Ketamine Onset:

IV 0.5-1 min Management of Complications

Dissociative analgesic, IM 3-5 min
Laryngospasm
Anxiolytic, Amnestic, Duration: IV 5-15 min
Procedural Sedation Meds Sedative IM 15-30 min
1. Wait: most resolve within 30 seconds
Avoid in: 2. Laryngospasm notch: jaw thrust with inward
Midazolam Onset: IN 1-3 min - ICP with obstruction
Recovery: 60-150 min
thrust towards brainstem
Anxiolytic, Amnestic Oral 15-30 min
- intraocular pressure Dosing Guidelines:
Dosing Guidelines: IV 1-3 min - active resp infxn
IV: Initial 1-2 mg/kg
IN: 0.5 mg/kg Duration: IN 60 min (peak 20 min) - poorly controlled
(max 100mg/dose)
(max 10mg) Oral 60-90 min asthma
* 50mg/dose usually effective
(Conc 5mg/mL) IV 45-60 min (peak 20 min) Repeat 0.5mg/kg (max 50mg/dose ) q5-10min prn
Oral: 0.5 mg/kg (max 20mg) Give over 60 seconds
* less predictable effect IM: 4-5 mg/kg, repeat 2-4 mg/kg after 10-20 min prn 3. Positive pressure
IV: (0.5 - 5 yrs): 0.05-0.1 mg/kg (max 2mg/dose), Adverse events: - Emesis - Laryngospasm 4. Deepen sedation: use midaz or propofol
titrate prn to total max 0.6 mg/kg - Hallucinations - Recovery agitation 5. Low dose succinylcholine: 0.1-0.2 mg/kg IV
(6 - 12 yrs): 0.025-0.05 mg/kg (max 2mg/dose), Comments: - Consider redosing q5min x 2, then prn * preferential vocal cord paralysis without affecting
titrate prn to total max 0.4 mg/kg - Resp complications may increase when total
> 12 yrs: 2 mg, titrate with 1 mg prn
diaphragm
dose >5mg/kg and with IM route 6. Full dose succinylcholine: 1mg/kg IV and intubate
Give over 10-20 seconds - Use higher end of dosing range for toddlers
Adverse events: - Paradoxical reactions - Consider midaz to treat recovery agitation
- Resp depression - mild infusion pain
Nausea/Vomiting (Consider pre-med with h/o motion sickness)
- Consider ondansetron ppx with h/o motion sickness
Comments: - If using with fentanyl, consider ratio of - Vocalizations or myoclonus may occur
Ondansetron: < 10 kg - 0.5 mg IV
2-3 doses of fentanyl for each 1 dose of midaz 10-30kg - 1 mg IV
Propofol Onset: IV < 1 min >30kg - 2 mg IV
Sedative-hypnotic Duration: IV 5-15 min
Reversal: See Management of Complications- Reverse
Benzo
Avoid in Dosing Guidelines:
Oversedation/Respiratory Depression
- egg or soy allergy
IV Induction: (0 - 4 yrs): 2 mg/kg
- hypotension
(5 - 10 yrs): 1.5 mg/kg
Reverse Opioid: Naloxone IV, IN, or IM
Fentanyl Onset: IV 2-3 min
(>10 yrs): 1 mg/kg 0.01 mg/kg - 0.1 mg/kg (max 2 mg/dose)
Analgesic IN 3-5 min Onset: 2 min Duration: IV/IN 20-40 min
Dosing Guidelines: Duration: *May require additional 0.5 mg/kg bolus every 60-90 sec
IV 30 min IM 60-90 min
IV: Initial 1-2 mCg/kg for induction
IN 30 min
(max 100 mCg/dose), - IV Maintenance via pump: 50 - 200 mCg/kg/min start low and titrate q2min to effect
Adverse events: -Bradycardia - Hypotension - Apnea * 0.1 mg/kg will bring about full reversal of depression
titrate with 1 mCg/kg (max 50 mCg/dose) q3min prn,
- Infusion pain AND analgesia
Give over 10-20 seconds
Comments: - Use with fentanyl for analgesia
Suggested total max 5 mCg/kg
- For infusion pain: Apply tourniquet just proximal to IV, Reverse Benzo: Flumazenil IV 0.02 mg/kg
IN: 2 mCg/kg (max 100 mCg/dose)
Lidocaine IV 1mg/kg (max 25mg), remove tourniquette (max 0.2mg/dose, total max 1 mg or 0.05 mg/kg)
(Conc 50 mCg/mL)
after 60 seconds and flush with initial propofol bolus Onset: 1-2 min Duration: 30-60 min
Adverse events: - Resp depression
Comments: - If using with midaz, consider ratio of start low and titrate q1min to effect
2-3 doses of fentanyl for each 1 dose of midaz
Pentobarbital Onset: IV 3-5 min
Hypnotic, Amnestic Duration: IV 15-45 min * Avoid in patients with seizure d/o
Dosing Guidelines:
Reversal: See Management of Complications - Reverse IV: Initial 2 mg/kg (max 100mg/dose) **Monitor for return of sedation as reversal agent wanes
Opioid titrate with 1-2mg/kg q5 min prn (total max 6mg/kg) ***May require redosing for longer acting agents
Give over 30 seconds
NOTE: The medication dosing contained within these guidelines is provided for Adverse events: - Paradoxical reaction
reference only. Please refer to your institutional formulary or ordering guidelines Note: Patients who receive any reversal agents must be
when placing orders for clinical care of patients. - resp depression - Hypotension - Prolonged recovery monitored for 2 hours after the last dose of the reversal
Comments: - Lowers ICP
Created in 2015 by Windsor RB, Johnson K, Fleegler E, Krauss B, Dwyer D,
Manzi S
 NPO Guidelines Sedation Teams
Procedural Sedation 2 hrs: Clear liquids DOM Sedation:
Quick Reference 4 hrs: unfortified breast milk
6 hrs: nonhuman milk, formula, fortified breastmilk
- Page “Sedation MD on Call” from 7a - 6p Mon-Fri
- Candidates: ASA I or II
ASA Physical Status Classification 8 hrs: solid food - Non-OR based sedations
ASA I: Healthy patient, no organic or psychiatric dz * Risk of aspiration in procedural sedation (not general - Exclusions: age < 3 mo, O2 requirement, difficult airway,
ASA II: Mild systemic dz with no impact on daily fxn anesthesia) is low regardless of NPO status HCT < 20, active URI or asthma, prior adverse reaction to
ASA III: Significant or severe systemic dz that limits fxn ** No formal NPO criteria for ED sedations sedation, OSA, active emesis, DNI
ASA IV: Severe dz that is constant threat to life
ASA V: Moribound pt likely to die within 24hrs Preparation and Setup Anesthesia: 5-9111 (Attending to Attending)
ASA VI: Brain dead organ donor - Responsible for all sedations in OR
“SOAP-ME”
Suction: Suction cannister, tubing, and Yankauer tip Capnography
Red Flags for Sedation Noninvasive ventilation monitoring
- Craniofacial abnormalities / high risk airway on exam
- h/o difficult airway and/or difficult sedation Oxygen: Preoxygenate with simple facemask or non-
- active vomiting or severe, uncontrolled GERD rebreather with 12-15 L/min for 3 min prior to induction
- active URI * Nasal cannulas do not provide preoxygenation
- OSA ** Continue facemask over capnography through case
- Symptomatic asthma FiO2: Room Air - 21%
Simple facemask (12-15L) - 50-60%
Nonrebreather (12-15L) - 90-100%
Levels of Sedation Resucitation bag (Anesthesia or self-inflating bag)
Appropriately sized mask
Minimal/ Airway: ETTs (uncuffed) = age (yrs) + 16
Anxiolysis Moderate Deep * Down 1/2 size for cuffed tubes 4
Capnography pearls:
Set up with appropriately sized ETT and one size smaller
Response Nml with Purposeful Purposeful - Cessation of airflow (flat waveform) - Central apnea or
verbal stim with verbal with repeat complete airway onstruction (ie laryngospasm)
Laryngoscope: < 2 yrs Miller 1
or tactile or painful - Detects cessation of ventilation immediately - pulse ox
* Estimates 2-12 yrs Miller 2/Mac 2
stim stim detects desaturations 1-5 minutes (depending on age,
>12 yrs Mac 3
preoxygenation, and comorbidities)
Adult/large adolescent Mac 4
Airway Unaffected No May require Oral Airway/Nasal airway
intervention intervention Age, Apnea duration, and desats (with preoxygenation)
required Pharmaceuticals: See Medication guidelines Age time (mean) -90% O2 sat time (range)- 90% O2 sat
(sec) (sec)
- Draw up initial dose and bolus doses before case
2 day - 6 mo 96.5 sec 77 - 118 sec
Unaffected Adequate May be - Keep saline flushes separate from medications
Spont. 7 mo - 23 mo 118.5 sec 79 - 163 sec
inadequate - Locate and have immediate access to reversal and 2 yr - 5 yr 160 sec 114 - 205 sec
ventilation
emergency drugs 6 yr - 10 yr 215 sec 165 - 274 sec
11 yr - 18 yr 382 sec 185 - 490 sec
CV fxn Unaffected Usually Usually Monitors:
Patel. Age and onset of desaturations in apnoeic children. Can J Anesth. 1994
unaffected unaffected - Cardiorespiratory (EKG) monitoring
Documenting levels of sedation: - Blood pressure monitoring
- Rising etCO2 or low etCO2 can reflect
- Continuous pulse oximetry
1 - Anxious, agitated, restless hypoventilation
- Continuous capnography
2 - Cooperative, oriented, or tranquil - Rising CO2: low RR, nml Vt (hypopnea)
3 - Asleep, brisk response to light stroke to cheek Extra: - Low etCO2: shallow respirations leading to
4 - Asleep, sluggish response to light stroke to cheek Ensure all procedural equipment and staff are in room dilution of alveolar gas by dead space
5 - No response to light stroke to cheek (US, fluoro, etc)