PROCEDURAL

SEDATION
FOR ADULTS
Dr. CATHERINE GALLANT
Department of Anesthesiology
University of Ottawa
General Campus
OUTLINE
Definition
Indications for use
Contraindications
Pharmacology
Complications
DEFINITION
A technique to provide an altered state of
consciousness by administration of
medications that permits a patient to undergo
painful procedures but still respond to verbal
commands while maintaining an unassisted
airway
INDICATIONS
Used to facilitate many diagnostic and
therapeutic procedures
May be used intra-operatively
May be performed in a location remote from
the operating room
Ever increasing demand fuelled by patients
Limited capacity for anesthesiologists to
provide these services
APPLICATIONS
Primarily day surgeries
Lack of dependence on hospital beds
More flexibility in scheduling
Shorter waiting lists
Improved efficiencies
Low morbidity and mortality
Low rates of complications
Lower costs
Less special investigations required
APPLICATIONS
Dental
Dermatology
Gynecology
General surgery
Ophthalmology
Orthopedics
Pain Clinic
Plastic surgery
Urology
DEFINITIONS
Analgesia - Relief of pain without
intentionally producing a sedated state.
Altered mental status may occur as a
secondary effect of medications administered
for analgesia.
DEFINITIONS
Minimal sedation drug induced state
where the patient responds normally to verbal
commands. Cognitive function and
coordination may be impaired but ventilatory
and cardiovascular function are unaffected.
Anxiolysis alternate term
DEFINITIONS
Moderate sedation and analgesia a drug
induced depression of consciousness where
the patient responds purposefully to verbal
commands alone or when accompanied by
light touch. Protective airway reflexes and
adequate ventilation are maintained without
intervention. Cardiovascular function remains
stable.
Conscious sedation
DEFINITIONS
Deep sedation and analgesia - A drug
induced depression of consciousness where
the patient cannot be easily aroused but
responds purposefully to noxious stimulation.
Assistance may be needed to ensure the
airway is protected and adequate ventilation
maintained. Cardiovascular function is usually
stable.
DEFINITIONS
General anesthesia a drug induced loss of
consciousness, during which the patient
cannot be aroused, even with painful stimuli,
and often requires assistance to protect the
airway and maintain ventilation.
Cardiovascular function may be impaired.
EUROPEAN UNION OF MEDICAL
SPECIALISTS
Level 1
Fully awake
Level 2
Drowsy
Level 3
Rousable by normal speech
OBJECTIVES
To achieve sedation level 2 and 3 (minimal to
moderate sedation) which allows patients to
undergo and tolerate unpleasant procedures
To avoid deeper levels of sedation and the
related complications
This cannot be completely avoided!
Continuum which is difficult to divide into
discrete stages
Always maintain verbal contact
BENEFITS
Appropriate sedation/analgesia will allow the
patient to tolerate unpleasant procedures by
relieving anxiety, discomfort or pain
In the uncooperative patient,
sedation/analgesia may facilitate those
procedures which are not uncomfortable but
which require that the patient not move
QUALIFIED INDIVIDUALS
Competency based education, training and
experience in:
Patient evaluation
Performance of sedation
Knowledge of pharmacology of drugs used
Rescuing the patient from complications of
deeper levels of sedation
Airway compromise
Inadequate ventilation

Cardiovascular instability
PATIENT EVALUATION
Screening for medical risk factors
How will these alter response to sedation?
Abnormalities of major organ systems?
Previous adverse reactions with
sedation/analgesia as well as regional and
general anesthesia?
Allergies to drugs?
Medications drug interactions?
History of drug and alcohol abuse?
NPO status
PATIENT EVALUATION
Abnormalities of major organ systems
Cardiac
Respiratory

Renal
Hepatic
PATIENT EVALUATION
Previous adverse reactions with
sedation/analgesia as well as regional and
general anesthesia
Details
Where it happened
PATIENT EVALUATION
Allergies to drugs?
What is the reaction?

When did it occur?

Family history?
PATIENT EVALUATION
History of drug and alcohol abuse?
May indicate tolerance
Cross tolerance between classes of
drugs
PATIENT EVALUATION
Review medications possible drug
interactions?
MAOIs such as phenelzine (Nardil) , tranylcypromine
(Nardil), moclobemide
PATIENT SELECTION
Focused physical exam
Evaluation of airway
Auscultation of heart and lungs
Assessment vital signs
Review labs
Consider consult prn
PATIENT SELECTION
Airway issues that may present concerns
History
Previous problems with anesthesia or sedation
Snoring, stridor or sleep apnea

Advanced rheumatoid arthritis

Chromosomal abnormalities e.g. trisomy 21

Physical examination
Obesity especially involving neck and facial
structures
PATIENT SELECTION
Airway issues that may present concerns
Physical examination
Short neck, limited neck extension, decreased TMD
of < 3 cm in adult, neck mass, c-spine disease or
trauma, tracheal deviation, dysmorphic features
Small mouth opening (< 3 cm in adult), protruding
incisors, loose or capped teeth, dental appliances,
high arched palate, macroglossia, tonsillar
hypertrophy
Micrognathia, retrognathia, trismus, significant
malocclusion
DIFFICULT AIRWAY
PATIENT SELECTION
Who is a candidate for sedation?
ASA 1 and ASA 2
ASA 3 in stable condition
Must be compatible with the procedure
Must be capable of giving informed consent
PATIENT SELECTION
Who is at increased risk of
complications?
Extremes of age
Multiple co-morbidities
Severe systemic disease
Drug and/or alcohol abuse
Uncooperative patient
Morbidly obese patient
Potential difficult airway
Obstructive sleep apnea
ADVANCED AGE
Higher risk of adverse events
Increased sensitivity to sedative drugs
Medication interactions
Higher peak serum levels of medications
MULTIPLE CO-MORBITIES
ing ASA status correlates with ing risk of
adverse events (ASA III or >)
Any co-morbidity that increases risk of
cardio-respiratory depression with sedatives is
significant
CHF, neuromuscular disease
COPD, dehydration
Anemia
PATIENT SELECTION
Who is not a candidate?
Language barrier
History of problems with previous anesthesia
Known or suspected difficult ventilation or
difficult intubation
No person to accompany them home
PREPARATION
Do you have informed consent?
Is patient aware of risks and the limitations?
Have they been given alternative choices to
procedure? Have questions been answered?
What is the NPO status?
Risks versus benefits
Machine and drug check?
Drugs and antagonists
Emergency equipment available and checked?
Defibrillator and skills of use
ASPIRATION RISK
Fasting pre-procedure decreases risks during
moderate sedation and strongly decreases
risks during deep sedation
ASA guidelines recommend if procedure is
elective fasting guidelines should be as for
GA
If not met then consider delaying procedure,
reducing sedation level or ETT
If emergency then may have to reconsider
approach
SUMMARY OF ASA PRE-PROCEDURE
FASTING GUIDELINES
INGESTED MATERIAL MINIMUM FASTING PERIOD
Clear liquids 2 hours
Breast milk 4 hours
Infant formula 6 hours
Nonhuman milk 6 hours
Light meal 6 hours
EQUIPMENT
Dedicated qualified personnel
Must be uninterrupted and continuous presence

IV access
Airway adjuncts
Bag valve mask, oral and nasal airways, equipment
for endotracheal intubation
Suction for secretions
MONITORING
Does monitoring level of consciousness
decrease risks of complications when
administering procedural sedation?
MONITORING
Maintain verbal contact with patient
Blood pressure, heart rate, respiratory rate
measured at regular intervals
Oxygen saturation, cardiac rhythm and ETCO2
should be monitored continuously
MONITORING
Monitor patients response to
medication and procedure
Level of alertness, depth of respiration and response
to painful stimuli all determine subsequent dosing
MONITORING
Supplemental oxygen often recommended to
maintain oxygen reserves and prevent
hypoxemia
May delay recognition of hypoventilation
ETCO2 monitoring useful
Brief episodes hypoxemia and hypoventilation
may occur clinical significance?
TECHNIQUES
Technique will vary from patient to patient
Dosing of analgesics and anxiolytics vary
widely
Dosing depends on procedure as well as the
anxiety of the patient
Comfort measures contribute to reducing
anxiety and pain
TECHNIQUES
Anxiety may be reduced by other
methods than pharmacological
Preoperative explanation of the procedure
Calm and reassuring manner
Quiet atmosphere with appropriate music
Comfortable room temperature or warm
blankets
AGENTS USED
Ideal drug has rapid onset of action and short
duration of action, will maintain hemodynamic
stability and have no side effects
No single drug available with all of these
features
AGENTS USED
Anxiolytics
Benzodiazepines
Diazepam, midazolam, lorazepam
Benzene ring fused to diazepine ring
All highly lipophilic
Highly protein bound
All absorbable after po administration
MIDAZOLAM
Midazolam most commonly used
Rapidly enters CNS then redistributed
Works through GABA pathways
Distribution of GABA receptors restricted to CNS
Minimal effects outside of CNS
Most important clinical effects
Sedative-hypnotic

Amnestic

Anxiolysis

Anti-convulsant

No analgesia
MIDAZOLAM
Favorable side effect profile
Minimal depression of ventilation

May cause mild BP esp in hypovolemic patient

Synergistic with narcotics

Combo may cause severe respiratory depression
Antagonist available: Flumazenil
Dosage 10 to 25 cg/kg q 3 to 5 minutes
AGENTS USED
Propofol
Phenol derivative, highly lipophilic
Can be painful on injection
Rapidly metabolized in liver with high plasma
clearance
Onset within 40 seconds with duration 8 - 10
minutes
Causes peripheral vasodilatation
BP more pronounced with age , intravascular
volume or with rapid injection
PROPOFOL
Potent respiratory depressant with doses
MV through TV and RR
Has anti-emetic effects
Sedative and amnestic not analgesic
No reversal agent
Difficult to titrate in some cases, can cause very
deep sedation
PROPOFOL
Dosage unchanged if renal or liver impairment
Metabolism appears to be slower in elderly
Reduce doses by 20% and increase dosing
interval
100 to 500 cg/kg every 3 to 5 minutes bolus
Continuous infusion 25 to 100 cg/kg/min
May require addition of short acting opioids due
to absence of analgesic activity. This increases
risk of respiratory complications
KETAMINE
Highly lipid soluble derivative phencyclidine
Rapid onset of action
Use limited by side effects
Dreams, halllucinations, out of body experiences
Significant cardiovascular effects
Sympathomimetic BP, HR, CO
Minimal respiratory depression
Bronchodilatation
KETAMINE
Profound analgesia
Multiple routes of administration
May supplement inadequate regional
anesthesia
50 to 100 mcg/kg usual single dose
No more than 10 mg/hour to avoid side effects
PENTOTHAL
IV barbiturate, induction agent
Hypnotic, sedatives, anticonvulsants
Undergoes hepatic metabolism
Recovery after bolus comparable to propofol
because of redistribution to inactive tissue
sites
Even single boluses can lead to psychomotor
impairment for several hours
PENTOTHAL
CNS depressant
Anti-analgesic properties
May reduce pain threshold
BP due to peripheral vasodilation
Transient as compensatory HR
Respiratory depressant
TV and RR transient apnea
ETOMIDATE
IV anesthetic with minimal hemodynamic
effects
Hypnotic but no analgesic properties
Rapid onset of anesthesia almost immediate
- with minimal changes in HR and CO
Usual dosing 0.1 to 0.15 mg/kg IV for PSA
Causes adrenocortical suppression so not
widely used
Myoclonus also seen frequently
AGENTS USED
Miscellaneous agents
Chloral hydrate
Pentobarbital
Methohexital
Dexmedetomidine
Local anesthetics
May reduce doses of sedatives and narcotics
Useful as co-analgesics
OPIOIDS
High degree of variability in dose response
Inter-individual variation
Analgesia, euphoria, sedation, concentration
Clearance primarily hepatic metabolism
May be active metabolites
SIDE EFFECTS
Cardiovascular
May produce orthostatic hypotension
Respiratory
Dose dependent depression of ventilation
Decreased responsiveness to CO2

May persist for several hours

Apnea

CNS
Do not reliably produce unconsciousness
Skeletal muscle rigidity
SIDE EFFECTS
Sedation
Nausea and vomiting
Direct stimulation CRTZ dopamine receptors
Biliary tract
Spasm of biliary smooth muscle
May be confused with angina
AGENTS USED
Fentanyl
Synthetic opioid structurally related to
meperidine (phenylpiperidine derivative)
75 to 125 times more potent than morphine
More lipid soluble than morphine crosses
BBB
Short acting with rapid redistribution to tissue
Clinically rapid onset (2 to 3 minutes)
No amnestic properties
FENTANYL
Primary side effect is respiratory depression
Will potentiate sedative effects of other drugs
Wide range of doses
0.25 to 0.5 cg/kg q 3 to 5 minutes
1 to 2 cg/kg for analgesia

With multiple bolus doses or continuous

infusion the duration of action is prolonged
ALFENTANIL
1/5 to 1/10th potency fentanyl
More rapid onset and shorter duration
1.4 minutes
May be useful for retrobulbar blocks

10 fold inter-individual variation in dosing

0.1 to 0.4 cg/kg/min by infusion
REMIFENTANIL
Unique because of ester linkage and
metabolism by plasma esterases
Short acting, titratable, rapid onset and offset,
rapid recovery after infusion
Boluses excellent for short painful procedures
Doses 0.25 to 1 cg/kg
Infusions for sedation
Doses 0.05 to 0.2 cg/kg/min
TECHNIQUES
May be by intermittent bolus or by continuous
infusion
Target controlled infusions
Plasma levels
Effect site levels
TECHNIQUE
Monotherapy may be desirable
Short acting drugs may be desirable
Onset of action
Small increments
If synergistic action reduce to usual dose
Antagonists readily available
TECHNIQUE
Sedation and inadequate block
Surgeon may have to supplement if block is
inadequate
Duration of surgery may exceed duration of local
anesthetic
Restlessness and hypoxia
Consider in differential diagnosis
TIPS
If elderly or co-morbid disease then may be
more conservative with approach
Start with lower dose
Administer meds more slowly
Be aware of slower circulation times
Redose at less frequent intervals
TIPS
NEVER BE AFRAID TO CALL FOR HELP
COMPLICATIONS
Serious complications rare
All sedatives and narcotics will cause adverse
reactions in some patients even within
recommended doses
Extremes of age most at risk
Most sedatives cause dose dependent
respiratory depression
Risk of desaturation up to 11% with propofol,
even with supplemental oxygen
Hypoventilation and apnea usually easily treated
COMPLICATIONS
Treat respiratory complications with patient
stimulation, oxygen, airway positioning or
brief ventilatory support
Cardiovascular instability uncommon
More likely to occur if significant cardiac
morbidity
Hypotension and bradycardia may develop in
patients on CV depressants
Usually transient
COMPLICATIONS
Vomiting
Seen in approximately 5% PSA
More common if narcotics given
Little evidence regarding prophylaxis
Inadequate sedation preventing completion of
procedure
Over sedation
Agitation
Allergic reactions
COMPLICATIONS
Inadequate evaluation
Inadequate monitoring
Inadequate practitioner skills
Premature discharge
RECORDS
Vital signs and level of consciousness
Document at baseline
Regular, frequent intervals during the
procedure
Regular, frequent intervals during recovery
Prior to discharge
RECOVERY PERIOD
Requires monitoring as during procedure
Patients may be at increased risk after
removal of painful stimulus
What is ideal length of recovery period?
Various criteria available such as Aldrete
Consciousness Activity
Respiration Saturation
Circulation
Consider pain and nausea
DISCHARGE CRITERIA
Fully conscious
Respond appropriately
Walk unassisted
Baseline vital signs
Pain, nausea and vomiting, bleeding all under
control
Must have accompanying responsible person
AFTERCARE
Responsible accompanying person for 24
hours
Written detailed instructions for dealing with
complications
Medical assistance readily available
Should be contacted next day by phone
No major life decisions, driving or alcohol for
24 hours
REFERENCES
Practice Guidelines for Sedation and
Analgesia by Non-Anesthesiologists - ASA
Basics of Anesthesia 5th edition - Stoelting
CLINICAL SCENARIOS
You are asked to provide sedation for cataract
surgery to an 80 year old male. He has a
history of controlled hypertension. NKDA.
Medications: Atenolol 50 mg bid

Any concerns? What would you choose for

sedation for this patient?
The procedure finishes and you bring the
patient back to the PACU in stable condition.
15 minutes later you receive a call that your
patient is no longer responsive

What is your differential diagnosis?

How do you approach the management?
You are monitoring a 62 year old patient
under spinal anesthesia for a total knee
replacement when she suddenly becomes
bradycardic - HR drops to 45 (from 70)

What are your first steps?

What treatment would you give if any?
You are in the endoscopy suite providing
sedation for colonoscopy. Your patient is a 50
year old for routine screening with no
significant past medical history. 10 minutes
into the procedure BP drops to 100/60 from
baseline 135/72

Any concerns?
You are monitoring a 73 yo male under SAB
who is undergoing TURP. One hour into the
procedure he is becoming increasingly
restless. You give 1 mg midazolam IV. He
becomes more confused and pulls out his IV

Differential??