Moderate sedation and anesthesia Questions and Answers 2024 Correctly done

Desired effects of moderate sedation - Answer-To maintain intact reflex and to decrease anxiety, increase patient cooperation. Four levels of sedation - Answer-Minimal/ANXIOLYSIS-a drug-induced state during which the patient response normally to verbal commands. Cognitive and coordination may be impaired but respiratory and cardiovascular or not. Moderate/conscious sedation-drug induced depression of consciousness, patient responds purposely to verbal commands, no intervention required to maintain a patent airway, and spontaneous ventilations are adequate. Deep sedation-patient cannot be easily aroused, but responded purposefully following repeated or painful stimulation. Ability to maintain ventilatory status is impaired, may need help maintaining patent airway, cardiovascular status is OK. Anesthesia-drug-induced, loss of consciousness. Patient is not arousable even with painful stimuli. Impaired ability to maintain patent airway, cardiovascular function may be impaired. No response even to paint, support needed to maintain airway. There is a loss of protective reflexes-inability to handle secretions without aspiration or to maintain A patent airway independently. Joint commission standards to administration of moderate sedation - Answer-Administered by qualified provider Patient is assessed - ASA, vital signs, past history and physical, airways status, procedure Risk of sedation options discussed with patient and family prior to procedure, informed consent is attained Patient reassessed by Dr. in procedure room just prior to the procedurePatient is monitored continuously through procedure i.e. heart rate, respiratory and pulmonary ventilation status, BP, EKG, entitled with deep sedation. Principles of sedation include incremental administration, synergistic effects and possible benzodiazepine related paradoxical complications i.e. agitation, onset of action, IV assessment, use of supplemental oxygen, reversal agents available Patient must be assessed in recovery prior to discharge. Must meet discharge criteria and Be accompanied. With a responsible adult ASA classification - Answer-ASA 1-healthy patient ASA 2-Patient with mild systemic disease with no functional limitations i.e. well-controlled high blood pressure, well-controlled diabetes without systemic of fact, anyway with him adequate greater than 30, history of asthma with no wheezing day of procedure, cigarette use with no COPD, obesity 20%, pregnancy, between ages of one and 70 Moderate sedation can be given to ASA 1 and 2 candidates ASA 3-severe systemic disease with functional limitations i.e. control disease of more than one system, controlled CHF, stable angina, Post am I less than three months ago, poorly controlled high blood pressure, symptomatic respiratory disease, morbid obesity 50 pounds or 30% over IBW, chronic renal failure. Medical consult required for evaluation for moderate sedation of ASA 3 ASA 4-severe systemic disease with constant threat to life i.e. one severe disease poorly controlled or in stage, unstable angina relieved with nitro and rest, symptomatic CHF or COPD ASA 5-Morbid patient not expected to survive another 24 hours ASA 6-declared brain-dead-organs to be donated Between ASA four and six patients are not candidates for moderate sedation Conditions that affect the use of moderate sedation - Answer-Indications of procedureAltered mental status Elderly Atypical airway Obesity Pregnancy Sepsis abuse Sleep apnea-especially if they use a CPAP Cardiovascular, respiratory, liver, kidney or neurological disease Drugs commonly used in Moderate sedation - Answer-Opioids- fentanyl, Demerol Benzodiazepines-versed, Valium Versed (midazolam) - Answer-Adult dose range-0.5 to 2 mg repeated every 2 to 3 minutes Usual total dose-2.5 to 5 mg Elderly patient-start with 0.5 mg, no more than 1.5 to2 mg Pediatric dose-six months to 5 years old-0.05 to 0.1 mg/ kilogram 6y-12y...0:025-0.05 mg/ kg Oral dose- 0.2-0.4 mg/kg Intranasal- 0.2-0.3 mg/kg. Max of 10 mg Time to onset IV-1 to 5 minutes, must wait 1.5 -2 minutes to observe initial patient response. Duration of effect-2 to 6 hours, increased with CHF, cirrhosis, obesity, and elderly Contra indications-sensitivity to Versed or other benzodiazepines, uncontrolled pain, existing CNS depression, shock, narrow angle glaucoma, concurrent use a protease inhibitor's ie AMPRENAVIR, NALFINAVIR, RITONAVIRE Administration-IV push over to to 5 minutes at concentration of 1 to5 mg per ml or by IV infusion of less than 0.5 mg/ mlPO-Do not mix with other liquid prior to administration Intranasal- With needleless syringe, inject into nare over 15 seconds, use 5 mg/mL concentration, half the dose can given in each nare Monitor-respirations, cardiovascular, blood pressure, oxygen saturation, LOC, possible oversedation one stimulating aspect of procedure is complete Major drug interactions - THEOPHYLLINE decreases sedative effects of versed Protease inhibitor's - increase toxicity of versed CNS depressants - increased sedation and increase resp depression Doses of anesthetic agents should be reduced Side effects/potential complications - decreased resp rate and tidal volume, apnea, hypotension Signs of overdose - respiratory depression, hypertension, stupor, confusion, apnea, coma Rapid injection or infusion in pediatrics/infant/neonate pt. May cause hypertension or seizures. Incidence is increased with fetanyl combination Valium/diazepam - Answer-And Acacian - light anesthesia, amnesia, management of anxiety, status epilecticus i.e. stops seizures Does-adults 1-5mg, repeated Q 15 minutes, not to exceed 20 mg Pediatric - 0.1-0.2 mg per kilogram On set-almost immediate Contra indications-hypersensitivity to diazepam or other benzodiazepines, uncontrolled pain, existing CNS depression, shock, narrow and gold glaucoma, coma, pregnancy.Monitor- respirations, cardiovascular status, blood pressure, O2 sats, LOC Major drug interactions - other CNS depressants cause additive CNS effects i.e. CARBAMAZPINE, RIFAMPIN increase volume metabolism therefore decreasing it's effect....Cipro, clarithromycin, diltazem, digoxin, erythromycin, fluconazole,Fluoxetine, intraconazole, ketoconazole, labetalol, Metropolol, Flagyl, valproic acid and verapamil may increase serum levels and or toxicity of diazepam Side effects/potential complications - Brady, am I, chest pain, tacky, amnesia, anxiety, ataxia/loss of full control of body movements, coma, confusion, drowsiness, rash, constipation, decrease elevation, nausea vomiting, phlebitis, blurred vision, DIPLOPI/double vision Signs of overdose - somnolence, Confusion, coma, hypo active reflexes, dyspnea, hypertension, impaired coordination Fentanyl - Answer-Indication - preop/pre-procedural sedation Adult dose - 25 to 100 µg per dose to one for 15 minutes. Do not exceed 10 µg per kilogram Total Pediatric dose-1-3µg per kilogram's Q 30 to 60 minutes. Do you have an 18 months to 36 months may require 2 to 3 µg per kilogram dose Onset is almost immediate. Duration 30 to 60 minutes Contra indications - hypersensitivity to Sublimaze, increased intracranial pressure, severe respiratory depression, severe renal or liver insufficiency Monitor - respirations, pause, BP, O2 sats, LOC. Major drug interactions-other CNS depressants cause addictive CNS effects, MAOIs Side effects/potential complications-Brady, hypertension, CNS depression, nausea vomiting, respiratory depression, hypersensitivity reaction, increased ICPSigns of OD/anaphylaxis-apnea, am I, circulatory collapse, coma, severe hypotension, death FENTANYL has potential to cause rebound respiratory depression postoperative period dosage should be adjusted for CLcr greater than 50 mls per minute Demerol - Answer-presedation, manage of moderate to severe pain Adult dosage -5 to 20 mg per dose me repeat Q5 to 15 minutes. Do not exceed 200 mg Pediatric dose- 0.5 to 2 mg per kilogram Time onset-IV within five minutes, PO within 10-15 minutes Duration- 2-4 hours Contra indications-hypersensitivity, receiving MAOI within the last 14 days renal failure patients Major drug interactions -Vitamin K-decrease analgesic effect, MAO I-FLUOXETINE potentiate the effects of Demerol ,RITONAVIR increases the formation of normeperidine which increases the risk of CNS toxicity. Side effects/potential complications-low BP, fatigue, drowsiness, dizziness, nausea vomiting, constipation, muscle weakness, histamine release, seizures Signs of OD-CNS depression, respiratory depression, and MYDRIASIS/pupil dilation,Brady, pulmonary Edema, chronic tremors, CNS excitability, seizures. Those should be adjusted for chloride clearance lesson 50 mils per minute, can cause renal impairment an elderly, toxicity of NORMEEPERDINE/half-life of 30 hours. Include seizures and muscle twitches Propofol (Diprivan) - Answer-Induction and maintenance of anesthesia. Treatment of vented ICU patient, post operative antiemetic.Adult dose range 6-9 mg per kilogram Pediatric dose range-0.5-1 mg per kilogram Time onset-9-51sec.. Average 30 seconds, after bolus infusion. Duration 3 to 10 minutes. Contraindications-hypersensitivity profile or it's emulsion....It contains so I, eggs, PHOSPHATIDEE and glycerol, pregnant/breast-feeding Relative - peds -No safety data, severe cardiac disease EF less than 50%, respiratory disease, epilepsy or history of seizures, increased intracranial pressure, hyperlipidemia, hemodynamically unstable patients Drug interactions-increase toxicity in neuromuscular blockers and see enough depressants. Decrease effectiveness with theophylline. Side effects-hypotension , apnea, anaphylaxis, patient urine may turn green Signs of overdose-decrease blood pressure, bradycardia, cardiovascular collapse Propofol only to be given by trained RN with documented competency No reversal agent for propofol Chloral hydrate - Answer-Short term sedative/hypnotic. Adult dose-generally not used. Pediatric dose-25 to 100 mg per kilogram PO or PR Time to onset 30 minutes to an hour Duration of effect-4 to8 hoursContra indications-hypersensitivity, Renal or hepatic impairment, Gastritis or ulcers, severe cardiac disease. Major drug interactions-CNS depressants May have addictive effects.. May displaced Coumadin from binding sites increasing Coumadin response, Flushing and hypertension with Lasix within 24 hours of chloral hydrate. Side effects/potential complications-ataxia, confusion, dizziness, fever, hallucinations, headache, rash, Uticaria, flatulence, nausea vomiting, diarrhea Signs of overdose-decrease blood pressure, respiratory depression, Colma, hypothermia, cardiac arrhythmias Avoid if chloride clearance is less than 50 ML per MIN. Gastric upset decreased if diluting dose in water or another liquid Narcan (naloxone) - Answer-Antidote for narcotic agonists Adult dose-0.1 to 0.2 mg Q3 to 5 minutes Pediatric dose-0.1 MG/KG Max dose 2 mg Time to onset-within two minutes, peak effect-5 to 15 minutes, half life-30 to 60 minutes, duration effect-20 to 45 minutes/repeat doses may be needed Contraindications hypersensitivity administer IV push 0.4 mg per ml concentration Monitor blood pressure, heart rate, respiratory rate, LOC Drug interactions-decrease effect of narcotic analgesiaSide effects potential complications-hypertension, hypotension, tacky, ventricular arrhythmias, MI, irritability, anxiety, narcotic withdrawal, nausea/vomiting/diarrhea, dyspnea, pulmonary edema, sneezing, diaphoresis Monitor patient for 120 minutes for resedation Romazicon (flumazenil) - Answer-Antidote for benzodiazepines Does adult 0.2 mg over 15 seconds..may repeat in 45 seconds.. then every minute with a total of 1 mg. Maximum dose 3 mg/h. Pediatric dose - 0.01 mg per kilogram/maximum dose 0.2 mg IV. Dose given over 15 seconds-may repeat in 45 seconds and then again every minute to the maximum cumulative dose of 0.05 mg per kilogram or 1 mg...... whichever dose is lower Time to onset 1 to 3 minutes, peak effect is 6 to 10 minutes, half-life is 41 to 79 minutes, duration of effect is 45 to 90 minutes Contraindications-hypersensitivity Monitor heart rate blood pressure oxygen saturation and LOC Drug interactions - use with caution with overdose patience, involving mix drugs. Toxic effects may emerge especially with cyclic antidepressants. Use as a reversal for Valium and versed Side effects/potential complications - nausea/vomiting/diarrhea, seizures if pushed to rapidly. If patient has not responded after five minutes after receiving 5 mg....oversedation not due to versed. Monitor 120 minutes post reversal Adjunct medications - Answer-These were given prior to or in combination with the narcotics and benzodiazepines for synergistic effects requiring smaller doses of the narcotics and benzodiazepinesBenadryl - antihistamine h+ receptor With anticholinergic and sedative properties. Dose 25 to 50 mg IV, up to 100 mg times one dose. Pediatric dose is 1.25 mg per kilogram times windows do not give to premature or Neonates Onset of action is in 2 to 3 minutes intravenously/give no more than 25 mg/m. Duration of effect is 240 minutes... Contra indications - hypersensitivity to antihistamine, nursing moms... Use with extra caution in the elderly. Science of overdosage - dry mouth, dilated pupils, Flushing. Phenergan...Is a phenothiazine that has antihistamine, sedative, antiemetic, anti-cholinergic effects... adult dose is 12.5 to 50 mg one time... Dilute because it can cause necrotic lesions if the IV extravates... no more than 25 mg per mill... Pediatric dose-do not using kids younger than 24 it has not been researched. Onset is 2 to 5 minutes, peak is unknown, duration is over 120 minutes... Contra indicationhypersensitivity, usage in less than two years of age. Use cautiously with elderly. Risks are low blood pressure, respiratory depression, extra pyramidal effects. Topical medications - Answer-Benzocaine-none of the upper airway before EGD, or lidocaine/Cetacaine/hurricane/Americain Topical application may interfere with gag reflects which may cause laryngeal spasm or anaphylaxis. Side effects methemoglobinemia,,seizures, convulsions, laryngospazms, anaphylaxis Methemoglobinemia- The oxidation of iron in the hemoglobin molecule from the ferrous form to the ferric state. This leads to low oxygen carrying capacity of the red blood cells, Central and peripheral cyanosis, metabolic acidosis,,, death.... increase in the methemoglobin concentration the closer SPO 2 to 85%. Clinical signs - fatigue, headache, syncope, dysrhythmia, dyspnea, lethargy, metabolic acidosis, stupor, death. Treatments - methylene blue one to 2 mg per kilogram as a 1% solution over 5 to 10 minutes iv..Can be repeated in 60 minute