Procedural sedation and analgesia - Inclusion, exclusion criteria, and recommended level of sedation and analgesia

Procedural sedation and analgesia - Inclusion, exclusion criteria, and recommended level of sedation and analgesia

Mild to moderate sedation

Heavy sedation

General anesthesia

Inclusion

Superficial/small wound care(≦10cm):

Dressing change / suturing / incision and drainage / debridement

Thoracocentesis / Abdominocentesis

Pig tail drainage

Cardioversion*

Sono-guided Biopsy*

Placement or removal of chest tube*

TEE *

Endoscopy*#

Bronchoscopy*#

Colonscopy*

Placement of IABP*

Placement of NG tube / Foley ** Placement of vascular accesses:**

  CVP / A-line / PA catheter

* Some patients may require heavy sedation

** As needed by the choice of patients, 

   recommend in difficult vascular assesses

# Some patients may require ETGA 

Deep/large wound care(>10cm):

Dressing change / suturing / incision and drainage / debridement

When patient can’t tolerate the procedures (listed in the left column) under mild to moderate sedation and analgesia, heavy sedation and analgesia must be considered. 

Bedside operation

Placement of ECMO

Placement of Endotracheal tube

When patient can’t tolerate the procedures (listed in the left column) under heavy sedation and analgesia, general anesthesia must be considered. 

IVGA (intravenous) is suitable when the airway is easily maintained or the patient has a ET tube intubation 

ET tube intubation should be considered when the airway is not easily maintained or the patients has great risk of aspiration of blood and vomits 

Exclusion

Patient < 12 y/o

Coma

Patient who has received continuous infusion of sedative and/or analgesic agents

Procedural sedation and analgesia – Cautions

l   For nonintubated and uncooperative patients, deeper level of sedation and analgesia can be considered, but great caution should be taken on keeping a patent airway, spontaneous respiration, and stable cardiovascular condition.

l   For intubated patients, deeper level of sedation and analgesia can be considered.

l   Patients with shock or hypoxemia may require cardiopulmonary support.

l   Patients with full stomach, UGI bleeding, ileus, may have great risk of aspiration.

l   Patients with possible difficult airway may have great risk of hypoxemia.

l   Elderly, head injury, or hemodynamic unstable patients may slip to deeper than desired level of sedation.

l   Patients with hepatic failure, renal failure, or both may require adjustment of dosage.

Procedural sedation and analgesia - Recommended sedative and analgesic agents for non-intubated patients

沒有插管的病人

Mild to moderate sedation

Heavy sedation

General anesthesia (IVGA)

血壓穩定

處置時間短

處置時間長

血壓不穩時

注意事項

Fentanly + Midazolam IV

Fentanyl 25-50μg (0.5-1μg/kg)

Repeat 25μg after 5 min as needed

Midazolam 1-2 mg (0.025-0.05mg/kg)

Repeat 1-2 mg  after 5min as needed

Fentanyl + Propofol IV

Fentanyl 25-50μg(0.5-1μg/kg)

Repeat 25μg after 5 min as needed

Then 25-50μg every 30-60 min

Propofol 20-30 mg (0.2-0.5mg/kg) slowly then infusion 0.02-0.05mg/kg/min ^*#

Ketamine 15-25mg (0.25-0.5 mg/kg)

Repeat 15 mg after 5min as needed

Then 15-25 mg every 30 min

May add Midazolam 1-2.5 mg if hemodynamic status regains stable

* For elderly (>65 y/o) or hemodynamic unstable patients, all drugs have to be administered with lowest recommended dose at first.

§ Ketamine may increase PVR and myocardial work. Avoid in patients with CAD, uncontrolled hypertension, CHF, or arterial aneurysms.

§ In severe end-stage shock, direct myocardial depressant effects of large dose of ketamine are unmasked by sympathetic block or exhaustion of catecholamine stores.

§ Avoid in patients with IICP.

Fentanly + Midazolam IV

Fentanyl 50-100μg (1-2μg/kg)

Repeat 25-50μg after 5 min as needed

Midazolam 2-5 mg (0.05-0.1mg/kg)

Repeat 1-2 mg after 5min as needed

Fentanyl + Propofol IV

Fentanyl 50-100μg (1-2μg/kg)

Repeat 25-50μg after 5 min as needed

Then 25-50 μg every 30-60min

Propofol 30-50 mg (0.5-1mg/kg) slowly then infusion 0.05- 0.1mg/kg/min^*#

Ketamine 25-50 mg (0.5-1 mg/kg)

Repeat 25 mg after 5min as needed

Then 25-50 mg every 30 min

May add Midazolam 2-5mg if hemodynamic status regains stable

#Continuous propofol infusion must be titrated from lowest recommended dose to highest recommended dose to achieve desired level of sedation

Fentanly + Midazolam IV

Fentanyl 100-200μg (2-4μg/kg)

Repeat 50μg after 5 min as needed

Midazolam 5-10 mg (0.1-0.2mg/kg)

Repeat 2-5 mg after 5min as needed

Fentanyl + Propofol IV 

Fentanyl 100-200μg (2-4μg/kg)

Repeat 50μg after 5 min as needed

Then 25-50 μg every 30-60min

Propofol 50-100 mg (1-2.5mg/kg) slowly then infusion 0.1-0.2mg/kg/min^*#

Ketamine 50-100 mg (1-2 mg/kg)

Repeat 50 mg after 5min as needed

Then 50-100 mg every 30 min as needed

May add Midazolam 2-5mg every 30min if hemodynamic status regains stable   

※May give xylocaine 2.5 ml priorly if propofol was administered via peripheral line

Procedural sedation and analgesia - Recommended sedative and analgesic agents for intubated patients

有插管的病人

Mild to moderate sedation

Heavy sedation

General anesthesia (IVGA)

血壓穩定

血壓不穩定

注意事項

基本用藥跟未插管病人相同

可考慮採用重度鎮靜止痛

若預期血壓可能不穩，不用Propofol

Fentanly + Midazolam IV

Fentanyl 50-100μg (1-2 μg/kg)

Repeat 25-50μg after 5 min as needed

Midazolam 1 mg

Repeat 1 mg  after 5min as needed

Ketamine 15-25mg (0.25-0.5 mg/kg) IV

Repeat 15 mg after 5min as needed

Then 15-25 mg every 30 min

May add Midazolam 1-2 mg if hemodynamic status regains stable

同未插管病人

基本用藥跟未插管病人相同

可考慮採用靜脈全身麻醉

若預期血壓可能不穩，不用propofol

Fentanly + Midazolam IV

Fentanyl 100-150μg (2-3μg/kg)

Repeat 25-50μg after 5 min as needed

Midazolam 1-2 mg

Repeat 1-2 mg after 5min as needed

Ketamine 25-75 mg (0.5-1 mg/kg) IV

Repeat 25 mg after 5min as needed

Then 25-50 mg every 30 min

May add Midazolam 2-3mg if hemodynamic status regains stable

同未插管病人

基本用藥跟未插管病人相同

可考慮加用肌肉鬆弛劑

Nimbex 2.5-5 mg (0.1-0.2mg/kg) q30min

Pancuronium 2-4 mg (0.04-0.1mg/kg)

    then 1-2 mg q60min

若預期血壓可能不穩，不用propofol

Fentanly + Midazolam IV

Fentanyl 150-250μg (3-5μg/kg)

Repeat 50-100μg after 5 min as needed

Midazolam 2-5 mg

Repeat 2-5 mg after 5min as needed

Ketamine 50-100 mg (1-2 mg/kg) IV

Repeat 50 mg after 5min as needed

Then 50-100 mg every 30 min as needed

May add Midazolam 3-5mg if hemodynamic status regains stable

同未插管病人