ANAESTHETICS AND AIRWAY
PROCEDURAL SEDATION
PromptFactors to decide on procedural sedation
ResponseUrgency (Neurovascular compromise requires urgent reduction)
Unfasted state
Other injuries requiring attention (Head injury, spinal precautions)
Haemodynamic instability/Vital signs
Lack of resources (Busy ED, absence of staff)
Significant co-morbidities (AS, pulmonary HT, Emphysema - impact choice of sedatives)
Level of distress and response to analgesia (eg: urgent reduction of joint to achieve comfort)
Unfasted state
Other injuries requiring attention (Head injury, spinal precautions)
Haemodynamic instability/Vital signs
Lack of resources (Busy ED, absence of staff)
Significant co-morbidities (AS, pulmonary HT, Emphysema - impact choice of sedatives)
Level of distress and response to analgesia (eg: urgent reduction of joint to achieve comfort)
PromptComplications of Procedural sedation and prevention techniques
ResponseRespiratory Acidosis - use of capnography as evidence of prolonged apnoea
Hypoxia - preoxygenation, use of High flow O2 throughout
Awareness and pain - Ensure adequate analgesia and clear communication between proceduralist and sedation provider to ensure timeliness of painful reduction
Hypotension - Fluid load, cautious use of titrated agents
Vomiting and aspiration - Pre-treatment with antiemetic
Failrue of procedure - use of sedative with muscle relaxant (eg: Propofol) rather than ketamine to aid mechanics of reduction
Hypoxia - preoxygenation, use of High flow O2 throughout
Awareness and pain - Ensure adequate analgesia and clear communication between proceduralist and sedation provider to ensure timeliness of painful reduction
Hypotension - Fluid load, cautious use of titrated agents
Vomiting and aspiration - Pre-treatment with antiemetic
Failrue of procedure - use of sedative with muscle relaxant (eg: Propofol) rather than ketamine to aid mechanics of reduction
PromptMinimum monitoring required for safe procedural sedation
ResponseContinuous pulse oxymetry
Q5min NIBP
ECG
If available ETCO2 + waveform capnography
Q5min NIBP
ECG
If available ETCO2 + waveform capnography
PromptPROCEDURAL SEDATION DRUGS
Response
PromptKetamine - Compare IM and IV doses
ResponseIM
Dose 4 mg/kg IM
Onset 2-4 mins
Duration of effect 10-20 mins
IV
Dose: 1 mg/kg
Onset 60-90 seconds
Duration of effect 15-30 mins
Dose 4 mg/kg IM
Onset 2-4 mins
Duration of effect 10-20 mins
IV
Dose: 1 mg/kg
Onset 60-90 seconds
Duration of effect 15-30 mins
PromptKetamine benefits
ResponseMaintain airway reflexes
Maintain respiratory effort
Stable haemodynamics in well patient
Optimal procedural environment (Keep child still)
Dissociative anesthetic - no awareness
Excellent analgesia
IM or IV
Maintain respiratory effort
Stable haemodynamics in well patient
Optimal procedural environment (Keep child still)
Dissociative anesthetic - no awareness
Excellent analgesia
IM or IV
PromptKetamine adverse effects
ResponseLaryngospasm
Hypersalivation/lacrimation - up to 50%!
Emergence phenomenon
Vomiting/Aspiratoin
Respiratory depression/Apnoea If pushed too qukckly IV
hypertonia
Hypersalivation/lacrimation - up to 50%!
Emergence phenomenon
Vomiting/Aspiratoin
Respiratory depression/Apnoea If pushed too qukckly IV
hypertonia
PromptStridor management with Ketamine
ResponseStridor + ketamine = Laryngospam! (question mentions stridor)
Stop the procedure, Call for help
Larson’s point/Jaw thrust
PPV/PEEP + 100% FiO2
Deepen with sedation - Propofol 2mg/kg
Paralysis (Sux ideally as quick) 1-2mg/kg IV (vs 3-4mg IM if no IV access)
Atropine if bradycardic.
See SA 2017.2 for much more detailed answer
Stop the procedure, Call for help
Larson’s point/Jaw thrust
PPV/PEEP + 100% FiO2
Deepen with sedation - Propofol 2mg/kg
Paralysis (Sux ideally as quick) 1-2mg/kg IV (vs 3-4mg IM if no IV access)
Atropine if bradycardic.
See SA 2017.2 for much more detailed answer
PromptPROPOFOL
Response
PromptDose of propofol for procedural sedation
Response
PromptAdvantages of Propofol for procedural sedation
ResponseShort acting
Effective muscle relaxation
Effective muscle relaxation
PromptDisadvantages of propofol for procedural sedation
ResponseNarrow therapeutic window
Cardiorespiratory depression, apnoea
No analgesic effect
Cardiorespiratory depression, apnoea
No analgesic effect
PromptMIDAZOLAM
Response
PromptMidazolam dose (Child) - procedural sedation
ResponsePO - 0.5mg/kg - onset 20 mins from administration
PromptAdvantages of midazolam for procedural sedation
ResponseMulti-route (PO, IN, Buccal, IM, IV)
Amnesic
Anxiolytic
Quick onset
Short acting
Amnesic
Anxiolytic
Quick onset
Short acting
PromptDisadvantages of Midazolam for procedural sedation
ResponseNo analgesic effect
Paradoxical effect after discharge
Agent failure
Paradoxical effect after discharge
Agent failure