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Subject: Procedural (Conscious) Sedation
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rapid sequence intubation (see Endotracheal Intubation)
Agent(s) for sedation
Foreign-body removal: ears
of children, rectum of adults
Incision and drainage of
an abscess: if local anesthesia is inadequate
Imaging in children
repair in children
Simple reduction of
Closed reduction of
Reduction of fracture
debridement, significant pain, large surface area, severe
Patient refusal in a
instability requiring immediate attention
Hemodynamic or respiratory
Altered sensorium or
inability to monitor side effects
PEARL: Peripheral access is usually
sufficient with a catheter size large enough to provide
resuscitation fluids if necessary.
PEARL: Recent studies have shown support
for preoxygenation and capnography, which may add to the
safety of procedural sedation by detecting hypoventilation
earlier than clinical assessment and pulse oximetry
PEARL: Titrate the procedural sedation to
the point that the patient’s pain is relieved. This
point will vary between procedures and during different
parts of procedures.
PITFALL: The most common clinical errors
are delayed recognition of respiratory depression and
respiratory arrest, inadequate monitoring, and inadequate
Nausea and vomiting.
Like all opioids, fentanyl can cause respiratory depression.
When respiratory depression occurs with fentanyl/midazolam procedural sedation, usually it
is due primarily to fentanyl. As the opioid
effect is most pronounced on the central nervous system
respiratory centers, apnea can precede loss of consciousness.
Caution must be exercised when using benzodiazepines and opioids
together, because the risks of hypoxia and apnea are
significantly greater than when either is used alone.
“emergence reactions”: These have been reported in
up to 30% of adults receiving ketamine (although rare in children) and
can be fascinating and pleasurable or alternatively unpleasant
and nightmarish. Concurrent benzodiazepines are believed to
blunt but not entirely eliminate such reactions in adults, and
apprehension regarding such unpleasant recoveries has limited
the popularity of ketamine.
Physiologic monitors and
laryngoscope devices can be ordered directly from Welch Allyn at http://www.welchallyn.com/ or through their
corporate headquarters at 4341 State Street Road, Skaneateles
Falls, New York, 13153-0220. Phone: 1-800-535-6663.
Other airway supplies can
be ordered from Mallinckrodt at http://www.mallinckrodt.com/ or their corporate
headquarters, 675 McDonnell Blvd. Hazelwood, MO 63042. Phone: