analgesia anest sedation procedure 33.pptx

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1. Procedural sedation analgesia PRESENTER : IZAZI FAKHIRA BINTI FAUZI SUPERVISOR: DR MOHD BONIAMI BIN YAZID

2. OUTLINE Definition Level of sedations Indications and contraindications ASA classifications Perform PSA

3. Definition Procedural sedation analgesia is the use of short acting analgesic and sedative medication to enable clinicians to perform procedure effectively , while monitor the patient closely for potential adverse effect.

4. Level of sedations Minimal sedation ( anxiolysis ) Moderate sedation (conscious sedation) Deep sedation / analgesia General anaesthesia Responsiveness Normal response to verbal stimulation Purposeful response to verbal/tactile stimulation Purposeful response following repeated or painful stimulation Unarousable even with painful stimulation Airway Unaffected No intervention required Intervention may be required Intervention often required Spontaneous ventilation Unaffected Adequate May be inadequate Frequently inadequate Cardiovascular function Unaffected Usually maintained Usually maintained May be impaired

5. Dissociative sedation? Trancelike cataleptic state in which the patient experiences profound analgesia and amnesia but retains airway protective reflexes, spontaneous respirations and cardiopulmonary stability. Example: Ketamine .

6. Precaution for PSA in older age: Lower starting dose Slower rate of administration Less frequent dosing interval

7. ASA CLASSIFICATIONS

8. Perform PSA Consent Pre requisites Equipment Monitoring and pre oxygenation Complications Medications Discharge criteria

9. CONSENT The risks, benefits and alternatives of the procedure must be discussed with patient and answer any question. Implied consent is acceptable in some case where patient unable to provide explicit consent due to mental illness/ severe pain

10. PRE-REQUISITES Clinician must have deep knowledge regarding the relevent drugs (MOA, doses, side effect, reversal agents) Clinician must also be well versed in advanced cardiovascular life support including airway management. Number of clinician may be varied according to procedure

11. Guidelines from American Society of Anaesthesiology (ASA) Call for someone with advanced life support skills to be immediately available (within 5 minutes) for PSA. He must be present in the procedure room whenever deep sedation is being performed.

12. EQUIPMENT Suction Oxygen Airway adjuncts – bag valve mask, oral & nasal airway Equipment to perform endotracheal intubation IV access Resuscitation medication Reversal agents – naloxone , flumazenil

13. MONITORING AND PRE OXYGENATION

14. How to monitor sedation ? Richmond Agitation Sedation Scale (RASS) Ramsay score Why monitoring important? It is important to determine subsequent medication dose .

15. RASS SCALE

16. Ramsay Score

17. Supplemental oxygen often recommended during PSA to maintain oxygen reserves and prevent hypoxemia caused by hypoventilation – high flow mask. Recommended for pulse oxymetry & EtCo2 for monitoring during PSA. EtCo2 correlate with arterial co2 thus provide early sign of hypoventilation / apnea.

18. COMPLICATIONS Respiratory depression Hypoxia Hypercarbia Cardiovascular instability Vomiting and aspiration Inadequate sedation preventing completion of procedure Emergence reaction

19. HOW TO AVOID COMPLICATIONS?

20. Appropriate selection of patients & sedations Careful monitoring of sedation & patient with patient whom oxygenation and ventilation may be difficult Cautious and unhurry medication administration to avoid oxygen desaturation Hypoventilation and apnea usually short lived due to brief duration of drugs, thus prevented by: 1. Patient stimulation 2. Supplemental oxygen 3. Positioning the airway 4. Brief ventilatory support – using bag valve mask

21. Reversal agents – naloxone and flumazenil may be necessary with more severe or prolonged respiratory depressed using opiods or benzodiazepine. Haemodynamically neutral sedation , ex: etomidate may be preferable at patient at risk from changes in blood pressure or heart rate.

22. MEDICATIONS

23. Drug Name Class Dose & Onset Benefit Contraindincation Notes Propofol Alkylphenol derivatives 1.5 to 3mg/kg Onset : 40 seconds Bronchodilatation Dose related hypotension & may lead to respiratory distress No absolute contraindication Fentanyl Opioids 0.5-1 mcg/kg Onset : 2-3 minutes Rarely cause hypotension Respiratory depression Prolonged effect in renal / hepatic patient Thipental sodium Ultra short acting barbiturate 3-5mg/kg Cerebroprotective and anticonvulsive properties Potent venodilator and myocardial depression, can cause hypotension. Relatively contraindicated in reactive airways due to histamine release Rarely used

24. Drug Name Class Dose & Onset Benefit Contraindincation Notes Midazolam Benzodiazepam 0.2-0.3mg/kg Onset 2-5 minutes Potent dose related amnestic properties Dose related myocardial depression , can results in hypotension Frequently underdosed Accumulate in adipose tissue Ketamine Phencyclidine derivatives 1-2mg/kg Onset : immediate Stimulate cathecholamine release Bronchodilatation Tachycardia Hypertension Laryngospasm Emergence reaction Increase ICP Hypersalivation May be an excellent induction agent for patient with bronchospasm , septic shock and haemodynamic compromise Etomidate Imidazole derivatives 0.3mg/kg Onset : immediate Excellent sedation with little hypo tension, maintain cardiovascular stability Known to suppress adrenal cortisol production Myoclonus Respiratory depression Use cautiously if patient had sepsis, initial dose of glucocorticoid may be needed.

25. HOW TO CHOOSE?

26. Patient at risk of hypotension : E tomidate / Ketamine Patient with difficult airway/ compromised respiratory function : Ketamine Elderly with multiple co-morbid and haemodynamic instability : Propofol (short acting) Head Injury / sepsis : Midazolam Asthma /COPD : Ketamine Status epilepticus : Propofol Cardiogenic shock : Etomidate / Midazolam

27. HOW TO DISCHARGE PATIENT?

28. DISCHARGE CRITERIA Vital signs stable Swallow & cough Able to ambulate ( patient demonstrate ability to ambulate at pre procedure level ) Nausea, vomiting, dizziness is minimal Absence of respiratory distress State of consciousness ( alert, oriented to time, place and person consistent with pre procedure level of consciousness ) Post procedure ( oral and written ) discharge instructions : purpose and expected effects of sedation, patient’s care. Emergency phone number, medications, dietary or activity restriction and necessary precautions ( no driving within 24 H, avoid alcohol etc.)