Sedation/Conscious Sedation =========================== þ Per Magee anaesthesia, for pregnant patients: - all drugs OK for moderate sedation except for Versed in first trimester. Propofol is good, as is ketamine. Etomidate OK too. þ Fasting has no incidence on adverse events for pediatric sedation. - [Roback MG et al. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: Are they related? Ann Emerg Med 2004 Nov; 44:454-9.] þ Brevital þ Classifying sedation and related states: - sedation: decreased consciousness + light sedation + deep sedation + general anaesthesia - dissociative sedation: dissociation from - analgesia - neurolepsis - Ketamine: analgesic, dissociative, but may become general anaesthetic in large doses. - Neuroleptics: haloperidol, droperidol; phenothiazines þ DPT for kids: classically 2:1:1 Demerol:Phenergan: mg/kg IM; prospective study: - required avg. of 27 minutes to produce sleep - only 71% moderately or well-sedated - 4.7 hour average ED stay - none desaturated to less than 91% - 11 hours to resume normal eating and drinking - 19 hours to acting normally again [Terndrup TE, et al. A prospective analysis of intamuscular meperidine, promethazine, and chlorpromazine in pediatric emergency department patients. Ann Emerg Med 1991; 20:31.] previous retrospective study: [Terndrup TE, et al. Ann Emerg Med 1989;18:528.] Not so hot. Also another prospective study (95 pts) shows more complications (4 respiratory depression, 1 respiratory arrest). [Clin Ped 1985;24:558.] þ Demerol(meperidine)/Thorazine(chlorpromazine) reported to cause long lethargy and greater depression of BP than with Demerol alone [Stambough. J Clin Pharmacol 1981;21:140.] þ Phenergan has anti-analgesic effect [Dundee. Br J Anesth 35:597.] þ Chloral hydrate: - prospective study of 50 children (2 mo.-14 yrs.): only 43 effectively sedated [Rumm, et al. Efficacy of sedation of children with chloral hydrate PO. South Med J 1990;83:1040.] - dose: 50-75(-100) mg/kg - more on chloral hydrate: - see also study of Versed vs. Chloral Hydrate, just below. þ Versed (midazolam): - prospective study, laceration repair, 55 kids < 6 yrs.: dose 0.2 mg/kg orally decreased anxiety in 70% vs. 12% with placebo. No significant changes in BP, HR, RR during 20 min. repair; all DC's within 15 minutes. [Hennes HM. The effect of oral midazolam on anxiety of preschool children during laceration repair.] - standard IV/IM dose is 0.1 mg/kg - placebo-controlled study of oral midazolam in 124 children (1-10 yrs.) in doses 0.25/0.5/0.75 mg/kg oral 30 minutes prior to anesthesia. 0.25 dose no different than placebo. 0.75 mg/kg oral dose well-tolerated. [Feld. Anesthesiology 1990;75:831] - study of 80 children with dental extraction: rectal midazolam 0.25/0.45 mg/kg. [Roeloffe et al. J Oral Maxillofacial Surg 1990;48:791.] - Intranasal vs. oral: + intranasal 0.1 mg/kg better than oral or rectal (faster: peaks in 10 minutes as compared to 53 for oral or 16-30 after rectal; levels about 60% of of IV. [Anesthesiology 1988;69:972.] + oral is better than nasal [Connors, Terndrup, Nasal Versus Oral Midazolam for Sedation of Anxious Children Undergoing Laceration Repair, Ann Emerg Med 1994; 24(6):1074-1079.] + so which is better? Dunno. - rectal can cause paradoxical reactions [Shane, Fuchs, Khine, Efficacy of Rectal Midazolam for the Sedation of Preschool Children Undergoing Laceration Repair, Ann Emerg Med 1994;24(6):1065-1073.] - "We recently completed a randomized, double-blind trial in children undergoing neuroimaging procedures. We found a 50% sedation failure in the midazolam group vs a 0% failure rate in the chloral hydrate group (dosage 80 mg/kg). If you want to hear more, we are presenting this data at the SAEM meeting in Denver. Send reply to: Thomas E. Terndrup MD FACEP " - Can mix Fentanyl and Versed oral: fentanyl 10mcg/kg (400mcg max) versed 0.5mg/kg (20mg max) given in liquid tylenol (usual dose for tylenol for that weight) "I know we went around in circles about this issue recently, so I thought I'd mention that at this dose, I have a child who drifts off, but easily responds to verbal stimuli, and who doesn't give a rat's ass that I'm about to stick that lidocaine in his laceration. --Dean Dobbert, M.D., F.A.C.E.P., Kent General Hospital - Jeffrey Sankoff of McGill University says that it is a myth that recovery time after Versed is less than after Valium, and cites the following reference: [Ariano et al., Comparison of Sedative Recovery Time After Midazolam Versus Diazepam Administration, Critical Care Medicine 1994;22(9): 1492-1496.] þ Ketamine