8 Amnestics Definition Examples Loss of memory, inability to recall eventsExamplesBenzodiazepineKetamine
9 Levels of Sedation Moderate Sedation Deep Sedation General Anesthesia Awake
10 Moderate Sedation Purposeful response to verbal stimulation Airway patentSpontaneous ventilation adequateCardiovascular function unaffected
11 Deep Sedation Difficult to arouse Purposeful response only to painful stimulationAirway may be obstructedSpontaneous ventilation may be impairedCardiovascular 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 llergiesM edicationsP ast Medical HistoryL ast MealE vents leading to sedation
14 Allergies Drug allergies Environmental allergies Contrast allergies Egg & soy allergy no PropofolContrast allergies
15 MedicationsKnowing current medications & therapeutic interventions can help tailor your sedation plan…Sedatives already being usedVasoactive medicationsNeuromuscular blockersRespiratory medicationsHemofiltration/dialysisAnd so on…
16 Past Medical HistoryKnow current patient problem list and significant past medical/surgical historyRespiratory (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 pastPrior adverse events with sedationAbility 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 patientASA II: mild systemic diseaseASA III: severe systemic diseaseASA IV: severe systemic disease that is a constant threat to lifeASA V: moribund patient not expected to survive without operation
19 Physical Exam Mallampati/Samsoon Classification Class I: soft palate, uvula, pillarsClass II: soft palate, portion of uvulaClass III: soft palate, base of uvulaClass IV: hard palate onlyOther predictors of difficult airwayObesity with short neckReduced neck movementInability to protrude the lower teethReduced mouth openingReceding mandibleThyromental distance of less than 3 fingers
20 Last Meal Full stomach is a risk of aspiration during sedation!!! NPO statusLast solid intake > 6 to 8 hoursLast opaque liquid/formula intake > 4 hoursLast clear liquid/breastmilk intake > 2 hoursThese guidelines do not apply for patients with GI disturbances
21 Last Meal Full stomachs include the following… Any patient with material in their stomachFoodMedicationsContrastCharcoalBloodAny patient with delayed gastric emptyingMorbid obesitySmall bowel obstructionPyloric stenosisGI dysmotilityAnd 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 combinationAnticipated duration of therapy
23 Choosing the Right Drug There is no magic cocktail…all drugs have potential complicationsDrugs to consider should fit your goals for sedation with minimum risk to the patientConsiderations when choosing a drugRoute of administrationOnset of actionDuration of actionContraindicationsTherapeutic advantages
25 Propofol Onset: 30 sec Duration: 3-10 min Dose: 1 mg/kg Infusion: mcg/kg/minDisadvantages: 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/minAnalgesia and amnesiapreserves upper airway tone and reflexesDisadvantages: excess secretions, increased ICP, emergence reactionMay 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 morphineAvailable reversal agentNaloxoneDisadvantages: 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:NaloxoneDisadvantages: no amnesia/ anxiolysis, histamine release
30 Midazolam (Versed) Onset: 2-6 min Duration: 45-60 min Dose: mg/kgAvailable reversal agentFlumazenilRetrograde amnesiaDisadvantages: NO analgesia, paradoxical reactionsPO, 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 taperingDisadvantages: 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/kgDisadvantages: mixed with propylene glycolAnion gap metabolic acidosis, osmolar gapAvoid infusions
33 Dexmedetomidine (Precedex) IV alpha-2 agonist1700x more selective for alpha 2Onset: minDuration: minDose: load with mcg/kgInfusion of 0.3 – 1.5 mcg/kg/hrDisadvantages: bradycardia, only approved for 24 hr infusions
35 Contraindications All drugs should be used judiciously!!! Commonly seen relative contraindications and adverse effectsKetamine increased ICP, excess salivation, emergence reactionPropofol hypotension, acidosisDexmedetomidine bradycardia, arrhythmiaBenzodiazepine hypotension
36 Therapeutic Advantages Not all side effects are harmfulConsiderations for choice of drugKetamine bronchodilatorPentobarbital or Midazolam anti-convulsantDiazepam muscle relaxation
38 Case #1An 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 # 2A 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 # 3You 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 # 4You 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 blockPentobarb … how is heart function, blood pressure
42 Case # 5You 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 + analgesicBenzo + narcHave airway, suction, O2, etc readyWhat 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 sedationCorrect acidosisKeep euvolemicKnow “AMPLE”Anticipate difficulties and be preparedBag, mask, oxygen, +/- airway boxSuctionNormal saline/Lactated Ringer’sMonitors – O2, CO2, CR monitor, BPTitrate 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, & amnesiaThere are several levels of sedationRemember mnemonic “AMPLE” when evaluating a patient for sedationChoosing the right drug involves knowing the goals of sedation alongside drug profile for sedativesAlways anticipate possible complications & be prepared to deal with them