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Anesthesia, Analgesia, Anxiolysis, Amnesia, And so on…

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Presentation on theme: "Anesthesia, Analgesia, Anxiolysis, Amnesia, And so on…"— Presentation transcript:

1 Anesthesia, Analgesia, Anxiolysis, Amnesia, And so on…
Ivy Pointer, M.D Pediatric Critical Care Fellow UNC Department of Anesthesiology

2 Overview Role of sedation in critical care Elements of sedation
Levels of sedation Choosing a sedation plan Choosing the right drug Preventative medicine

3 Sedation in Critical Care
Medical illness Post-operative care Diagnostic imaging Invasive procedures Mechanical ventilation

4 Elements of Sedation Anesthesia Analgesia Anxiolysis Amnesia

5 Anesthesia Definition Examples (Intravenous anesthetics)
Loss of sensation & loss of consciousness Examples (Intravenous anesthetics) Etomidate Ketamine Propofol Thiopental

6 Analgesia Definition Examples Inability to sense pain
Non-sedating Analgesics Lidocaine/L.M.X. 4 Acetaminophen NSAIDs (Ibuprofen, Ketorolac) Sedating Analgesics Narcotics (Fentanyl, Morphine, Oxycodone, Methadone) Ketamine

7 Anxiolytics Definition Examples
Relief of apprehension, fear, and/or agitation Examples Benzodiazepines (Midazolam, Lorazepam, Diazepam) Chloral Hydrate

8 Amnestics Definition Examples
Loss of memory, inability to recall events Examples Benzodiazepine Ketamine

9 Levels of Sedation Moderate Sedation Deep Sedation General Anesthesia
Awake

10 Moderate Sedation Purposeful response to verbal stimulation
Airway patent Spontaneous ventilation adequate Cardiovascular function unaffected

11 Deep Sedation Difficult to arouse
Purposeful response only to painful stimulation Airway may be obstructed Spontaneous ventilation may be impaired Cardiovascular function usually unaffected

12 General Anesthesia Loss of consciousness Positive pressure ventilation
Cardiovascular function may be affected

13 Choosing a Sedation Plan
Remember mnemonic AMPLE!! A llergies M edications P ast Medical History L ast Meal E vents leading to sedation

14 Allergies Drug allergies Environmental allergies Contrast allergies
Egg & soy allergy no Propofol Contrast allergies

15 Medications Knowing current medications & therapeutic interventions can help tailor your sedation plan… Sedatives already being used Vasoactive medications Neuromuscular blockers Respiratory medications Hemofiltration/dialysis And so on…

16 Past Medical History Know current patient problem list and significant past medical/surgical history Respiratory (hypoxia, pneumothorax) Cardiovascular (hypotension, myocardial dysfunction) Neurologic (increased ICP, seizure disorder) Hepatic/Renal failure

17 Past Medical History Past history of sedation
Medications used in the past Prior adverse events with sedation Ability to manage airway (Pierre Robin, croup, mediastinal mass, prior radiation, asthma) Family history of problems with sedation

18 Past Medical History ASA Physical Status Score
ASA I : normally healthy patient ASA II: mild systemic disease ASA III: severe systemic disease ASA IV: severe systemic disease that is a constant threat to life ASA V: moribund patient not expected to survive without operation

19 Physical Exam Mallampati/Samsoon Classification
Class I: soft palate, uvula, pillars Class II: soft palate, portion of uvula Class III: soft palate, base of uvula Class IV: hard palate only Other predictors of difficult airway Obesity with short neck Reduced neck movement Inability to protrude the lower teeth Reduced mouth opening Receding mandible Thyromental distance of less than 3 fingers

20 Last Meal Full stomach is a risk of aspiration during sedation!!!
NPO status Last solid intake > 6 to 8 hours Last opaque liquid/formula intake > 4 hours Last clear liquid/breastmilk intake > 2 hours These guidelines do not apply for patients with GI disturbances

21 Last Meal Full stomachs include the following…
Any patient with material in their stomach Food Medications Contrast Charcoal Blood Any patient with delayed gastric emptying Morbid obesity Small bowel obstruction Pyloric stenosis GI dysmotility And so on…

22 Events leading to sedation…
Know why your patient needs sedation!! Is it safe to sedate your patient?? What kind of sedation are you trying to achieve?? Analgesia, anxiolysis, amnesia, or a combination Anticipated duration of therapy

23 Choosing the Right Drug
There is no magic cocktail…all drugs have potential complications Drugs to consider should fit your goals for sedation with minimum risk to the patient Considerations when choosing a drug Route of administration Onset of action Duration of action Contraindications Therapeutic advantages

24 Our favorite PICU drugs
Anesthetics: Propofol, Ketamine, Pentobarbital Analgesics: Fentanyl, Morphine Anxiolytics: Midazolam, Lorazepam, Diazepam Other: Dexmedetomidine, Clonidine

25 Propofol Onset: 30 sec Duration: 3-10 min Dose: 1 mg/kg
Infusion: mcg/kg/min Disadvantages: respiratory depression, hypotension, bradycardia, NO analgesia, metabolic acidosis with prolonged infusion

26 Ketamine Onset: 30 sec (IV), 3-4 min (IM)
Duration: 5-10 min (IV), min (IM) Dose: mg/kg (IV), 4-5 mg/kg (IM) Infusion: 5-20 mcg/kg/min Analgesia and amnesia preserves upper airway tone and reflexes Disadvantages: excess secretions, increased ICP, emergence reaction May be the preferred agent when fasting not possible due to UA reflexes maintained. Also a good agent in patients with asthma.

27 Pentobarbital Onset: 3-5 min (IV) Duration: 15-45 min Dose: 1-2 mg/kg
Disadvantages: NO reversal agent, no analgesia (enhances pain perception) PO, IV, IM, PR dosing routes

28 Fentanyl Onset: 2-3 min Duration: 30-60 min Dose: 1 mcg/kg
100x more potent than morphine Available reversal agent Naloxone Disadvantages: no amnesia/ anxiolysis, “steel chest” Fentanyl is preferred over other opioids because of its faster onset and shorter recovery period and lack of histamine release.

29 Morphine Onset: 5-10 min (IV) Duration: 4-6 hours Dose: 0.05-0.1 mg/kg
Available reversal agent: Naloxone Disadvantages: no amnesia/ anxiolysis, histamine release

30 Midazolam (Versed) Onset: 2-6 min Duration: 45-60 min
Dose: mg/kg Available reversal agent Flumazenil Retrograde amnesia Disadvantages: NO analgesia, paradoxical reactions PO, IV, IM, IN, PR dosing routes

31 Diazepam (Valium) Onset: 1-1.5 hours (oral)
Duration: variable but LONG (oral) Dose: mg/kg/day (oral) Useful for tapering Disadvantages: accumulation, long half-life, avoid rapid IV push

32 Lorazepam (Ativan) Onset:15-30 min (IV)
Duration: 3-4 hours (up to 12 hrs) Dose: mg/kg Disadvantages: mixed with propylene glycol Anion gap metabolic acidosis, osmolar gap Avoid infusions

33 Dexmedetomidine (Precedex)
IV alpha-2 agonist 1700x more selective for alpha 2 Onset: min Duration: min Dose: load with mcg/kg Infusion of 0.3 – 1.5 mcg/kg/hr Disadvantages: bradycardia, only approved for 24 hr infusions

34 Clonidine Centrally acting alpha-2 agonist Onset: 30-60 min (oral)
Duration: 6-10 hours Dose: 0.05 mg/day (oral) Can convert to transdermal patch Eases withdrawal & decreases anesthetic requirements

35 Contraindications All drugs should be used judiciously!!!
Commonly seen relative contraindications and adverse effects Ketamine  increased ICP, excess salivation, emergence reaction Propofol  hypotension, acidosis Dexmedetomidine  bradycardia, arrhythmia Benzodiazepine  hypotension

36 Therapeutic Advantages
Not all side effects are harmful Considerations for choice of drug Ketamine  bronchodilator Pentobarbital or Midazolam  anti-convulsant Diazepam  muscle relaxation

37 Cases

38 Case #1 An 8 year old known asthmatic is in the ED having received continuous albuterol nebs, steroids, and subcutaneous epinephrine. You check on him and find him unresponsive with a RR of 6 and very poor air movement. An RT runs in with a ABG showing pH 6.9, pCO What medications do you consider for intubation & sedation? Sedative choices that may help the situation include ketamine for its bronchodilatory effects. Propofol is also a bronchodilator. Using a short-acting paralytic or reversing the paralysis soon after intubation may help by letting the patient use their muscles of expiration.

39 Case # 2 A transport team has just arrived to pick up a 4 year old child with severe stridor. On exam she is alert, sitting in Mom’s lap & maintaining her sats, but has severe retractions with every breath and drooling. She appears frightened, and the paramedic asks you to order something to sedate her so that she can be strapped to the gurney. What is your response? Epiglottitis, although now rare, is in the differential here. Sedation should be avoided, as should anything that might upset the child. It is best to allow her to continue to sit in Mom’s lap & maintain the position which maintains a patent airway. Definitive airway management by anesthesia/ENT should be considered prior to transport.

40 Case # 3 You consult in the ED on a 7 year old who has presented with sore throat and noisy breathing. He has received 2 gm of chloral hydrate 1/2 hour before for an attempted CT scan of the neck. In the ED you find him in the back room with his mother, with a sat probe on his finger not attached to a monitor. He has retractions and poor air movement with every breath. What happened and what would you do? He received too high a dose of chloral hydrate, and the depth of sedation has caused upper airway obstruction (already at risk with possible airway swelling). He is also not being adequately monitored. The important point is that ANY sedating agent can lead to airway compromise, and monitoring is essential. You should intervene by monitoring, performing a jaw thrust, placing a nasal airway, or intubating if necessary.

41 Case # 4 You are taking care of a 9 mo post-op cardiac patient who is intubated and requiring sedation. She initially had issues with heart block and required pacing but is now in a sinus rhythm of 110. She has been difficult to sedate with Fentanyl & Midazolam and the nurses ask you if you can add a 3rd agent. What agents would you want to avoid in this patient and what do you need to consider? Precedex … h/o heart block Pentobarb … how is heart function, blood pressure

42 Case # 5 You are called to the ED to see a 6 year old trauma patient who luckily has a normal head CT but unfortunately has a severely displaced tib-fib fracture. The orthopedic surgeons are gathering equipment to reduce and splint the fracture. What drugs do you think about using and what else do you consider? Ketamine (any head trauma? Ketamine can raise ICP) Propofol + analgesic Benzo + narc Have airway, suction, O2, etc ready What is the neuro status? If there has been a head injury or there is waxing/waning mental status, you need to be careful that you are able to continue to monitor the patient & don’t cause hypotension. If there is a head + orthopedic injury requiring OR care it may be necessary to delay the OR trip to observe neuro status or to place an ICP monitor.

43 Preventative Medicine is Key!!
Optimize your patient prior to sedation Correct acidosis Keep euvolemic Know “AMPLE” Anticipate difficulties and be prepared Bag, mask, oxygen, +/- airway box Suction Normal saline/Lactated Ringer’s Monitors – O2, CO2, CR monitor, BP Titrate medications to effect…it is easier to give more drug than it is to remove it!!!

44 Summary Many situations require sedation in the ICU
Components of sedation include anesthesia, analgesia, anxiolysis, & amnesia There are several levels of sedation Remember mnemonic “AMPLE” when evaluating a patient for sedation Choosing the right drug involves knowing the goals of sedation alongside drug profile for sedatives Always anticipate possible complications & be prepared to deal with them


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