Endoscopy Safe Sedation

Dr Alan Hope Western Infirmary, Glasgow

Safe Sedation the problem

Unpleasant procedures are not good

for the patient: non-cooperation,

hypertension, tachycardia, angina, retching and vomiting, bronchospasm, coughing, straining etc etc for the doctor: poor conditions for procedure, failure of procedure.

The solution: Sedation

What clinical state do I aim to achieve?

What do I give?
How do I give it? What might go wrong? What do I do then? Will the judges summing up be

sympathetic?

The plan = Conscious Sedation

Awake, apprehensive. Drowsy, communicating, cooperative

awake to speech. Very Drowsy, uncooperative. Difficult to rouse, obstructed respiratory pattern. Comatose, profoundly depressed respiration, cyanosis.

Safe Sedation - principles

Preparation: anticipate and prevent

problems Know your drugs If in doubt dont proceed, get advice

Safe Sedation before you start

Check equipment: Suction, oxygen,

ambubag, airways, defibrillator, tipping table / trolley. Monitors: ECG, SaO2 (alarm at 90%), NIBP, competent assistant Drugs: including naloxone, flumazenil, resuscitation drugs. Patient: ?hypovolaemic, reliable IV (expose cannula), position.

Safe Sedation - drugs

Benzodiazepines
Opioids Intravenous anaesthetic agents (propofol) Nitrous oxide

Safe Sedation - midazolam

A benzodiazepine: sedation, hypnosis,

unconsciousness, loss of muscle tone, amnesia, no analgesia, resp depression at high doses, occasionally agitation / aggression. GABA agonist, depresses limbic system. Technique: titrate (0.5-2mg boluses) to an endpoint (slurred speech), supervise for 1hr after injection, accompanied home.

Safe Sedation - pethidine

An opioid. Half-life 2.5-4h.

Sedation, analgesia, respiratory depression,

nausea, CVS stable, v. occ. histamine release. Mu agonist. Technique: give 10-25mg IV increments to 1-1.5mg/kg, depending on age, medication (MAOIs!), renal function, body size, conscious level, respiratory status.

Not-so-safe Sedation airway obstruction

Snoring, paradoxical see-saw chest

movement, poor air entry, cyanosis Airway manoeuvres / insert airway Oxygen No prompt resolution give antagonists and call for help.

Not-so-safe Sedation profound respiratory depression

Rate into low single figures
Give no more sedation, start oxygen Shake patient, and tell patient to breathe

If losing it support respiration, give

antagonists, call for help

Safe Sedation - summary

Know drugs, effects, side effects

Prepare: equipment, monitoring, antagonists

Dont rush - slow titration of drugs Have a game-plan for clinical problems,

you may need to move quickly You are responsible until patient has fully recovered from your sedation