Care 3S Intermediate Intensive Care LPCH. The Players. MD RN Patient. Sedation VS Analgesia. Levels of Sedation. Minimal Sedation (anxiolysis)

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Procedural Sedation:

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  1. Procedural Sedation: In A Nutshell Deb Updegraff, R.N., M.S.N. P.N.P. Clinical Nurse Specialist Pediatric Intensive Care 3S Intermediate Intensive Care LPCH

  2. The Players • MD • RN • Patient

  3. Sedation VS Analgesia

  4. Levels of Sedation • Minimal Sedation (anxiolysis) • Moderate Sedation/Analgesia (formerly called conscious sedation) • Deep Sedation

  5. American Association of Anesthesiologists: ASA RiskClassification ASA I - A healthy patient ASA II - A patient with mild systemic disease ASA III - A patient with severe systemic disease (limits activity but not incapacitating) ASA IV- A patient with an incapacitating systemic disease that is a constant threat to life ASA V- A moribund patient not expected to survive 24 hours with or without surgery

  6. Pre-sedation Risk AssessmentAmpule • Allergies • Medications • Past Medical History • Last Meal • Events leading up to the need for sedation

  7. Other Risks • Previous problems with anesthesia or sedation • Known difficult intubation • Cranial facial syndromes • Decreased airway protective reflexes • Obesity • GERD or problems with gastric motility

  8. Equipment (SOAP) • Suction • Oxygen • Airway • Pharmacy

  9. Monitoring Continuous: • ECG • O2 Sat Blood Pressure • Q 5 min for moderate to deep sedation • Q 15 min for others

  10. Pharmacology: Selecting the MedsDepends on the Procedure and Patient History • LP • MRI • PICC placement • Central Line Placement • Bronchoscopy • Chest tube placement

  11. Choice of Drugs • Analgesics • Narcotics • Fentanyl • Morphine • Ketamine • Sedation • Benzodiazepines • Midazolam • Lorazepam • Barbiturates • -Propofol

  12. Fentanyl Bolus= 0.5-1.0 mcg/kg (MAY REPEAT Qq5-10MIN) Rigid Chest Syndrome Morphine - Bolus=0.05-0.1mg/kg (may repeat q5-10min) Histamine Release + Sedative and Hypnotic properties Narcotics Narcotics have both sedative and analgesic qualities

  13. Midazolam Bolus=0.05-0.2 mg/kg Lorazepam Bolus=0.05-0.2 mg/kg Benzodiazepines Benzodiazepines have both sedative and Amnesic qualities NO Analgesic Properties

  14. Ketamine Dissociative anesthetic: phencyclidine derivative (PCP) • IV - 0.5 to 2mg/kg • IM -3-4 mg/kg • + Analgesia/Sedation • Contraindicated Increased Intracranial Pressure Increased Intraoccular Pressure • Onset of action IV 1-2 minute • IM 3-10 minutes Can cause larygospasms and hallucinogenic emergent reactions.

  15. Propofol • General Anesthetic Agent • NO Analgesic Properties • Advantages: • Rapid Onset and Emergence • Profound Sedation • Disadvantages: • Metabolic Acidosis • Severe  SVR

  16. Propofol - dosing Continuous Infusion 5-50 mcg/kg/hr Induction 2.5 – 3.5 mg/kg Over 20-30 seconds Repeat as child emerges

  17. Reversal Agents Narcan: For Narcotic Reversal dose: 1-10mcg/kg IV push (1/10th of dose recommended for full reversal of narcotic poisoning) May need to repeat. OK: IV, IM, endotracheal Flumazenil: For Benzodiazepine Reversal- Can reverse benzo-induced respiratory depression and paradoxical excitatory reactions. dose: 0.01-0.02 mg/kg. May be repeated.

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