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Rizk conscious-sedation
1. What we need to know about
Conscious Sedation
BY
Rizk Elazhary
MD, Anesthesiology
Benha University
2. Introduction and definition
Conscious Sedation: A drug induced depression of the patient’s
level of consciousness such that the patient responds appropriately to
physical and verbal commands and maintains airway protective
reflexes, that is intended to facilitate the successful performance of
the diagnostic or therapeutic procedure while providing patient
comfort and cooperation.
3. Purpose of the lecture
Dissemination of medical knowledge
Fulfill requirements for conscious sedation understanding
and privileges
Differentiate conscious sedation from light sedation, deep
sedation and general anesthesia.
Describe the desired outcomes of conscious sedation.
4. Purpose of the lecture (continue)
Record the normal dosage, rate of administration, onset
and duration of action and adverse effects of specific
pharmacologic agents used in conscious sedation.
Describe the correct technique for administering reversal
agents.
Identify potential complications related to conscious
sedation
5. Target Audience
Attending staff who wish to be credited in
conscious sedation.
Anyone who cares conscious sedation also
requires current ACLS certification.
6. Indications
Any procedure where the patient will be
unable to cooperate, and that procedure may
cause the patient significant pain
7. Clinical Areas Administering Sedation
OR and ICU : for GIT endoscopies & ECT.
Emergency Room.
Delivery Room.
Radiology Department.
Uro-surgery, ESWEL unite.
Others: Orthopedic , Cardio-Thoracic
8. Levels of Sedation
Light Sedation
The administration of
medication in dosages
causing the sedation and
allowing the patient to
sleep and rest.
Moderate Sedation
A medically controlled
state of depressed
consciousness that allows
the patient to
independently maintain a
patent airway and respond
to verbal stimuli.
Deep Sedation
A medically controlled state
of depressed consciousness
from which the patient is not
easily aroused, is unable to
maintain a patent airway
independently, and is unable
to respond purposefully to
physical stimulation or verbal
command.
General Anesthesia
A medically controlled state
of unconsciousness which
includes loss of protective
reflexes and inability to
respond to stimuli.
9. Goals of Sedation
To titrate the medication such that the
smallest amount of medication is administered
to achieve the desired depression of
consciousness while minimizing the potential
complications.
Desired Effects:
Depressed consciousness
Amnesia
Maintaining the patient vital signs
10. Eligible Patients
Patients with the following indications
Stable vital signs
NPO
No medical contraindications to the medications that
will be given
ASA 1 & ASA 2
Malampati I or II
11. Fasting Recommendations
Ingested Material minimum fasting hours
Clear Liquids 2 h
Breast milk 4 h
Infant formula 6 h
Non-human milk 6 h
Light meal 6 h
Heavy meal ≥ 8 h
14. Classifications (continued)
ASA 3 --- Severe systemic disease that results
in functional limitation (e.g. poorly controlled
hypertension, diabetes mellitus with vascular
complications, angina pectoris, prior
myocardial infarction, pulmonary disease that
limits activity.
ASA 4 --- Severe systemic disease that is a
constant threat to life (e.g. congestive heart
failure, unstable angina pectoris, renal or
hepatic dysfunction)
15. Classifications (continued)
ASA 5 --- Moribund patient not expected to
survive without the operation (e.g. ruptured
abdominal aneurysm, pulmonary embolism, head
injury with increased intracranial pressure)
ASA 6 --- A declared dead patient whose organs
are being removed for donation.
16. Mallampati Classification
Class 1: Full visibility of tonsils, uvula and soft palate
Class 2: Visibility of hard and soft palate, upper portion of tonsils and
uvula
Class 3: Soft and hard palate and base of the uvula are visible
Class 4: Only hard palate is visible
The Mallampati classification is
used to predict the ease of
intubation.
A high Mallampati score (class 3 or
4) is associated with more difficult
intubation as well as a higher
incidence of sleep apnea.
17. “At Risk” Patients for Sedation or Analgesia
The ASA physical status risk classification of 3 or greater
Critical care patients
Extremes in age (<1 or >70 years of age)
Patients with chronic respiratory disease, chronic
obstructive pulmonary disease, emphysema
History of sleep apnea
Mentally and neurologically handicapped patients
Patients at risk for aspiration (i.e. hiatal hernia with
regurgitation, diabetes with gastroparesis
Altered mental status
18. Technique of conscious sedation
The procedure begins once oxygen is given via nasal
cannula, the intravenous (IV) access established,
skin sensitivity test for local anesthetic done,
cardiopulmonary and other required monitors
connected.
23. Monitoring of Patients
Personnel
*Nurse or *physician other than the physician
performing the procedure
Team member able to establish an airway, provide
positive pressure ventilation (Ambu bag)
Mechanism for additional personnel with Advanced
Life Support capability
*ACLS required for physicians and nurses
24. Monitoring of Patients (continued)
Record:
Blood pressure
ECG
Pulse oximetry
Respiratory rate & depth of respiration
Supplemental oxygen throughout procedure
Level of consciousness—ask simple questions
Medications – dose & times
25. Monitoring of Patients (continued)
Record
Supplemental oxygen throughout procedure
Level of consciousness—ask simple questions
Medications – dose & times
26. Ramsey Sedation Scale
Level of Sedation Clinical Description
1 – Anxious, bordering
2 – Cooperative, oriented, tranquil
3 – Responds only to verbal commands
4 – Asleep with brisk response to light stimulation or
physical stimuli
5 – Asleep with sluggish response to stimulation
6 – Asleep with no response to stimulation
**Levels 2, 3 and 4 are desired range of levels during moderate sedation
34. Narcotic Analgesics
Morphine Meperidine Fentanyl
Initial Dosage 5-10 mg IV 0.5-1 mg/kg 0.51.5 mcg/kg
Incremental
Dosage
0.02-0.1 mg/kg/5-10
minute intervals
0.5 mg/kg/5
minute intervals
0.50 mcg per dose at
2-3 minute intervals
Pediatric
Dosage
0.1 mg/kg oral
0.03 -0.05 mg/kg IV
0.5-1 mg/kg 1 mcg/kg followed by
0.25-1.5 mcg/kg at
2-3 minute intervals
Onset 2-5 minutes 1-5 minutes 1-2 minutes
35. Narcotic Analgesics (continued)
Morphine Meperidine Fentanyl
Duration 2-6 hrs 2 hrs 20-30 minutes
Side Effects ↓ HR / ↑BP
Respiratory
depression
↓ HR / ↓ BP
Respiratory
depression
↓ BP
Respiratory
depression
Anaphylaxis
Muscular rigidity
Contraindications &
Comments
Head injury Head injury Use with caution in
patients with reactive
airway disease
Reversal Agents Naloxone 0.4 mg IV Naloxone 0.4 mg IV Naloxone 0.4 mg IV
36. Midazolam
A short-acting, water-soluble benzodiazepine,
an ideal agent for its amnestic and anxiolytic
properties.
Midazolam, with a half-life of 2 hours, has limited
cardiovascular effects, allows for quick recovery and
has no postoperative sequelae such as nausea and
vomiting.
Dose: 0.05 mg/kg bolus IV.
37. Propofol
A rapidly-acting sedative and hypnotic agent having a
quick recovery property.
Can be used in bolus and infusion dose along with
local anesthetic injection.
Slow administration maintains hemodynamics.
Does not cause postoperative nausea or vomiting .
May cause postoperative shivering.
Dose: Bolus - 0.5-1 mg/kg; infusion - 25 µg/kg/min
38. Ketamine
Agent of choice as an analgesic in conscious sedation.
Produces dissociated anesthesia.
Psychotic reactions such as hallucination, serious
cardiovascular adverse effects, seizures and
postoperative shivering have been reported.
Dose: 2 mg/kg IV or 6-10 mg/kg IM.
39. Dexmedetomidine
Has both sedative and analgesic properties.
Does not cause respiratory depression, though
hemodynamic parameters need to be closely
monitored.
Has a high incidence of postoperative dry mouth.
Dose: 1 μg/kg IV.
40. The disadvantages of conscious sedation
Mainly are the lack of airway control and the risk of
airway obstruction or aspiration.
Thus to minimize the disadvantage, the medication
should be selected and titrated by the
anesthesiologist
41. Discharge Criteria
Patient awake and alert to pre-sedation levels
Stable vital signs
Aldrete Score equal to or greater than 8 or equal to
baseline
Patient able to walk unassisted
Discharge to a responsible adult
42. Points to Remember
When appropriately administered, moderate sedation
should make the patient’s procedures tolerable to
pain and reduce anxiety.
Moderate sedation is the responsibility of the
anesthesiologist.
Give drugs “slowly”.
Let “routine” be your friend.
44. Conscious sedation in pregnancy
Consider the physiological changes in pregnancy.
Propofol is taken as a safe agent.
The American College of Obstetricians and
Gynecologists (ACOG) has recommended that
intermittent or continuous fetal monitoring during
conscious sedation is a more sensitive and important
indicator of placental perfusion and fetal oxygenation
than observations of maternal hemodynamic stability.
45. References
• Longnecker DE, Tinker JH, Morgan Jr., GE.
• Principles and Practice of Anesthesiology 1998; Vol. 1:(12) 227-228 and Vol. 2:
(86) 2268.
• Mallampati S, Gatt S, Gugino L, Desai S, Waraksa B, Freiberger D, Liu P
(1985).
• “A clinical sign to predict difficult tracheal intubation; a prospective study”.
• Can Anaesth Soc J 32 (4): 429-34.
• Nuckton TJ, Gledden DV, Browner WS, Claman DM (Jul 1, 2006).
• “Physical examination: Mallampati score as an independent predictor of
obstructive sleep apnea”. Sleep 29 (7); 903-8.
• http://sedationconsulting.blogspot.com/2008/09/guidelines-for-conscious-moder
• JAYASHREE SEN*, BITAN SEN: “Conscious Sedation: An Observation”,
Indian Journal of Clinical Practice, Vol. 24, No. 10, March 2014