Conscious Sedation

Complications:
- Hypoventilation/apnea
- Airway obstruction
- Oxygen desaturation
- Medication errors
- Hypotension

Risk Factors for complications:
- Significant underlying disease
- Abnormal airway
- Age < 6 yo
- Use of multiple sedation agents

ASA classifications
- I: normal healthy patient
- II: mild systemic disease
- III. Severe Systemic disease
- IV. Severe systemic disease, threat to life
- V. Morbid patient
* ok to do conscious sedation on class I-II

Informed Consent:

Benefits:
- To minimize pain
- Help patient relax and be cooperative
- Diminish anxiety
- Amnestic
• Make sure the parents know that the patient will still be conscious during the entire procedure and this is not meant to make the patient unconscious

Risks:
- Oversedation
- Hypoventilation/apnea
- Airway obstruction
- Oxygen desaturation
- Hypotension
- Paradoxical excitation
- Chest wall spasm/laryngospasm
- Hallucinations
- Vomiting

Prepare!!

- NPO: 6 hrs for solids, 4 hrs breast milk, 2 hrs clears
- AMPLE hx (Allergies, Meds, PMH- chronic airway problems, Last meal, Events), prior to sedation (pt and family members- malignant hyperthermia)
- Physical exam (especially dentition)
- IV access
- Pulse ox and cardiac monitoring
- O2, suction, oral airway, bag/mask, intubation supplies, NG tubes, crash cart nearby

Anxiolytics/Sedatives (no analgesia)

Versed 0.1 mg/kg IV, IM or .2 mg/kg PO 0.5 mg/kg(max 10mg)
- Onset: 1-2 min, Duration 2-6 hours
- SE: Respiratory depression, excitation, hypotension, ataxia, myoclonic activity
Valium 0.1 mg/kg IV, IM or 0.2mg/kg PO
- Onset: 10-15 min, Duration 2-4 hrs
Etomidate 0.15 mg/kg IV
- Ultra short acting
- Duration 10-15 min
- SE: myoclonic activity, cortisol suppression
Chloral hydrate 75 mg/kg PO
- light level of sleep
- best in children <3
- onset 15-60 min and may last up to 4 hrs

Opioids (analgesia sedation)

Morphine 0.1 mg/kg IV, IM (max dose 15 mg/dose)
- Onset 10-30 min, Duration 2-4 hrs
- SE: respiratory depression, hypotension, N/V delirium, urinary retention, pruritus

Fentanyl 2 mcg/kg IV
- Onset: 4-5 min, duration 0.7- 3.5 hours
- SE: Muscle rigidity and chest wall spasm (use Narcan+succinylcholine to reverse) hypotension, bradycardia, seizures, delirium

Antidote = Narcan (0.1 mg/kg/dose under 20 kg, 0.2mg/kg over 20 kg IV, IM

Barbiturates (sedating only, no analgesia)

Pentobarbital 3-5 mg/kg IV, IM titrate to effect q 5 min

- Onset: 1 min (peak at 5-10 min) duration: variable
- SE: respiratory depression, myocardial dysfunction, hypotension, laryngospasm, hallucinations, confusion, anxiety, ataxia, contraindicated in liver impairment

Systemic Anesthetics (sedation + analgesic+amnesic)
Ketamine 1.0 mg/kg IV, 3 mg/kg IM
- IV onset: 1-2 min, duration 10-15 min
- SE; Laryngospasm, nystagmus, increased secretions, elev BP/HR, emergence phenomenom, hallucinations, increased IOP, vomiting
- CI: Head trauma, increased ICP, open globe injury

Local Anesthetics

LET (lidocaine/epi/tetracaine) – Open wound
or
EMLA (lidocaine) – skin intact
apply to area at least 30 min prior to procedure, and cover w tegaderm

Commonly Used Medications

** For imaging and non-painful procedures,
Pentobarbital 1-3 mg/kg IV
Titrate to effect q 5 min

Chloral hydrate 50-100 mg/kg PO
- light level of sleep
- best in children <3
- onset 15-60 min and may last up to 4 hrs

** For painful procedures/reduction, (always have extra doses ready)
1. Atropine 0.01 mg/kg IV, then flush (one time dose)

2. Ketamine 1 mg/kg IV in first syringe; have another 1 mg/kg in 2 nd syringe begin to slowly administer contents of 1st syringe observe patient response to calling name and eye movements once having sustained nystagmus, patient has had enough ketamine

Discharge Criteria (resp rate, circulation, responsiveness, neuro exam)
- CV function and airway patency satisfactory and stable
- Patient easily arousable and protective reflexes intact (back to baseline state)
- Patient can talk (age appropriate) and walk
- State of hydration adequate and takes PO fluids.