The phrase “procedural sedation” refers to techniques of managing a patient’s pain and anxiety to facilitate appropriate medical care in a safe, effective and humane fashion.
Chloral Hydrate
Chloral Hydrate
Usually given to Outpatients due to relative low risk profile. For non-painful procedures only.
EEGs
MRI/CT Scans
Echocardiograms
Chloral Hydrate
PO/Rectal
Dose: 50mg/kg give 30-60 minutes prior to procedure.
Can repeat x1 25mg/kg
Not to exceed 100mg/kg in a 24 hour period
Chloral Hydrate
Expect a moderate decrease in heart rate and blood pressure in patients ASA I-II
For infants < 6 months there is ↑ risk for apnea and hypoxia.
Age a limiting factor. High failure rate in children > 4 years.
Pentobarbital : Nembutal®
Nembutal
PO/Rectal/IM/IV
Dose for procedural sedation:
4mg/kg , may repeat 2mg/kg, max 100mg
Nembutal: precautions
Rapid IV injection ie, can cause respiratory depression, apnea, laryngospasm, bronchospasm and hypotension
Recommended to infuse IV dose over 10-30 minutes.
Can significantly decrease cardiac output and should be avoided with CHF
Benzodiazepines
Midazolam- Versed®
Lorazepam - Ativan®
Induce anterograde amnesia (not retrograde)
May have some opioid sparing effect by ↓ anticipatory pain response
Midazolam -® Versed
Most commonly used Benzo for preoperative and pre-procedural sedation.
Undergoes hepatic metabolism and renal excretion and prolonged effects seen with dysfunction of either system
Sedative, amnestic and anxiolytic with no analgesic properties
Commonly used with an opioid analgesic such as Fentanly®
Versed®
Onset in 1 to 2 minutes
Duration 30 min
Caution for respiratory depression and hypotension
Fentanyl- Sublimaze®
Used in combination with Versed for many years due to rapid onset and effectiveness
Synthetic opioid
Metabolized by the liver
Short duration of effect
Pure analgesic (should not be
used alone)
Least histamine release of opiates
Fentanyl
Dosage for Pediatrics:
-IM or IV 0.5-1.0 mcg/kg/dose
-onset 1-2 min
-lasts 30 minutes
Ketamine-Ketalar®
Classified as a general anesthetic
Rapid acting dissociative anesthetic that produces a profound analgesic effect
Gaining favor in children due to reliable effects and strong safety profile
Ketamine
IV 1-2 mg/kg/dose
-Onset is 1 minute
-Duration 10-20 minutes
IM 2-4 mg
-onset 5 minutes
-duration 15-45 minutes
Propofol-
Classified as a general anesthetic
-Lower doses
sedation
hypnosis
Anmestic, anxiolytic, antiemetic, and
antiepileptic properties
No Analgesic effects
Propofol
Dosing 2.5 -3.5 mg/kg/ dose over 20-30 seconds
Onset 10-30 seconds
Duration 10-20 minutes
For prolonged procedures may require continuous infusion 125-300mcg/kg/minute. (smaller children may require smaller infusion rates.
