Sedation and Analgesia

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Sedation and Analgesia

• Dan Quan, DO
• Department of Emergency Medicine
• Maricopa Medical Center
• Phoenix, Arizona

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Goals of Sedation and Analgesia

• Provide patient comfort for procedures
• Anxiolysis
• Pain control
• Decreases risk to both provider and patient
• Sedation without compromising oxygenation
• Choose agents with reliable effects to achieve
  rapid results
• Make your emergency department noise free

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Levels of Sedation

• Minimal sedation (anxiolysis)
• Awake and responsive, no airway problems
• Moderate sedation/analgesia (conscious sedation)
• Patient able to follow commands but level of
  consciousness is decreased
• Able to maintain airway and spontaneous breathing

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Levels of Sedation

• Deep sedation/analgesia
• Deeply sedated, but able to follow commands
• May require ventilatory support and supplemental
  oxygen
• Anesthesia
• Uh oh, this better be happening in the operating
  room

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Routes of Administration

• Intravenous (IV)
• Direct route, pharmacokinetics are predictable,
  IV access may be difficult to obtain
• Intramuscular (IM)
• Indirect route, sporatic absorption, slightly
  unpredictable
• Intraossesous (IO)
• Direct route, similar to IV pharmacokinetics

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Routes of Administration

• Oral (PO)
• Affected by first pass effects and metabolism
  through the liver so exact dosing is difficult,
  unpredictable absorption (empty stomach vs.
  full),
• Rectal (PR)
• Indirect route, may require longer to absorb,
  unpredictable absorption
• Nasal
• Direct route, nasal irritation

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Nebulizer vs. Nasal Plasma Concentration
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General Preparation

• Obtain procedural consent before administering
  drugs
• Good IV site preferably two with maintenance
  fluids running
• Administer supplemental oxygen
• Cardiac monitoring with pulse oximetry

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General Preparation

• End tidal CO2 monitoring is helpful
• Pulse oximetry indicates hypoxia earlier than end
  tidal CO2 detection
• Ready at hand bag valve mask, suction and
  intubation equipment
• Size up the patient for intubation success
• Mouth opening, thyromental distance, range of
  neck motion

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Choosing an Agent(s)

• Procedure duration
• Analgesic requirement
• Local vs systemic
• Most sedating medications do not control pain
• Recovery time
• Hemodynamic effects
• Side effects

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Opioids and Benzodiazepines

• Fentanyl
• Morphine
• Hydromorphone

• Midazolam (Versed)
• Lorazepam (Ativan)
• Diazepam (Valium)

• May be used in any combination
• Most common combination fentanyl and
• midazolam
• Sedating medications are not analgesics

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Fentanyl (Sublimaze)

• Used for anxiolysis, analgesia, and anesthesia
• May cause bradycardia and hypotension
• Does not release histamine
• Skeletal and chest wall rigidity have been
  reported after rapid high-dose administration
• Dose 1-10 mcg/kg IV (adult 100-300 mcg)
• Onset of action lt1 minute, duration of 30 minutes

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Opioid Adverse Effects

• Respiratory depression
• Reverse with naloxone 0.2-0.4 mg for respiratory
  depression
• Histamine release
• Itching
• Hypotension
• Vomiting
• May cause bradycardia and hypotension

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Midazolam (Versed)

• Produces amnesia, anesthesia, and anxiolysis
• No analgesia
• Commonly used in combination with opioids such as
  fentanyl
• Respiratory depression
• Decreases heart rate and blood pressure

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Midazolam Adult Dosing

• IV 1 2.5 mg over 2 minutes, titrate in 2 minute
  increments
• Onset 1 minute, Duration of action 30 minutes
• Lower dose 50 in gt 55 years

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Midazolam Pediatric Dosing

• PO/PR 0.5 - 0.75 mg/kg
• Onset 10 - 20 minutes, duration 60 minutes
• lt 6 years old may require 1 mg/kg
• IM 0.1 0.15 mg/kg (max total dose 10 mg)
• Onset 15 minutes, duration 120 minutes
• IN 0.2 - 0.5 mg/kg (max total dose 10 mg)
• Onset 10 minutes, duration 60 minutes
• Causes mucosal irritation, lidocaine may help

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Midazolam Pediatric Dosing

• IV (titrate to max total dose 6 mg)
• 6 months 5 years
• 0.05 - 0.1 mg/kg
• Dose increased because of increased metabolism
  and enzyme activity
• 6 12 years
• 0.025-0.05 mg/kg
• Onset 1 minute, Duration of action 30 minutes

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Midazolam

• Up to 15 of children have a paradoxical reaction
• Crying, combativeness, agitation, and restlessness

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Benzodiazepine Reversal

• Romazicon (flumazenil)
• Adult
• 0.2 mg (2 mL) IV repeat every one minute up to 4
  doses
• Children
• 0.01 mg/kg (up to 0.2 mg) up to 4 doses (maximum
  total dose of 0.05 mg/kg or 1 mg)
• Use caution in patients who are on chronic
  benzodiazepine therapy
• Refractory seizures (status epilepticus)

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Propofol (Diprivan)

• Mechanism of action
• Inhibits NMDA receptors, GABAA receptor agonist
• Produces amnesia and anesthesia but not analgesia
• Antiemetic (serotonin receptors)
• Decreases ICP, cerebral blood flow (increased
  vascular resistance) and intraocular pressure

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Propofol Dose

• IV 0.5-1 mg/kg
• Repeat by 0.5 mg/kg increments q 3-5 min
• Onset 30 to 60 seconds
• Duration 5 to 10 minutes

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Propofol (Diprivan)

• Cautions
• Dose dependent hypotension
• gt 30 reduction in SBP and DBP
• Decreased cardiac output
• Avoid in egg (emulsifier) or soybean allergic
  patients

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Etomidate (Amidate)

• Mechanism of action
• GABA agonist
• No analgesia
• Minimal respiratory and cardiovascular effects
• Myoclonus in 20-45
• Blocks 11-ß-hydroxylation to cause adrenal
  suppression

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Etomidate (Amidate)

• Dose gt 10 years
• 0.1 - 0.2 mg/kg IV repeat 0.05 mg/kg every 3 5
  minutes
• Onset 30 60 seconds, Duration 3 - 5 minutes
• Decrease dose
• Elderly
• Liver and kidney dysfunction

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Barbiturates

• GABAA receptor agonist
• No analgesia
• Good for non painful procedures such as imaging
• Sedation in infants
• Pentobarbital has longer duration of action,
  multiple routes of administration
• Methohexital is shorter acting

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Barbiturates Cautions

• Decreases cardiac output and systemic arterial
  pressure
• Peripheral vasodilatation
• Causes histamine release
• Rash
• May cause anaphylactoid reactions
• Extravasation
• Pain, edema, erythema and tissue necrosis

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Pentobarbital Adult Dosing

• IM 150 to 200 mg
• Onset 10 15 minutes, Duration 1 2 hours
• IV 100 mg to total dose 200-500 mg
• Onset 1 - 2 minutes, Duration 15 - 45 minutes

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Pentobarbital Pediatric Dosing

• Infants (maximum total dose 8 mg/kg)
• PO 4 mg/kg repeat 2 - 4 mg/kg every 30 minutes
• Children (maximum dose 100 mg)
• IM 2 - 6 mg/kg
• Onset 10 15 minutes, Duration 1 2 hours
• IV 1 - 2 mg/kg (repeat 1 - 2 mg/kg, every 3 -5
  minutes)
• Onset 1 - 2 minutes, Duration 15 - 45 minutes
• PO/PR lt 4 years 3-6 mg/kg
• 4 or more years 1.5 - 3 mg/kg
• Onset 10 - 20 minutes, Duration 1 4 hours

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Methohexital (Brevital)

• Adults 0.75 - 1 mg/kg IV repeat 0.5 mg/kg every
  2 to 5 minutes
• Pediatric (more than 1 month of age)
• IV 0.5 mg/kg repeat 0.5 mg/kg every 2 - 5 minutes
  (max 2 mg/kg)
• PR 25 mg/kg every 5 - 15 minutes (max 500 mg)
• IV Onset 1 minute, duration 4-6 minutes
• PR Onset 5-15 minutes, duration 45 minutes

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Chloral Hydrate

• Metabolized to trichloroethanol (TCE) by alcohol
  dehydrogenase
• A good agent for those less than 3 years old
• Rapidly absorbed
• Cautions
• Oversedation, respiratory compromise can occur
  especially at higher doses
• Avoid in liver and renal impairment

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Chloral Hydrate

• Adults PO/PR
• 500 - 1000 mg
• Children PO
• 50 - 75 mg/kg repeat 25 50 mg/kg in 30 minutes
  (Max total dose 120 mg/kg or 1 g)
• Onset 30 - 60 minutes, duration 4 - 8 hours

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Ketamine (Ketalar)

• Dissociative anesthetic similar to phencyclidine
  (PCP)
• Provides analgesia
• Increases heart rate and blood pressure but no
  respiratory depression
• Increases skeletal muscle tone
• Potent bronchodilator, increases bronchial and
  oral secretions

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Ketamine (Ketalar)

• Emergence reactions occur in up to 30 of adults
  (elderly, females, doses gt 2 mg/kg)
• Can give midazolam or propofol to decrease
  reaction
• Use with caution in psychiatric patients
• Nausea and vomiting (5 to 15)
• Rapid IV push can cause apnea

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Ketamine Dosing

• Adult
• 1 - 1.5 mg/kg IV over 1 minute
• Pediatric
• IV 0.5 - 1 mg/kg repeat 0.25 - 0.5 mg/kg q10 - 15
  minutes
• IM 2 - 5 mg/kg
• IV Onset 30 seconds, duration 5 - 10 minutes
• IM Onset 5 minutes, duration 12 - 30 minutes

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Ketofol

• Using both agents was thought to
• Decrease the total amount of medication required
  to achieve sedation
• Decrease hypotension induced by propofol
• Decrease respiratory depression induced by
  propofol
• Shorter recovery time
• Decrease ketamine induced recovery phase
  agitation and vomiting

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Ketofol

• Administered 11 amounts
• 1 mg/mL propofol with 1 mg/mL ketamine
• May be associated with increased respiratory
  depression than with propofol alone

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Dexmedetomidine (Precedex)

• ?2-agonist
• Sedative, anxiolysis, analgesic
• Use with caution in patients with liver and
  kidney problems
• No studies have looked at its use in painful
  procedures
• Has analgesic properties

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Dexmedetomidine (Precedex)

• Does not have respiratory depression
• Does not interfere with EEG findings
• Adverse effects
• Hypertension then hypotension
• Bradycardia
• Sinus arrest

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Dexmedetomidine Dose

• 1 mcg/kg IV over 10 minutes then 0.6 mg/kg/hour
  (titrate 0.2 to 1 mcg/kg/hour)
• Dosing that appears to be the best in gt 2 years
  old
• 3 mcg/kg over 10 minutes then 2 mcg/kg/hour
  infusion

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32 year old man playing basketball

• Fell backward and has severe right shoulder pain
• Holding his right shoulder
• There is an obvious deformity to the right
  shoulder

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10 month old girl fell from a bed onto a concrete
floor

• Mother is unsure if there was loss of
  consciousness
• Crying and agitated during the examination

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65 year old man in a motorcycle accident

• Posteriorly dislocated knee that requires
  reduction because his pulses are diminished
• History of CAD, DM, Afib, HTN, hypercholesterolemi
  a, COPD, hypothyroidism

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Summary

• Choose an agent that will adequately sedate the
  patient for the procedure duration and lowest
  risk for adverse events
• Most sedating medications do not control pain
• Evaluate patient and have all resque equipment
  ready for use
• Consider co-morbid conditions that may impact
  your choice of agents

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References

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  Wathen JE. Etomidate for short pediatric
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  Emerg Care. 2012 Sep28(9)898-904.
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  department. Curr Opin Crit Care. 2011
  Aug17(4)317-22.
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• Lexi-Drugs