EMCrit Podcast 29 – Procedural Sedation, Part II

It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. This continues the discussion started in Part I, where we discussed etomidate, ketamine, and versed/fentanyl. In this podcast, I discuss propofol, ketofol, and dexmedetomidine.

the emcrit procedural sedation chapter has tons of references for all of this

Propofol

great propofol articles:

Ann Emerg Med 2008;52:392-398
Ann Emerg Med. 2007;50:182-187

Start with fentanyl 1-1.5 mcg/kg

Then give propofol 0.5-1 mg/kg

may need additional injections of 0.5 mg/kg

When patient is where you want them, begin the procedure

May need to give additional 20-30 mgs if the patient becomes too light

Burns on injection, you can precede with 20-40 mg of lidocaine to numb the vessels

Ketofol

read more here: (Ann Emerg Med. 2007;49:23-30)

1:1 mix of ketamine and propofol

In 20 ml syringe, place 10 ml of propofol (10 mg/ml)

And 10 ml of ketamine at a concentration of 10 mg/ml

Note: your ketamine may come in a different concentration, if so dilute down to 10 ml of 10 mg/ml

Shake like a martini

Dexmedetomidine

Precede with fentanyl 1 mcg/kg

Start with 0.5-1 mcg/kg over 10 minutes for loading dose

then use an infusion 0f 0.2-1 mcg/kg/hr

Beware in the bradycardic, hypotensive or patients with heart blocks

May need to supplement with 1-2 mg of midazolam

Procedural Sedation Checklist

here it is

Stay tuned for part III coming to you some time in the future.

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Comments

  1. Sent by email from a reader:

    Hey
    I enjoyed your sedation talk. A strategy that is used in our burns department for a dressing change is to mix 200 mg of ketamine with 10 mg of midazolam and made up to a volume of 20 ml in 1 syringe. It is then given as a PCA (usually as 1 ml with a lock out of 3 minutes). Seems to work well.

    David

  2. anthony ferkich says:

    Scott
    when using Ketofol, is it taking substantially longer for your patients to awaken and discharge as opposed to just Propofol and fentanyl?http://blog.emcrit.org/wp-content/plugins/wp-notcaptcha/lib/vertical_sign.png

    • It will take on average an additional 10 minutes of monitoring time in my experience. But this is time that the pt is not at risk of airway compromise.

  3. Dr. Weingart,

    Love the podcast! I have only recently discovered it, and am part way through my catch-up. I believe it is in this podcast you discuss pain elicitation to increase ventilation rate in sedated patients (sorry if it was a different one, I listen to groups of them at a time). Regardless, you stated that pressing between the posterior mandible and the mastoid process can elicit a good pain response to increase ventilation rate without appearing harmful. However, I’m concerned about the fragility of the styloid process, which I believe is being compressed in this maneuver. Is there a risk of fracture to the process in using this method? Thanks!

  4. Hi Scott,

    Did you ever get to part III? I can’t find it. This is great. ER nurse…it’s annoyingly hard to find anyone in the nursing world to give you a straight but complete answer on anything. It’s awesome to get this all laid out in one place.

    I’m going to go back and listen to both of these a couple of times and make my own notes. Thanks for all the info.

    Paul

Trackbacks

  1. […] ACEP clinical policy 2011 Procedural Sedation Emedicine Medscape Emcrit Procedural Sedation part I Emcrit Procedural Sedation part II Emcrit Procedural Sedation Guidelines Pediatric Procedural Sedation with Ketamine su […]

  2. […] Dr. Weingart is also describing post-intubation sedation, so this is not entirely the same as pre-cardioversion sedation. He does cover this in Procedural Sedation – Part I and EMCrit Podcast 29 – Procedural Sedation, Part II. […]

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