Sedation


  1. Versed vent sedation: (mix 25 mg in 50 cc NS bag  OR 50mg in 100 cc NS Bag)  5 mg load, repeat q15 min until sedated, maintenance 0.02-0.2 mg/kg/hr
     
  2. Fentanyl 150 mcg/hr (not mg), titrate or wean 25-50mcg to desired effect, max 200 mcg/hour.
    DC if <50 mcg/hour, and return to bolus 25-50 mcg Q 2 hours PRN.
     
  3. Diprivan vent sedation 5 mcg/kg/min X 5 min then titrate to desired effect, 5-10 q 10 min to max of 80 mcg/kg/min
  4. Ketamine Drip: (mix 500 mg in 500 cc NS Bag) - 2-4 mg/kg/hr


 

  Minimal Sedation
(Anxiolysis)
Moderate 
Sedation/Analgesia
(Conscious Sedation)
Deep Sedation/Analgesia  General Anesthesia
Responsiveness Normal Response to Verbal Stimulation Purposeful* resonse to verbal or tactile stimulation Puposeful response after repeated or painful stimulation Unarousable, even w/painful stimulus
Airway Unaffected No intervention required Intervention may be required Intervention often required
Spontaneous Ventilation Unaffected Adequate May be inadequate Frequently inadequate
Cardiovascular Function Unaffected Usually maintained Usually maintained May be impaired

DEEP SEDATION

Ketamine 1-2 mg/kg IV
Onset
1 - 3 minutes
Duration
10 - 20 minutes
Advantages
airway reflexes maintained, no respiratory depression
Adverse Effects
hypersalivation, laryngospasm, vomiting, emergence reactions
Relative Contraindications
infants < 3 months, children with URIs, CAD
Ketamine 2-5 mg/kg IM
Onset
5 - 20 minutes
Duration
30 - 60 minutes
Propofol 1 mg/kg IV, then 0.5 mg q3min prn
Onset
1 - 2 minutes
Duration
5 - 10 minutes
Advantages
rapid onset, short duration, antiemetic, cerebral protective
Adverse Effects
sudden respiratory depression, apnea, hypotension, injection pain
Contraindications
allergy to eggs or soy
Fentanyl 1-2 mcg/kg IV + Midazolam 0.1 mg/kg IV
Onset
1 - 2 minutes
Duration
1 hour
Adverse Effects
rigid chest syndrome from rapid bolus of fentanyl (usually requires RSI)
Etomidate 0.15 mg/kg IV, then 0.1 mg/kg q2min prn
Onset
30 - 60 seconds
Duration
5 - 10 minutes
Advantages
rapid onset, short duration, minimal CV effects, cerebral protective
Adverse Effects
respiratory depression, myoclonic jerking, adrenal supression

MODERATE SEDATION


Methohexital 1-2 mg/kg IV
Onset
1 minute
Duration
5 - 10 minutes
Advantages
rapid onset, short duration, airway reflexes maintained
Adverse Effects
Respiratory depression, apnea, hypotension
Midazolam IV 0.05-0.1 mg/kg, then 0.05 mg/kg q2min prn
Onset
2 - 3 minutes
Duration
1 hour
Adverse Effects
mild CV depression, hypotension, paradoxical agitation
Pentobarbital 2.5 mg/kg IV, then 1.25 mg/kg x 2 prn; IV rate < 50 mg/min
Onset
30 - 60 seconds
Duration
30 - 60 minutes
Advantages
rapid onset, airway reflexes maintained, useful for pediatric radiology
Adverse Effects
Respiratory depression, apnea, hypotension, recovery time

MINIMAL SEDATION


Fentanyl 1-3 mcg/kg IV; max 5 mcg/kg
Onset
< 1 minute
Duration
30 - 40 minutes
Advantages
Rapid onset, short duration, minimal CV effects
Adverse Effects
Respiratory depression, rigid chest syndrome
Midazolam 0.1 mg/kg IM
Onset
15 - 30 minutes
Duration
1 - 2 hours
Adverse Effects
mild CV depression, hypotension, paradoxical agitation
Nitrous oxide 50:50 mix with oxygen
Onset
2 - 3 minutes
Duration
15 - 20 minutes
Advantages
Rapid onset, short duration, minimal CV effects
Adverse Effects
mild CV depression, pulmonary vasoconstriction, emesis
Relative Contraindications
Pulmonary hypertension
Contraindications
pregnancy, pneumothorax, pneumocephalus, air embolism

Pediatric Sedation

Pediatric Sedation for Emergency Procedures

Caution: monitor child at all times (pulse oximeter) and other vital signs (most hospitals have specific policies and procedures outlining obligatory monitoring) with appropriate antidotes & airway management apparatus bedside; use only drugs with which you are comfortable & familiar; ask about last meal (better to delay a non-emergent procedure if child ate a full meal in last 3 hrs)

Pain Control
Fentanyl:
  • Dosing: 2-3 mcg/kg IV; 15-20 mcg/kg PO
  • Safe, effective; short t1/2
  • "Lollipop" form (200, 300, 400 mcg Oralets)
  • Side effects reversible with naloxone
  • Emesis, facial pruritis potential ADR's
  • No intrinsic anesthetic effect
Morphine:
  • Dosing: 0.1 mg/kg IV/IM
Chloral hydrate:
  • Dosing: 50-75 mg/kg PO or rectally (up to 100 mg/kg prn)
  • Fast onset, few side effects, wide safety margin
  • No analgesic effect
  • Best for radiologic procedures
  • Rectal route preferred: is foul-tasting nausea & vomiting
Demerol (IV/IM)
  • 0.25-1 mg/kg
  • MAX: 100 mg/dose
  • May repeat q 5-10 min
  • Reversal: Narcan
Sedation
Midazolam (Versed):
  • Dosing: 0.1 mg/kg IV/IM; 0.5 mg/kg PO; 0.4-0.5 mg/kg pr
  • No prepared oral or rectal dose available use IV form
  • Safe & effective PO
  • +/- incr complications with narcotics
  • Amnestic effect beneficial
  • No intrinsic analgesic effect
 
 Ketamine:
  • Dosing: 2-4 mg/kg IM, 1 mg/kg IV, 6 mg/kg pr
  • Dissociative anesthetic
  • Rapid onset (1-2 min), short t1/2
  • Wide safety margin
  • Laryngospasm rare occurrence; observe closely
  • Use with 0.01 mg/kg IM of Atropine; min 100 mcg, max 500 mcg
  • Midazolam 0.05-0.1 mg/kg IM to decr emergence rxn phenomenon
 
Nitrous oxide:
  • Dosing: 30% N2O (50% has not been tested in pediatric population)
  • Only effective >8 yo
  • Difficult to manage, requires close monitoring & drug scavenger system.
 Propofol:
  • Currently being used in some EDs
  • Establish departmental protocol before its use, as deep sedation & general anesthesia may result