Sedation in Endoscopy

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Bangkok, Thailand
Title Sedation in Endoscopy by
Endoscopist Speaker Dr Pradermchai Kongkam
Chulalongkorn University Bangkok
Thailand Time 1045 (TH)
CanalAVIST Medical Forum 19 September 2008
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Sedation in Endoscopy by Endoscopist

• Pradermchai Kongkam, MD
• Chulalongkorn University
• Bangkok, Thailand

CanalAVIST Medical Forum 19 September 2008
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Aims for Ideal Sedation

• Safety
• Painless procedure
• Cost effective sedation
• Medications rapid onset/ brief duration/ fast
  recovery
• Acceptable intra and post-procedural monitoring

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Topics

• Pre-procedure assessment
• Level of consciousness
• Review of common medications
• Monitoring
• Post-procedure care
• Future trend

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Pre-procedure assessment
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Essential Medical History

• Cardiac or pulmonary disease
• Neurological disease, seizure
• Stridor, snoring or sleep apnea
• Adverse reaction to sedation
• Current medication/ allergy
• Alcohol or drug abuse
• Time of last oral intake
• ASA classification I - III

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ASA classification
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Physical Examination

• Vital signs and weight
• Heart and lung
• Baseline level of consciousness
• Assessment of airway

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Mallampati Score
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Procedural Variables

• Degree of invasiveness
• Level of procedure-related discomfort
• Duration of examination

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Documentation

• Assessment
• Informed consent
• Monitoring
• Recovery and discharge

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Level of Consciousness
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Level of Sedation

• Minimal sedation normal response to verbal
  stimulation
• Moderate sedation purposeful response to verbal
  or tactile stimulation, adequate ventilation
• Deep sedation purposeful response following
  repeated or painful stimulation, may be
  inadequate ventilation
• General anesthesia un-arousable even with
  painful stimulus

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Moderate Sedation

• Preoperative assessment
• At least, one participant must pass ACLS
• Knowledge about medications and antidote, mostly
  opioids and benzodiazepine
• Resources for treatment of complications

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Deep Sedation

• Knowledge about propofol and its character of
  rapid transition between level of consciousness
• Well trained person

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Review of Common Medications
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Meperidine 1

• Opioids analgesics, sedation
• Induction dose 25- 50 mg
• Additional dose 25 mg q 2-5 minutes
• Onset of action 3-6 minutes
• Duration 1-3 hours
• Mostly combined with benzodiazepine
• Prolonged half life in renal insufficiency

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Meperidine Adverse Effect

• Respiratory depression, cardiovascular
  instability
• When combined with BZP more respiratory
  depression
• Nausea and vomiting not a dose dependent
  reaction
• Neurological reaction reported in patients with
  renal failure
• Life threatening interaction with MAOI

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Fentanyl

• Highly lipid soluble, rapidly reaches opioid
  receptors
• Onset 1-2 min/ duration 30-60 min
• Elderly 50 dose reduction is recommended
• SE respiratory depression, chest wall rigidity
  in large dose
• Little effect on CVS

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Naloxone

• Opioid antagonist ventilatory depression,
  excessive sedation and analgesia
• Dose of 0.2-0.4 mg IV
• Onset 1-2 min, half life 30-45 min
• Monitored for up to 2 hours
• Caution for drug withdrawal symptoms in chronic
  opioid drug abusers

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Diazepam

• BZP anxiolysis, sedation, amnesia,
  anticonvulsant, muscle relaxation and anesthesia
• Binding to GABAA receptor subtype
• Onset 2-3 min, duration 6 hrs
• Hepatic conversion to active metabolite with slow
  clearance
• SE respiratory depression, dyspnea, coughing

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Midazolam

• Water soluble, short acting BZP
• 1.5-3 times more potent than diazepam, more rapid
  onset, shorter duration
• Onset 1-2 min, duration 15-80 min
• Reduced clearance in elderly, obese, hepatic or
  renal impairment, ASA III
• Indication procedural sedation, induction of GA

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Midazolam

• Respiratory depression administration-related
  phenomenon
• Apnea may occur as long as 30 min after last dose

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Flumazenil

• GABAA receptor complex BZP antagonist
• 0.1-0.3 mg
• Half life 0.7-1.3 hrs
• Reversal of respiratory depression occurs 120 sec
  after administration
• Re-sedation of BZP may occur

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Propofol

• Hypnotic with minimal analgesic effect
• Sub-hypnotic level sedation and amnesia
• Metabolized rapidly by liver to water soluble
  compounds excreted through kidney
• Cirrhosis and renal failure does not effect
  pharmacokinetics

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Propofol

• SE decrease in cardiac output/ systemic vascular
  resistance and arterial pressure
• Negative cardiac inotropy and respiratory
  depression can be rapidly treated with dose
  reduction or interruption

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Propofol

• FDA ..should be administered only by persons
  trained in the administration of GA
• ACG, ASGE, AGA with adequate training,
  physician-supervised nurse administration of
  propofol can be done safely and effectively

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Risks Minimization

• Ensure compliances with guideline
• Low risk patients
• Good recognition and management of respiratory
  depression/ complication
• Well equipped room
• Verbal and written informed consent

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Patient monitoring
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Person

• Trained visual assessment may be sensitive than
  objective monitoring
• Moderate sedation assigned person may perform
  interruptible task of short duration
• Deep sedation assigned person should have no
  other procedure-related responsibility

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Equipment
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Homodynamic and EKG

• Baseline vital sign should be recorded
• Tachycardia and hypertension gt inadequate
  sedation gt vice versa
• EKG is recommended only in high risk patients

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Pulse Oximetry

• Generally, it should be routinely monitored
• Hypoventilation gt oxygen sat maintain 90 until
  PaO2 less than 70 mmHg
• Clinical significance of transient de-saturation
  ??
• Decrease incidence of CVS event ??
• Limitation inability to detect signal during
  hypothermia, low cardiac output and motion

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Supplemental Oxygen

• ASA ..should be considered in moderate sedation
  and administered in deep sedation..
• ASGE ..it reduces oxygen de-saturation..
• However, it may delay recognition of hypoxemia
  and apnea

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Capnography

• It may recognize hypoventilation earlier than
  visual assessment or pulse oximetry
• ASA ..should be considered for all patients
  receiving deep sedation and for patients whose
  ventilation can not be observed directly during
  moderate sedation..

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Post procedure care
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Aldrete Scoring Systems

• Patients can be discharged to home or unit when
  score is 9 or greater

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Conclusion

• Good pre-procedural evaluation
• ACLS certified physician
• Knowledge and familiarity with medication/
  procedure
• Target at desired level of consciousness
• Good post procedure care
• Do not hesitate to call for help

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Thank you
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Bangkok, Thailand
End of Presentation by Dr Pradermchai Kongkam
CanalAVIST Medical Forum 19 September 2008