Procedural Sedation Pharmacology

Deb Updegraff R.N., P.N.P, C.N.S.Clinical Nurse SpecialistLPCH Pediatric Intensive Care Unit

Procedural Sedation

The phrase “procedural sedation” refers to techniques of managing a patient’s pain and anxiety to facilitate appropriate medical care in a safe, effective and humane fashion.

Age

Concurrent disease states

Concurrent drug therapy

Sedation Pharmacolgy

Individual responses are dependant on:

Chloral Hydrate

Hypnotic-“Short term sedative and hypnotic given priorto nonpainful procedures

Chloral Hydrate

Usually given to Outpatients due to relative low risk profile. For non-painful procedures only.

EEGs

MRI/CT Scans

Echocardiograms

Chloral Hydrate

PO/Rectal

Dose: 50mg/kg give 30-60 minutes prior to procedure.

Can repeat x1 25mg/kg

Not to exceed 100mg/kg in a 24 hour period

Chloral Hydrate

Expect a moderate decrease in heart rate and blood pressure in patients ASA I-II

For infants < 6 months there is ↑ risk for apnea and hypoxia.

Age a limiting factor. High failure rate in children > 4 years.

Pentobarbital : Nembutal®

Barbituate- Non elective central nervous system depressants

primarily used as Hypnotic sedative for non painful procedures.

Nembutal

PO/Rectal/IM/IV Dose for procedural sedation:

4mg/kg , may repeat 2mg/kg, max 100mg

Nembutal: precautions

Rapid IV injection ie, can cause respiratory depression, apnea, laryngospasm, bronchospasm and hypotension

Recommended to infuse IV dose over 10-30 minutes.

Can significantly decrease cardiac output and should be avoided with CHF

Benzodiazepines

Midazolam- Versed® Lorazepam - Ativan®

Induce anterograde amnesia (not retrograde)May have some opioid sparing effect by ↓ anticipatory pain response

Midazolam -® Versed

Most commonly used Benzo for preoperative and pre-procedural sedation.

Undergoes hepatic metabolism and renal excretion and prolonged effects seen with dysfunction of either system

Sedative, amnestic and anxiolytic with no analgesic properties

Commonly used with an opioid analgesic such as Fentanly®

Versed®

Onset in 1 to 2 minutes Duration 30 min Caution for respiratory depression

and hypotension

Dosage for children having procedures:

PO; 0.5 mg/kg/dose may repeat once with 0.25mg/kg/dose. Max dose: 20mg.

IV: 0.05-0.1 mg/kg dose. May repeat over several minutes to a max dose of 0.1-0.2 mg/kg.

Intranasal: 0.2-0.3 mg/kg. May repeat in 15 min

Adults: 0.5 mg to 2mg slow push over at least 2 min. Usual dose needed is 2.5 – 5 mg . > 5mg generally not needed.

Fentanyl- Sublimaze®

Used in combination with Versed for many years due to rapid onset and effectiveness

Synthetic opioid Metabolized by the liver Short duration of effect Pure analgesic (should not be

used alone) Least histamine release of opiates

Caution:

Chest rigidity with rapid infusion and hypotension

Fentanyl

Dosage for Pediatrics:

-IM or IV 0.5-1.0 mcg/kg/dose

-onset 1-2 min

-lasts 30 minutes

Etomidate

Classified as a General Anesthetic

Ultra short acting nonbarbituratehypnotic used for the induction of Anesthesia

Used for Sedation in Adults0.2mg/kg IV given over 30-60 seconds

Onset <1minutes Duration 3-5 minutes

Limited data, Action too short for some procedures

Ketamine-Ketalar®

Classified as a general anesthetic Rapid acting dissociative anesthetic

that produces a profound analgesic effect

Gaining favor in children due to reliable effects and strong safety profile

Ketamine

When patients are on ketamine they may appear awake. Eyes may remain open, they may have nystagmus.

Ketamine is a potent phencyclidine deriviative

Produces potent analgesia and rapid sedation while it preservesrespiratory drive and airway protective reflexes

Ketamine

IV 1-2 mg/kg/dose

-Onset is 1 minute

-Duration 10-20 minutes

IM 2-4 mg

-onset 5 minutes

-duration 15-45 minutes

Ketamine Caution:

Nystagmus can occur alongwith hypersecretions, agitationDelirium, vomiting , myoclonus and laryngospasm

Propofol-

Classified as a general anesthetic

-Lower doses

sedation

hypnosis Anmestic, anxiolytic, antiemetic, and

antiepileptic properties No Analgesic effects

Propofol

Dosing 2.5 -3.5 mg/kg/ dose over 20-30 seconds

Onset 10-30 seconds Duration 10-20 minutes For prolonged procedures may

require continuous infusion 125-300mcg/kg/minute. (smaller children may require smaller infusion rates.

Propofol Caution

Profound Respiratory Depression Profound Irreversible bradycardia Profound Hypotension

Avoid with Soy or Egg allergies