Goals of sedation: Minimal Sedation (Anxiolysis)

1.Patient safety • Patients respond normally to commands • Coggynitive function and coordination may 2.PtitPatient comf ort be impaired • Ventilatory and cardiovascular functions are unaffected

Conscious Sedation Moderate Sedation

• Depressed consciousness • Minimal Sedation • Patients respond purposefully to verbal (anxiolysis) commands • Moderate Sedation • No interventions are required to maintain airway • Deep Sedation • Spontaneous ventilation is adequate • • Cardiovascular function is usually maintained

1 Deep Sedation

• Depressed consciousness • Patients cannot be easily aroused but will respond after repeated or painful stimuli • Ventilatory function may be impaired • May required airway assistance • Spontaneous ventilation may be inadequate • Cardiovascular function is usually maintained

General anesthesia

• Patients are not arousable even with The sedation plan painful stimuli must be clearly • Ventilatory function is often impaired • Often require airway assistance articulated among • May require mechanical ventilation all members of the • Cardiovascular function may be impaired procedure team

2 Pre-sedation history Other key elements of the history: • Cardiac conditions • Prior surgical or • Current medications • Pulmonary airway issues conditions • Prior intubation • Allergies • Renal disease • Stridor • Pregnancy status • Hepatic disease • Snoring • Endocrine disorders • Sleep apnea • Last oral intake • Head trauma • Previous reactions to • Need for isolation for infections sedative medications • Alcohol, tobacco, and drug use

STOP-BANG Physical examination

S – Snore: have you been B – BMI: is your BMI • Cardiac exam told you snore greater than 28 T – Tired: are you tired A – Age: 50 or over • Pulmonary exam during the day N – Neck: circumference O – Obstruction: do you greater than 17 inches • Ability to lay in the proper stop breathing at night G – Gender: male P – Pressure: do you have procedure position high blood pressure • Airway assessment

Yes to 3 or more = high risk for sleep apnea

3 ASA Physical Status P1 - normal healthy patient Airway Assessment P2 – mild systemic disease P3 – severe systemic disease P4 – severe systemic disease that is a John S. Rogoski, DO constant threat to life Assistant Professor, Clinical P5 – moribund and likely to die Medical Director, Outpatient Surgery Center The Ohio State University P6 – brain dead organ donor

When to consider Four Types of Difficulty anesthesia consult? • Significant co-morbid disease • Significant sleep apnea • Difficult to bag/mask • History of airway problems during ventilate/oxygenate sedation • Difficult laryngoscopy • History of adverse reaction to sedation • Difficult intubation • High risk airway • Difficult to perform cricothyroidotomy • Chronic opioid or sedative use

4 How Does the ASA Define Causes of Difficulty the Difficult Airway? • Anatomical – Obesity • Difficult mask ventilation – Short neck - Impossible for an unassisted – Prot rudi ng t eeth , l ong hi gh arch ed anesthesiologist to prevent of palate reverse signs of inadequate – Receding mandible ventilation during positive pressure – Decreased distance between occiput mask ventilation and spinous process – Increased alveolar-mental distance

How Does the ASA Define Causes of Difficulty the Difficult Airway? • Acquired • Difficult rigid laryngoscopy – Acute neck swelling: trauma, infection, - It is not possible to visualize any post-operative bleeding portion of the vocal cords with – Restricted jaw opening: Trismus , conventional laryngoscopy fibrosis, rheumatoid arthritis, mandibular fracture • Difficult intubation – Restricted neck movement: - proper insertion of an endotracheal osteoarthritis, scarring, C-spine tumor, tube requires more than 3 attempts or ankylosing spondylitis greater than 10 minutes

5 Predicting Difficult Bag & Mask Ventilation

• B - bearded Grade 1 Grade 2 Grade 3 Grade 4 • O -ob/bttibese /obstetric • N - no teeth • E - elderly Class 1 Class 2 Class 3 Class 4 • S - snores/sleep apnea

Predicting Difficult Predicting Difficult Intubation Intubation Mallampati 3 - 3- 2 Rule Classification • 3 finger mouth opening • Class 1: view of the entire posterior oropharynx to the bases of the • 3 fingers mentum to hyoid tonsillar pillars distance • Class 4 : no view of the posterior oropharynx or uvula • 2 fingers hyoid to thyroid

6 Predicting Difficult Intubation • Review medical record, history • Assess – teeth especially protruding incisors – patent nares – open mouth & ext end t ongue ( mall mpati) – protrude mandible – thyromental distance, submental space – neck - short, thick ?, overall mobility & sniffing position – body habitus

Video of Airway Supplemental Examination Oxygen

• Nasal cannula • Simpl e mask • Non-rebreather mask

7 Video Of Airway Airway Support Maneuvers • Jaw thrust • Nasal airways • Oral airways

Bag / Mask Ventilation Before the procedure

• Technique dependent • There must be signed written consent for: • Mask seal essential 9 The procedure • 2 are better than 1 9 The sed ati on • Incorporate jaw thrust • If 2 procedures are planned, get consent • Nasal / Oral airways for both before giving sedation • Assist spontaneous • A “time-out” must be performed ventilation

8 Q 5 minutes during the Post-procedure transport: procedure: • Accompanying personnel trained in sedation • Level of consciousness • Pulse oximeter • Blood pressure • Supplemental oxygen • Oxygen saturation • Ventilation equipment • Respiratory rate • Nasal and/or oral airways • Cardiac rhythm (only required in • Emergency drug supplies patients with known heart disease) • Cardiac monitor (in patients with heart disease)

Monitoring every 15 Post-procedure minutes until: discharge: • Instruction sheet • Patient is awake, alert, and oriented 9 No driving • Recovered protective reflexes 9 NlhlNo alcohol or sed dtiatives • Vital signs returned to normal 9 No operating machinery • Oxygen saturation > 95% or at 9 Phone number for questions baseline • A responsible adult to accompany (taxis do not count!)

9 Pharmacology of Opioids Sedatives and Reversal Agents • Class II Controlled Substances • Mu receptor agonists 9FtFentanyl Mary Beth Shirk, PharmD, RPh 9Hydromorphone Specialty Practice Pharmacist, Emergency Medicine 9Morphine Clinical Associate Professor The Ohio State University Medical Center and 9Meperidine College of Pharmacy • Hepatic metabolism with varying t ½

Agents for Procedural Opioids Sedation Adverse Effects • Opioids • Benzodiazepines • Respiratory depression • Etomid at e • Hypotension • Ketamine • Miosis • • Decreased GI motility • Propofol • Urinary retention • Dexmedetomidine

10 Opioids Benzodiazepines Estimated Potency • Class IV Controlled Substances • Fentanyl 75 - 100 micrograms • GABA and Benzodiazepine agonists • HdHydromorp hone 1 15.5 mg 9Midazolam • Meperidine 75 mg 9Lorazepam • Morphine 10 mg 9Diazepam • Hepatic metabolism with varying t ½

Fentanyl Benzodiazepines Adverse Effects • Phenylpiperidine opioid agonist • Preferred opioid for procedural sedation • Respiratory depression • Precautions • Hypotension 9 Skeletal muscle and chest wall rigidity • Dose and administration rate related • Paradoxical reactions • Reversible with naloxone • Nausea/vomiting 9 Bradycardia • Black box warning with CYP3A4 inhibitors • Hiccoughs

11 Benzodiazepines Etomidate Estimated Potency

•Diazeppgam 5 mg • Not currently controlled substance • Lorazepam 1 mg • Nonbarbiturate benzylimidazole hypnotic • 0.1 – 0.3 mg / kg IVP over 30-60 seconds • 2 mg

Midazolam Etomidate

• Preferred BZD for procedural sedation • Inhibits 11-β hydroxylase • CYP3A4 substrate • Blocks cortisol production • Elimination t ½ ppgrolonged • Myoclonus (up to 33%) 9CHF • Injection site pain (30-80%) 9Renal function impairment 9Propylene glycol 9Hepatic function impairment • Minimal effect on hemodynamics 9Obesity • Decreases ICP 9Elderly

12 Ketamine Ketamine • Emergence reaction (12 - 50%) • Class III Controlled Substance 9Severity varies • NMDA receptor antagonist and PCP derivative 9Least common in < 15 yrs and > 65 yrs • Analgesic properties appealing 9Less frequent with IM administration • IM or IV administration 9Minimize verbal, tactile, visual • 0.5 – 2 mg/kg IVP over at least 60 stimulation during recover seconds 9?pretreat with BZD or butyrophenone

Ketamine Ketamine

• Emergence reaction (12- 50%) • Respiratory drive maintained • Hypersalivation ?pretreat? • Three concentrations available • NtNystagmus 910 mg/mL • Increases ICP/IOP 950 mg/mL • Minimal affect on BP/HR or increase 9100 mg/mL (dilute if administered IV) • Increased skeletal muscle tone

13 Methohexital Propofol • Class IV controlled substance • Ultrashort acting IV barbiturate anesthetic • Contraindicated if • pH of 1% solution is 10-11 9 egg allergy • Contraindicated in porphyria 9soy intolerance • Hypotension 9peanut allergy (Fresenius brand) • Respiratory depression • 0.5 - 1 mg/kg IV over 2-3 min once then • Dose 0.25 – 1 mg/kg at <10mg/5 seconds 0.5 mg/kg every 3-5 min if needed • 500 mg vials!

Propofol Dexmedetomidine

• Currently not controlled substance • “relatively selective” alpha adrenergic agonist • Patient can transition in unpredictable 2 • FDA approval in 2008 fashion to deeper level of sedation 9 Sedation of nonintubated patients prior to • At OSUMC physician must be and/or during surgical and other credentialed for deep sedation procedures • Cardiovascular depressant – • Limited published experience for procedural hypotension! sedation

14 Dexmedetomidine Dexmedetomidine

• 0.5 - 1 mcg/kg over 10 minutes then 0.2 – 1 mcg/kg/hr • Hypotension 54% vs 30% (Placebo) 9 SBP<80 or DBP <50 or >30% from • t½=2t ½ = 2 – 2. 5 hours baseline • Dose reductions 9 72% in ≥ 65yo patients (n=131) 9impaired hepatic function • Bradycardia/sinus arrest 14% vs 4% (Placebo) 9> 65 yrs old 9 <40BPM or >30% from baseline 9combined with other sedatives

Onset Peak Duration Elimination Dexmedetomidine (Min) (Min (Min) Fentanyl Immed Immed 30-60 Hepatic

Midazolam 1-2 2-2.5 30 Hepatic + (Renal) • Two unpublished trials Etomidate <1 1 3-5 Hepatic

9n = 318 Ketamine 1 1 15-20 Hepatic Active 9Elective MAC surgeries/procedures Metabolite Methohexital Immed Immed 10-20 Hepatic • Mean duration of infusion 1.5 hours Propofol ½ 1 3-10 Hepatic

Dexmedetomidine 4 hours Hepatic

15 Amnestic Analgesic Anxiolytic Dose

Benzodiazepines +- + • No universally safe & effective dose

Opioids -+ -/+ • Variable dose requirements

Etomidate +- + 9 Age

Ketamine + + Dissociative 9 Weight properties 9 Medical condition Methohexital -- + 9 Medication history Propofol +/- - + 9 Previous requirements during Dexmedetomidine ++ + procedures 9 Goal depth of sedation

Recommended Agents at OSUMC Dose • Combination agents have added • Midazolam ± fentanyl agents of choice risks/benefits • Propofol limited to physicians •TITRATE credentialed in deep sedation 9 Small incremental doses • Meperidine no longer recommended for 9 Sufficient time must elapse between routine use doses to evaluate effect of previous dose • Alternative agents used by physician 9 Time between doses longer for experienced in their use nonintravenous routes

16 Fentanyl: JCAHO & Medication Administration During Typical Initial Regimen* Procedures • Sterile technique! • 25-100 micrograms SLOW IVP • Proper product labeling • IVP over at least 2 minutes 9Label: drug name, strength, and • Dilute to permit slower administration amount • Additional doses in 2 minutes if needed 9Single individual process and • Administer prior to midazolam if using immediate administration = no label combination regimen 9Two individual process = product *Dose is highly variable verification with vial and label

Midazolam: JCAHO & Medication Administration During Typical Initial Regimen* Procedures • Document waste of Controlled • 0.2 – 2.5 mg IVP Substances • IVP over at least 2 minutes • Complete charting • Dilute to permit slower administration 9Medication • Additional dose(s) in 3 minutes if needed 9Dose • Administer after opioid if using 9Route combination regimen 9Time of administration *Dose is highly variable 9Who administers

17 Reversal Agents Flumazenil

• Used to treat overdose or to reverse • Adverse Effects sedatives 9Seizures • Half lives can be shorter than sedative 9Panic attacks and emotional • Can precipitate withdrawal symptoms lability • May not completely reverse all 9Withdrawal symptoms complications of sedatives 9Dizziness

Flumazenil Flumazenil • Reversal of Procedural Sedation • Onset of action 1-2 minutes 9 0.2mg IVP q 1 min prn to MAX of 1mg 9 Repeat every 20 min as needed • Half life 41-79 minutes • Suspected Overdose • Flumazenil use requires 90 min 9 0.2 IVP then 0.3mg in 30 sec if needed monitored recovery time 9 Repeat 0.5mg in 1 min intervals to MAX of 3mg if needed • Hepatic clearance 9 With partial response can administer additional doses to total of 5 mg

18 Naloxone Deep sedation

• Opiate receptor antagonist • Emergency medicine • Onset of action 2-3 minutes • Pulmonary medicine • Half life 30-81 minutes • Critical care • Naloxone use requires 90 min monitored • Oral maxillary facial surgery recovery time • Or demonstrated advanced airway • Duration of effect varies (45min – 4 hrs) expertise and intubation skill • Hepatic clearance

Naloxone •Dosing 9 0.1 – 0.2 mg IVP every 1-2 minutes Case #1: 52 year-old 9 Doses up to 2 mg may be required man with a lung 9 May need to redose if naloxone wears off before opiate mass andhd cough • Adverse Effects 9 Opiate withdrawal referred for 9 Pulmonary edema bronchoscopy 9 Acute hypertension and dysrhythmias 9 Seizures

19 Case #2: 60 year-old Case #4: 23 year-old woman with COPD undergoing dental exacerbation and pprocedurerocedure requiresrequires respiratory failure oxygen then requiring intubation develops bradycardia

Case #3: 50 year-old man with HIV on Case #5: 21 year-old anti-retroviral man with medications needs a pneumothorax needs colonoscopy a chest tube

20 Key Points

• Sedation is a continuum defined by the Case #6: patient with degree of impairment, not by a specific atrial fibrillation drug • AhitA history and ph ysi cal with att enti on t o needs external airway assessment must be completed cardioversion prior to sedation • Sedation consent is required • Bradycardia during sedation = respiratory acidosis until proven otherwise

Key Points

Case #7: after TEE, • Midazolam and fentanyl are the patient develops appropriate drugs for most procedures cyanosihdhis, headache, • Meperidine should no longer be used and SaO2 = 85%. • IV and topical anesthetics require a physician order Blood looks brown • Beware of methemoglobinemia

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