Procedural sedation by endoscooist

-patient selection vital

- patient at risk for

Anesthesia care
Thorough pre-anesthetic assessment
Standard pre-anesthesia care
Development of sound anesthetic plan w/ appropriate monitoring

Levels of sedation
Minimal sedation
Moderate sedation (conscious sedation)
Deep sedation
General anesthesia

Propofol - deep sedation

Deeper sedation - greater risk of respiratory depression, apnea

Hemodynamic instability, airway obstruction

Goals of anesthesia for endoscoopy

-Rapid onset
- brief durataion
Prompt recovery
Assurance of patient comfort

Sedation techniques
Inhaled - sevoflurane
- non pungent, sweet smelling, used for gas induction
- speed of onset
- route - via lungs
- easy to titrate
-provide rapid recovery
-more expensive
-provide anesthesia amnesia analgesia muscle relaxation

Intravenous - propofol, ketamine

Benzodiazepine - no analgesic properties
Midazolam diazepam lorazepam
Produce dose dependent depression of ventilation,
Synergistic with opioids
Antagonist is flumazenil

propofol
Sedative hypnotic
Minimal analgesic
Excellent recovery profile
Increased sense of well being
Dose dependent depression of ventilation
Apnea occurs in 25% - 35% of patient
Cardiovasc depressant effects
Excellent recovery

Dexmedetomidine (precedex)
Selective alpha 2 receptor agonist
Target sedation level longer to achieve than propofol
High incidence of hypotension and bradycardia
 Ketamine
Produces dissociative anesthesia
Potent analgesic
Does not depress cardiovascular and respiratory
Produce psychotropic effects
Short elimination half life 2-3 hrs

Opioids
Adverse effect - respiratory depression, muscle rigidity, emesis
Fentanyl
remifentanil
Demerol
Compromise upper airway patency
Depress protective airway reflexes
May depress respiratory drive and limit response to hypoxia and hypercapnia especially
when sedative hypnotics are combined

Drug interactions
No inhaled or IV drug can provide analgesia , anzxiolysis, hypnosis amnesia
Combination of drugs used to achieve balanced anesthesia
Dose dependent potentiating effect may lead to cardiorespiratory depression

ABCDE and essential monitors in PACU

A - Airway
Maintain airway patency
Keep patient in lateral decubitus best for recovery
Seretion drains naturally
Check airway patency by movement of air on mouth and nose

Recognize signs of obstruction

See saw chest movement - abdomen mvmt compared to chest
Partial obstruction - stridor snoring secretions
Tongue common cause for airway obstruction
Open airway - head tilt chin lift, jaw thrust
Internal maneuver - nasopharyngeal airway or oropharyngeal
Important to choose correct size

B - Breathing
Assess for adquacy, spot the color
Watch for chest rise (12 bpm)
Count the RR
Get SpO2

For patient with inadequate respiration - bag mask ventilation (rescue breathing)

Oxygenation
Ventilation

C - Circulation
Check the color - healthy pink color
Palpate for peripheral pulse
Check capillary refill time
Get the heart rate and blood pressure
Monitor ECG (rate rhythm possible ischemia)
D - Disability
Assess neurologic function
Airway reflexes -swallowing and coughing
Eye opening verbal and motor response
Follows commands
Correlate with pre sedation neurologic function

E- Exposure
Thermoregulation
Low ambient temperature
Avoid hypthermia and shivering
Adverse effects - increased O2 consumption, delayed clearance of
Use forced air warming device