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Procedural Sedation Tintinalli Chap. 38

Procedural Sedation Tintinalli Chap. 38. Prepared by Darren Shiley , D.O. Levels of Sedation. Minimal Sedation drug-induced anxiolysis Patient responds normally to verbal commands Cognitive function and coordination may be impaired Ventilatory and cardiovascular function is unaffected

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Procedural Sedation Tintinalli Chap. 38

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  1. Procedural SedationTintinalli Chap. 38 Prepared by Darren Shiley, D.O.

  2. Levels of Sedation • Minimal Sedation • drug-induced anxiolysis • Patient responds normally to verbal commands • Cognitive function and coordination may be impaired • Ventilatory and cardiovascular function is unaffected • Moderate Sedation and Analgesia • PSA or “conscious sedation” • Drug-induce depression of consciousness • Patient responds purposefully to verbal commands alone or with light tactile stimulation • Deep Sedation and Analgesia • Patient cannot be easily aroused but responds purposefully after repeated or painful stimulation • May require assistance in maintaining patent airway and spontaneous ventilation may be inadequate • Anesthesia • Drug-induced loss of consciousness • Patient cannot be aroused even with painful stimulation • Requires assistance in maintaining a patent airway and may need positive pressure ventilation • Cardiovascular function may be impaired

  3. Procedural Sedation and Analgesia • Indications • Treatment of severe pain • Attenuation of pain and anxiety associated with procedures • Rapid tranquilization • Need to perform a diagnostic procedure • Agents • Often have narrow therapeutic index • Should be given in small incremental doses • Monitoring • Should be performed by another provider who understands the pharmacology, possesses sound airway-management skills, and will not be distracted by other tasks

  4. Patient Assessment • Classification • I • Normal healthy patient • II • Mild systemic disease • Asthma • Controlled diabetes • III • Moderate systemic disease • Stable angina • Diabetes with hyperglycemia • Moderate COPD • IV • Severe systemic disease • Unstable angina • DKA • V • Moribund • +E • All ED patients

  5. Agents in PSA • Opioids • Morphine • Fentanyl • Anxiolytics • Midazolam • Anesthetic Agents • Propofol • Etomidate • Ketamine • Methohexital

  6. Midazolam • Benzodiazepine • potentiate inhibitory activity of GABA in CNS • Result in sedation, amnesia, anxiolysis, respiratory depression, and anticonvulsant effects • Use cautiously in combination with alcohol or opioids d/t increased sedative and respiratory-depressant effects

  7. Antidotal Agents • Naloxone • Competitive opioid antagonist at µ receptors • Indicated for reversal of unwanted respiratory depression after opioid administration • May not reverse fentanyl-induced chest wall rigidity • Patients who are opioid dependent may develop withdrawal with large doses • Flumazenil • Competitive antagonist of benzodiazepines • Use with caution in benzodiazepine-dependent patients • Indicated for reversal of respiratory depression caused by benzodiazepines

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