• Sedation/analgesia for patients undergoing diagnostic or therapeutic procedures
• Typically maintained IV

1. minimize or eliminate axiety and pain
2. Keep patient able to respond purposfully
3. Maintain normal Cardio/pulmonary function

1. Patient is sedated but maintains consciousness
2. maintains his or her airway
3. Responds
4. not anxious
5. acceptable vital sign changes
6. cooperative
7. mild amnesia
8. proptly resume pre-prosedural status

1. Agitation and Combativeness
2. unarousable sleep
3. Bradycardia and Hypotension
4. Apnea
5. Airway Obstruction

•Dental procedures

1. HX (allergies, current meds, last oral intake)
2. PE (height, wt., ausculations chest, airway)
3. MEDS (anticoags, herbals)
4. LABS (BMP for diabetic)

• Naloxone for Opioids
• Flumazenil for benzodiazepines

• Want to chart every five minutes:
• drugs given
• vitals
• pulse ox

• Patien self report
• OR
• sings:  muscle rigidity, tears, grimacing, faces, groaning, agitated, change in vitals

• Opiates--most reliable pain control
• agonist-antagonistsubstances--less able to alleviate procedural pain

• Lipid soluble with rapid distribution
• agonist on MU, Kappa and Delta
• Analgesia and some sedation
• alter mood and some perception of surrounding
• Hepatic metabolism (some renally excreted)
• Apnea
• possible bradycardia
• Altered hemodynamics
• GI, constipation, pruritis

• Based on half life and duration (while also comparing that with the patients needs).

• Know that there is a stepwise method of dosing to minimize side effects

• Onset: Minutes
• Peak: 20 minutes
• Duration: 2-4 hrs

based on the stats above this may not be the first choice

• Onset: Minutes
• Peak: 5-7 minutes
• Duration: 2.5-4hrs

• Onset: Minutes
• Peak:15-30 min.
• Durations:2-4 hrs

• Onset:1-2 mintues
• Peak:3-5 mintues
• Half-life:3.7 hrs

look: onset and peak very quick

• Onset: 1-2 minutes
• Peak: 5 minutes
• Duration: 2.7 hrs

short onset

• onset: 2 minutes
• Peak: 5 minutes
• halflife: 1.5 hrs

notice that the half life is short..quick procedure

• making the patient comfortabel but allwoing them to respond

MOA: Short acting hypnotic.  No analgesic properties.  Very lipophilic.  Give as an emulsion.

Contraindications: Soy, egg, or glycerol allergy.

Adverse Reactions: Apnea, bradycardia, hypotension, GI; more serious effects are rare but might include pancreatitis or opisthotonus.

Onset: 40 seconds;

Duration 3-5 minutes. (quick in and out patient)

Half-life: Two phases; the first phase is 2-4 minutes, while the second phase is 30-60 minutes.

MOA: GABA-agonist.  Reticular activating system depression results in hypnosis.

Precautions: Reduce dose  elderly.

Adverse Reactions: Transient myoclonus, mild GI irritation.  Pain with injection, give with lidocaine.

Half-life: 75 minutes (still quick) 

MOA: Derivative of phencyclidine.  Blocks glutamic acid excitation at NMDA receptors.  Produces a dissociative anesthesia marked by catatonia, analgesia and amnesia.  Derivative of PCP.

Contraindications: HTN, elevated ICP, CHF, thyrotoxicosis, hepatic impairment.

Adverse Reactions: Increased ICP(bad for spinal tap), respiratory depression, laryngospasm, hypotension, bradycardia are the more serious problems. 

Half-life: 2.5 hours

• reduce anxiety
• decrease muscle spasms
• Amnesia at higher dose
• NO analgesic properties (with opiate decrease by 1/3 dose)

MOA: GABA agonist to benzodiazepine receptor.

Contraindications: Glaucoma, depression, shock, addictions, COPD, CHF, hepatic or renal impairment.

Adverse Reactions: Apnea or cardiac arrest at high doses, addiction, GI effects.

Onset: 1-5 minutes

Peak Effect: Rapid

Duration: 2-6 hours

Half-life: 2.5 hours --takes a little while to wear off

MOA:  GABA agonist to benzodiazepine receptor.

Onset:  1-5 minutes

Peak:  15-30 minutes

Duration:  15-60 minutes

Half-life:  irregular and bimodal

Cautions:  Due to the great variation in response, diazepam is rarely used for conscious sedation.

Antiemetic

MOA: Blocks alpha adrenergic and dopamine receptors.  Related to haloperidol.

Adverse Reactions: Drowsiness, tachycardia, lightheadedness are infrequent.  Rarely oculogyric crisis or tardive dyskinesia develop.

QT interval problems--dosing reworked

•ondansetron (Zofran)

Giving patient to much Analgesia:

What to do?

• Discontinue, support as necessary and monitor untill effect disipates
• ALWAYS decrease benzodiazapine first because we want the patient to still have pain medication (opiate)
• Reversal agents must be readily available

• Reversal agent 
• can give for suspected narcotic overdose

MOA: Competes for opioid binding sites.

Half-life: 30-80 minutes

Adverse Events: Rare unless underlying condition.  Patients with a history of heart disease are more prone to arrhythmias and hypertension.

MOA: Antagonizes benzodiazepine receptors.

Contraindications: Seizures

Adverse Reactions: Dizziness, diaphoresis, agitation, shivering, tachycardia, bradycardia

Pregnancy: C

Half-life: 54 minutes

Rapid Sequence Induction

AKA

Rapid Sequence Intubation

•Giving a rapid sequence of pharmacologic agents to anesthetize and paralyze a patient for a brief procedure such as endotracheal intubation.

Goals:

establish airway and prevent aspirations

minimize trauma, anxiety and pain

***want fast acting ans short lived agents***

--Beta-blocker: esmolol

--Lidocaine--blunting cough and gag

• Sufentanyl
• Alfentanyl
• fentanyl and morphine have very long half lives and are not good for this procedure

Anesthesia Induction

(Rapid Sequence Intubation)

• quickest: 
• Propofol
• Etomidate
• midazolam--longer and patient usually going to ICU after procedure
• Ketamine--not first choice
• Those are in order of choice

Neuromuscular blockade

Depolarizing versus Non-Depolarizing

•Depolarizing agents depolarize the NMJ causing exhaustion of acetylcholine and paralysis results.

•Non-depolarizing agents block the motor endplate from acetylcholine and cause paralysis.

MOA: Depolarization of the NMJ resulting in paralysis.

Duration: 6-10 minutes (rapid)

Contraindications: Hyperkalemia or major trauma, malignant hyperthermia, cholinesterase deficiency, myasthenia gravis, glaucoma, hx of rhabdomyolysis

Adverse Reactions: Cardiovascular collapse, malignant hyperthermia, anaphylaxis, rhabdomyolysis.

MOA: Block the motor endplate from acetylcholine transmitters without depolarization.

Adverse Reactions: Hypotension, arrhythmias, bronchospasm, dizziness, flushing

Half-life: 1.5 – 2 minutes  (very short)

MOA: Block the motor endplate from acetylcholine transmitters without depolarization.

Adverse Reactions: Hypotension, arrhythmias, bronchospasm, dizziness, flushing

Half-life: 65-75 minutes  (long and good for patients going to ICU)

MOA: Block the motor endplate from acetylcholine transmitters without depolarization.

Adverse Reactions: Hypotension, arrhythmias, bronchospasm, dizziness, flushing

Half-life: 1.4-2 hrs  (long and good for patient going into ICU)

•Atracurium (Tracrium):  Half-life 20 minutes

• Titrate to desired dose 
• Decrease dose in elderly, renally and hepatic impaired patients
• Make sure person giving drug is familiar with the drugs effects
• Increased sensitivity in Peds (especially < 6mo
• NEVER give Meperidne to a patient when the have been on an MAO inhibitor in the last two wks.