See: [Tintinalli - agents for procedural sedation](x-devonthink-item://A78A6685-C1F4-4E11-9859-5C21E4393390?page=295&istart=3814&ilength=38&search=Agents%20for%20Procedural%20Sedation%20in%20Adult), [paediatric procedural sedation](x-devonthink-item://E383FFBD-9FD8-4DE9-B350-0F6F60D3E600?page=1580), [RCH procedural sedation](https://www.rch.org.au/clinicalguide/guideline_index/Procedural_sedation/), [RCH ketamine for procedural sedation](https://www.rch.org.au/clinicalguide/guideline_index/Ketamine_use_for_procedural_sedation/) see also: [[Induction agents]], [[Airway]] **Mnemonic** SOAP MI - suction - oxygen - airway - OPA / NPA - intubation stuff - difficult airway stuff - pharmacological agents - adrenaline/atropine - naloxone - bronchodilators - RSI - monitoring equipment - noninvasive stuff - pulse ox - HR - ECG - RR - +/- ETCO2 - IV access # medications table | agent | advantages | disadvantages | best suited for | | ----------------- | ------------------------------------------------------------------------------------------------- | -------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------ | | [[ketamine]] | - preservation of airway reflexes<br>- haemodynamic stability<br>- analgesia<br>- can be given IM | - dysphoria<br>- little amnesia<br>- laryngospasm<br>- long duration of action<br>- rigidity<br>- emesis | - long procedures<br>- if limited airway support available | | [[propofol]] | - rapid onset and offset<br>- antiemetic<br>- amnesia | - hypotension<br>- resp depression | - short procedures (eg ortho needing muscle relaxation)<br>- procedures needing no movement | | [[midazolam]] | - amnesia<br>- IN and IM routes available | - doses required for procedural sedation have long duration of action | - extremes of cardiovascular stability (eg cardioversion of unstable VT) <br>- help with amnesia | | [[sucrose]] | - orally administered<br>- neonates 32 weeks-4 months | - only effective in neonates<br>- mod effect | short, relatively painless procedures (eg IV cannulation) | | [[Nitrous Oxide]] | inhalation <br>- rapid onset/offset<br>- maintain airway reflexes<br>- amnesia | - vomiting<br>- moderate effects | - short procedures (eg shoulder reduction) | # contraindications to sedation in ED? - unstable - high ASA >2 - procedure not quick or indicated - high airway risk - no resources or appropriate skill - allergies - high aspiration risk # complications and strategies to avoid | complication | strategy to avoid | | ------------------------------------------- | ----------------------------------------------------------------------------------------- | | resp depression | - minimum dose required<br>- use agent less-likely to suppress resp<br>- EtCO2 monitoring | | loss of airway reflexes and aspiration risk | - head up 30 deg<br>- agent selection | | hypoxia | 15L NRB | | hypotension | cautious dose, choice of cardiac stable agent | | oversedation | avoid long-acting sedatives, lower dose | | delirium/agitation | avoid benzos unless EtOH withdrawl | #anaesthetics #tables