By ULY CLINIC

 

SEDATION

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The aim of providing sedation is to reduce anxiety, agitation and pain so as to tolerate unpleasant medical procedures or intervention while the patient retains control of airway, breathing and blood pressure.This procedural sedation and analgesia is commonly used in emergency units, radiological /diagnostic units, dentistry and for certain endoscopic and gynaecological procedures. 

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General Measures

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Procedural sedation is a continuum, ranging from minimal sedation (anxiolysis), moderate sedation (conscious sedation), and deep sedation (anesthesia). 

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It is often difficult to predict levels of sedation and therefore clinicians undertaking procedural sedation should be adequately trained in this technique.

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They should have a detailed understanding of the risks and benefits of the medicines used, and should be competent in resuscitation, airway management and assisted ventilation. 

 

Procedural sedation should be performed only in an area with adequate light and space, and adequate fully functional monitoring/observation and resuscitation equipment.

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Appropriate sedation protocols and guidelines for patient care from preparation to discharge should be available and implemented. 

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Medicines used in Sedation

Note:

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Patient characteristics and required depth and duration of sedation lead to differences in dosing requirements; the doses listed serve only as a guide

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Providers should titrate sedative dosage according to the desired clinical response 

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Minimal Sedation/Anxiolysis (no analgesic effect is required)

Midazolam: IV, 0.05mg/kg (In a 60 kg patient, give boluses of 1 mg every minute; may require up to 3mg) OR Diazepam: IV 0.1mg/kg (In a 60 kg patient, give boluses of 2 mg every minute; may require up to 10 mg) OR Nitrous oxide inhaled 20 to 50%, in oxygen (will also provide some analgesia) 

 

Note:Oral sedation may be appropriate for certain procedures

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Medicines for moderate sedation & analgesia

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If analgesia is required, one of the above is usually combined with an opiate. However, ketamine has analgesic activity and can be used on its own, or combined with a benzodiazepine.Fentanyl: IV 0.25 µg/kg OR Morphine: IV 0.1 mg /kg, in increments of 2 mg every 5 minutes OR Ketamine: IV, 0.5 mg/kg (the addition of a benzodiazepine is often recommended to reduce the incidence/severity of emergence phenomena such as hallucinations and dreaming, but the benefit of this is unclear).

Repeat doses of 0.5 mg/kg as required, every 5–10 minutes OR Nitrous oxide: 20–50% inhaled, in oxygen the choice of sedative will depend on the availability and easy of safe administration 

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Alternative medicines:

•  Propofol: IV, 0.5 mg/kg, repeated as 0.25 mg/kg boluses every 5 minutes as required

• Etomidate IV, 0.1 mg/kg. Repeat doses of 0.05 mg/kg every 5 minutes, as required. But it is more likely to cause myoclonus

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Medicines for Deep Sedation & Analgesia

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This is usually achieved with either higher doses of medications used for moderate sedation, or by combining an opiate, a benzodiazepine, and either Propofol or Etomidate. When agents are combined, lower doses may be adequate. 

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Supplemental Analgesia: Simple analgesics can be given before or after the procedure:

 

• Paracetamol, oral, 1 g 4–6 hourly when required to a maximum of 4 doses per 24 hours.

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Maximum dose: 15 mg/kg/dose. Maximum dose: 4 g in 24 hours. 

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• Ibuprofen, oral, 400 mg 8 hourly with meals after the procedure. 

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NOTE: Sedation in intensive care

• Indications for sedation in intensive care needs to be defined for each patient, and may include one or more of anxiolysis, analgesia, agitation control, or to help patients tolerate uncomfortable situations or procedures (e.g. intubation and ventilation)

• Sedation requirements fluctuate rapidly so, it warrants regular review

• Individualized sedation objectives should be clearly defined, and level of sedation regularly recorded

• Sedation protocols that recognize the need for dose minimization, weaning and sedation interruptions probably improve outcomes

• Adequate pain control is often more efficacious than sedatives for reducing agitation. Delirium should be considered, and managed appropriately. 

• The doses listed apply to ventilated patients in whom short term respiratory depression is not a concern

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Short–term and long–term sedation

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Medicines for short–term sedation (less than 24 hours) Midazolam: IV infusion, 0.05–0.2 mg/kg/hour. OR Propofol: IV infusion, 0.5 mg/kg/hour

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Medicines for longer–term sedation (72 hours or more)  

Lorazepam: IV, 0.1 mg/kg/hour OR Midazolam: IV, 0.2 mg/kg/hour 

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Note: 

• Lorazepam (0.1 mg/kg/hour) is as effective (and as easy to wean) as midazolam 0.2 mg/kg/hour) but more difficult to titrate. 

• Due to high fat solubility, midazolam also becomes ‘long acting’ after infusions of more than 24 hours

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Supplemental analgesia:

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Morphine: IV infusion, 0.1–0.2 mg/kg/hour OR Fentanyl: IV infusion, 1 µg/kg/hour (also becomes long acting after prolonged infusion due to fat solubility)

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Updated on, 11.11.2020

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References

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1. STG page number 14-16