Foreign Body Extraction: particularly in pediatric populations
Surgery
Relative Contraindications to Procedural Sedation
Older Age: older patients have higher rates of adverse events due to increased sensitivity to sedatives, medication interactions, and higher peak levels achieved with drugs
Comorbid Disease: patients with comorbid disease (ASA 3 or greater) have higher rates of adverse events
Administration: usually 0.5-0.75 mg/kg for each agent
Adverse Effects: may be decreased, as compared to using each agent alone
Lorazepam (Ativan) (see Lorazepam, [[Lorazepam]]): see below
Midazolam (Versed) (see Midazolam, [[Midazolam]]): see below
Administration
Use Decreased Dose in Combination with Other Agents
Nitrous Oxide (see Nitrous Oxide, [[Nitrous Oxide]])
Propofol (Diprivan) (see Propofol, [[Propofol]]): see below
Management of Procedural Sedation
Pre-Procedural Fasting
Clinical Efficacy: there is little evidence to support the practice of pre-procedural fasting
No Clear Evidence That There is an Association Between Fasting Time, Gastric Volume, Gastric pH, Depth of Sedation and the Risk of Aspiration
Endotracheal Intubation May Not Protect the Patient from Patient From Aspiration [MEDLINE] [MEDLINE]
Endotracheal intubation itself increases the risk of aspiration
Recommendations: despite the lack of evidence, it is recommended to use the same fasting requirements for procedural sedation as for general anesthesia [MEDLINE]
Usual Protocol for Fasting Pre-Procedure
No Clear Liquids for 2 hrs Pre-Preprocedure
No Cow’s Milk or Solid Foods for 6 hrs Pre-Procedure
In the Case of Emergent Procedures, Consideration Should Be Given to Delaying the Procedure If the Patient Has Not Been Fasting: this is especially true in patients with increased risk of aspiration
Considerations Related to Procedural Sedation in Elderly Patients and Patients with Comorbid Disease
Giver Lower Starting Doses of Medications
Use Slower Rates of Medication Administration
Use Longer Intervals Between Repeat Doses
Considerations for Procedural Sedation in the Pregnant Patients
Pre-Procedural Medications to Increase Gastroesophageal Sphincter Tone and Decrease Gastric Volume: may reduce the risk of vomiting and aspiration
Metoclopramide (Reglan) (see Metoclopramide, [[Metoclopramide]])
Pre-Procedural Medications to Decrease Gastric Acidity: may reduce the risk of vomiting and aspiration
Pre-Procedural Hydration and Left Lateral Displacement of Uterus (In Late 2nd-3rd Trimester): decreases the risk of hypotension, uteroplacental insufficiency, and fetal hypoxemia
Supplemental Oxygen (see Oxygen, [[Oxygen]]): recommended (due to decreased functional residual capacity present in pregnancy, which may result in maternal hypoxemia)
Avoidance of Deep Sedation
Clinical Efficacy
No Evidence Indicates That Deeper Levels of Sedation Increase the Risk of Aspiration [MEDLINE]: however, lighter sedation may allow the patient to better protect their airway during the procedure (decreasing the risk of aspiration)
Performance of the Procedure Under General Anesthesia
Clinical Efficacy
Performing the Procedure Under General Anesthesia Has Not Been Proven to Decrease the Risk of Aspiration [MEDLINE] [MEDLINE]
Recommended During Procedural Sedation to Prevent Hypoventilation-Associated Hypoxemia: with pulse oximetry
However, Supplemental Oxygen at Low Concentrations Does Not Reliably Prevent Hypoxemia and May Delay Detection of Respiratory Depression (If End-Tidal CO2 Monitor is Not Being Used): due to the fact that SaO2 may not decrease until a significant prolonged period of hypoventilation or apnea has occurred
End-Tidal CO2 Monitoring (see Capnography, [[Capnography]])
Recommended During Procedural Sedation to Monitor for Hypercapnia: EtCO2 values correlate closely with arterial pCO2 values and provide early evidence of hypoventilation or apnea
Other Measures
Bispectral Analysis Monitoring (BIS): does not appear to be useful for monitoring the depth of procedural sedation
Originally developed to monitor the level of general anesthesia
Pre-Procedural Antacids/Motility Agents: no clinical benefit -> not recommended
Nausea/Vomiting (see Nausea and Vomiting, [[Nausea and Vomiting]]): nausea/vomiting occurs in approximately 5% of patients undergoing procedural sedation
Epidemiology: incidence of 16.4 per 1000 sedations [MEDLINE]
Incidence of Nausea/Vomiting May Be Higher When Opiates are Used
Prophylactic Anti-Emetics: may be useful
Need for Intubation
Respiratory Depression with Hypoxemia/Hypercapnia (see Acute Hypoventilation, [[Acute Hypoventilation]])
Epidemiology: hypoxemia is the most common adverse event with procedural sedation with an incidence of 40.2 per 1000 sedations [MEDLINE]
Reversal Agents
Flumazenil (Romazicon) (see Flumazenil, [[Flumazenil]]): to reverse the effects of benzodiazepines
Naloxone (Narcan) (see Naloxone, [[Naloxone]]): to reverse the effects of opiates
Intensive Care Unit Sedation
Indications for Sedation in the Intensive Care Unit
Facilitation of Measurement of Lung Compliance
Prevent Disconnection of Life-Sustaining Therapy
Prevention of Extubation
Prevention of Removal of Arterial Line
Prevention of Removal of Central Venous Catheter
Prevention of Removal of Nasogastric Tube
Promotion of Patient-Ventilator Synchrony
Reduction in the Work of Breathing
To Allow the Use of Rescue Therapies: such as mechanical ventilation (especially for high frequency oscillation ventilation), etc
Agents
Dexmedetomidine (Precedex) (see Dexmedetomidine, [[Dexmedetomidine]])
Dexmedetomidine (Precedex) Compared to Lorazepam (Ativan) (2007) (see Dexmedetomidine, [[Dexmedetomidine]] and Lorazepam, [[Lorazepam]]) [MEDLINE]
Dexmedetomidine Resulted in More Days Alive Without Delirium/Coma and More Time at the Target Level of Sedation
Dexmedetomidine (Precedex) Compared to Midazolam (Versed) (2009) (see Dexmedetomidine, [[Dexmedetomidine]] and Midazolam, [[Midazolam]]) [MEDLINE]
Dexmedetomidine is Similarly Effective for Sedation, as Compared to Midazolam
Dexmedetomidine Shortened the Time to Extubation, as Compared to Midazolam
Dexmedetomidine was Associated with Less Delirium, as Compared to Midazolam
Dexmedetomidine was Associated with Less Tachycardia/Hypotension, but More Bradycardia, as Compared to Midazolam
Dexmedetomidine (Precedex) Compared to Midazolam (Versed) (2010) (see Dexmedetomidine, [[Dexmedetomidine]] and Midazolam, [[Midazolam]]) [MEDLINE]
Dexmedetomidine Resulted in Less Cost in the ICU, as Compared to Midazolam: due to decreased length of ICU stay and decreased ventilator days
MIDEX and PRODEX Trials: Dexmedetomidine (Precedex) Compared to Midazolam (Versed) and Propofol (Diprivan) (2012) (see Dexmedetomidine, [[Dexmedetomidine]], Midazolam, [[Midazolam]], and Propofol, [[Propofol]]) [MEDLINE]
General Comments: data from randomized MIDEX (Midazolam vs. Dexmedetomidine) and PRODEX (Propofol vs. Dexmedetomidine) trials
Dexmedetomidine was Equivalent in Maintaining Light-Moderate Sedation
Dexmedetomidine Decreased the Duration of Mechanical Ventilation, as Compared to Midazolam (But Not When Compared to Propofol)
Dexmedetomidine Improved Patients’ Ability to Communicate Pain, as Compared with Midazolam and Propofol
Dexmedetomidine Demonstrated More Adverse Effects (Bradycardia/Hypotension), as Compared with Midazolam and Propofol
In the First 24 hrs of PRODEX Trial, Discontinuation of Dexmedetomidine was More Frequent Due to Lack of Efficacy: this suggests that adequate sedation may not be possible in all patients with dexmedetomidine alone (and it is likely that dexmedetomidine is not equivalent to propofol)
Propofol (Diprivan) Compared to Midazolam/Lorazepam (2014) (see Propofol, [[Propofol]], Midazolam, [[Midazolam]], and Lorazepam, [[Lorazepam]]) [MEDLINE]
Propofol Decreased Mortality Rate, as Compared to Benzodiazepines (Midazolam/Lorazepam)
Propofol Increased Probability of ICU Discarge at 28 Days, as Compared to Benzodiazepines (Midazolam/Lorazepam)
Propofol Decreased Ventilator Days at 28 Days, as Compared to Benzodiazepines (Midazolam/Lorazepam)
Dexmedetomidine (Precedex) to Lessen ICU Agitation (DahLIA) Trial (JAMA, 2016): Dexmedetomidine Compared to Placebo in Agitated Delirium in Mechanically-Ventilated Patients in the Intensive Care Unit (see Dexmedetomidine, [[Dexmedetomidine]]) [MEDLINE]
Dexmedetomidine Increased Ventilator-Free Hours at 7 Days, as Compared to Usual Care
Dexmedetomidine Decreased Time to Extubation and Accelerated Resolution of Delirium
Minimization of Sedation/Daily “Sedation Vacation”
Benefits of Minimization of Sedation/Daily “Sedation Vacation”
Studies Supporting the Performance of Paired Daily Sedation Vacation and Spontaneous Breathing Trials (SBT’s) (see Ventilator Weaning, [[Ventilator Weaning]])
Effect of Daily Sedation Vacation and Spontaneous Breathing Trials (NEJM, 1996) [MEDLINE]: daily spontaneous breathing trials decrease the duration of mechanical ventilation, decrease the cost of intensive care, and decrease complication rates
Awakening and Breathing Controlled (ABC) Trial (Lancet, 2008) [MEDLINE]: paired daily sedation vacation and spontaneous breathing trial decreases duration of mechanical ventilation, decreases ICU/hospital length of stay, and decreases mortality rate
Study of Standardized Weaning Protocols from Mechanical Ventilation (Cochrane Database Syst Rev, 2014) [MEDLINE]: standardized weaning protocols decrease duration of mechanical ventilation, weaning duration, and ICU length of stay
Other Studies
Australian/New Zealand SPICE Study (Am J Respir Crit Care Med, 2012) [MEDLINE]: evaluated ventilation time, sedation intensity using Richmond Agitation Sedation Scale (RASS), delirium, and mortality
Early Sedation Depth (Deep Sedation Within 4 hrs of Intubation) Predicted Delayed Extubation, Increased Hospital Mortality, and Increased 180-Day Mortality
However, 54.6% of the patient population was receiving midazolam at the first assessment point of 4 hrs (with 56.6% receiving propofol and 18.3% receiving both midazolam and propofol)
Early Sedation Depth Had No Effect on Delirium Occurring After 48 hrs
Continuous Sedation Infusion
Provides more constant level of sedation than intermittent bolus dosing and may increase patient comfort
Increases ventilator days and ICU length of stay
May limit the clinician’s ability to distinguish changes in mental status (perhaps prompting the increased use of diagnostic studies to rule out neurologic injury)
References
Procedural Sedation
Pulmonary aspiration of gastric contents in anaesthesia. Br J Anaesth. 1999;83(3):453 [MEDLINE]
Practice guidelines for sedation and analgesia by non-anesthesiologists. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology. 2002;96(4):1004 [MEDLINE]
Side effects of opioids during short-term administration: effect of age, gender, and race. Clin Pharmacol Ther. 2003;74(2):102 [MEDLINE]
Procedural sedation and analgesia in the emergency department: what are the risks? Emerg Med Clin North Am. 2005;23(2):551 [MEDLINE]
Preoperative fasting for preventing perioperative complications in children. Cochrane Database Syst Rev. 2005 [MEDLINE]
Pre-operative fasting guidelines: an update. Task Force on Scandinavian Pre-operative Fasting Guidelines, Clinical Practice Committee Scandinavian Society of Anaesthesiology and Intensive Care Medicine). Acta Anaesthesiol Scand. 2005;49(8):1041 [MEDLINE]
The incidence and outcome of perioperative pulmonary aspiration in a university hospital: a 4-year retrospective analysis. Anesth Analg. 2006;103(4):941 [MEDLINE]
Aspiration pneumonitis requiring intubation after procedural sedation and analgesia: a case report. Ann Emerg Med. 2007;49(4):462 [MEDLINE]
Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med. 2007;49(4):454 [MEDLINE]
American College of Chest Physicians Consensus Statement on the Use of Topical Anesthesia, Analgesia, and Sedation During Flexible Bronchoscopy in Adult Patients. Chest 2011; 140(5):1342–1350 [MEDLINE]
Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014 Feb;63(2):247-58.e18. doi: 10.1016/j.annemergmed.2013.10.015 [MEDLINE]
The use of propofol for procedural sedation in emergency departments. Cochrane Database Syst Rev. 2015 Jul 29;7:CD007399. doi: 10.1002/14651858.CD007399.pub2 [MEDLINE]
Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2016 Feb;23(2):119-34. doi: 10.1111/acem.12875. Epub 2016 Jan 22 [MEDLINE]
Intensive Care Unit Sedation
Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary. Crit Care Med. 1995;23:1596-1600
Effect on the duration of mechanical ventilation of identifying patients capable of breathing spontaneously. N Engl J Med 1996; 335:1864-1869 [MEDLINE]
The use of continuous IV sedation is associated with prolongation of mechanical ventilation. Chest 1998; 114:541-548
Sedation, where are we now? Intensive Care Med 1999; 25:137-139
Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342:1471-1477 [MEDLINE]
Hyperlactatemia, increased osmolar gap, and renal dysfunction during continuous lorazepam infusion. Crit Care Med. 2000;28:1631-1634
Short-term lorazepam infusion and concern for propylene glycol toxicity. Pharmacotherapy 2001; 21:1140
Severe hyperosmolar metabolic acidosis due to a large dose of intravenous lorazepam. N Engl J Med 2002; 346:1253
The long-term psychological effects of daily sedative interruption on critically ill patients. Am J Respir Crit Care Med. 2003;168:1457-1461 [MEDLINE]
Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Crit Care Med. 2004;32:1272-1276 [MEDLINE]
Dexmedetomidine a novel analgesic with palliative medicine potential. J Pain and Palliative Care Pharmacotherapy 2006; 20 (2): 23–7. doi:10.1080/J354v20n02_05 [MEDLINE]
Relationship of continuous infusion lorazepam to serum propylene glycol concentration in critically ill adults. Crit Care Med 2004; 32:1709-1714
Effect of sedation with dexmedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial”. JAMA 2007; 298 (22): 2644–53 [MEDLINE]
Central sympatholysis as a novel countermeasure for cocaine-induced sympathetic activation and vasoconstriction in humans. J Am Coll Cardiol 2007; 50 (7): 626–33. doi:10.1016/j.jacc.2007.03.060 [MEDLINE]
Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet. 2008 Jan 12;371(9607):126-34 [MEDLINE]
Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients: A Randomized Trial”. JAMA 2009; 301 (5): 489–99 [MEDLINE]
Sedation Management in Australian and New Zealand Intensive Care Units: Doctors’ and Nurses’ Practices and Opinions”. Am J Crit Care 2009; 19 (3): 285–95 [MEDLINE]
A cost-minimization analysis of dexmedetomidine compared with midazolam for long-term sedation in the intensive care unit. Crit Care Med 2010; 38 (2): 497–503 [MEDLINE]
Role of α2-agonists in the treatment of acute alcohol withdrawal. Ann Pharmacother. 2011 May;45(5):649-57. doi: 10.1345/aph.1P575. Epub 2011 Apr 26 [MEDLINE]
Dexmedetomidine as adjunct treatment for severe alcohol withdrawal in the ICU. Ann Intensive Care. 2012 May 23;2(1):12. doi: 10.1186/2110-5820-2-12 [MEDLINE]
SPICE Study. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med October 15, 2012; 186(8):724-731 [MEDLINE]
MIDEX and PRODEX Trials: Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials. JAMA. 2012 Mar 21;307(11):1151-60 [MEDLINE]
American College of Critical Care Medicine: Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013, 41:263-306 [MEDLINE]
Sedative choice: a critical decision. Am J Respir Crit Care Med 2014;189(11):1295-1297 [MEDLINE]
Propofol is associated with favorable outcomes compared with benzodiazepines in ventilated intensive care unit patients. Am J Respir Crit Care Med 2014;189(11):1383-1394 [MEDLINE]
American Society of Anesthesiologists (ASA) Guidelines [ASA Website]
Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev. 2014 Nov 6;11:CD006904. doi: 10.1002/14651858.CD006904.pub3 [MEDLINE]
Ketamine for continuous sedation of mechanically ventilated patients. J Emerg Trauma Shock. 2015 Jan-Mar;8(1):11-5. doi: 10.4103/0974-2700.145414 [MEDLINE]
Clinical effectiveness of a sedation protocol minimizing benzodiazepine infusions and favoring early dexmedetomidine: a before-after study. Crit Care. 2015 Apr 2;19:136. doi: 10.1186/s13054-015-0874-0 [MEDLINE]
DahLIA Trial: Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium. JAMA. 2016 Mar 15. doi: 10.1001/jama.2016.2707 [MEDLINE]