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Who are considered the fathers of sedation?
William Morton and Horace Wells
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When the intent is minimal sedation, what should the appropriate initial dose be?
No more than the maximum recommended dose (MRD) of a drug that can be prescribed for home use.
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In minimal sedation and moderate, what abilities does the patient retain?
- - independently and continuously maintain an airway
- - respond to physical stimulation and verbal command
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A drug induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following repeated of painful stimulation
Deep sedation, patients may lose independent ventilatory function.
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General loss of consciousness, patients are NOT arousable even by painful stimulation and often require assistance maintaining airway. Cardiovascular function may be impaired
General Anesthesia
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Disadvantages or oral sedation
- Long latent period
- Unreliable drug absorption
- Inability to titrate
- Slow onset and prolonged duration
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Advantages of IV sedation
- Short latent period
- Can produce amnesic periods
- 2-5 minutes for titration
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2 main types of respiratory complications
- Ventilatory depression (physiologic problem)
- Airway Obstruction (anatomic problem)
- *These 2 complications can occur simultaneously
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Areas of lung which are perfused but not ventilated (no gas exchange occurs)
Shunt
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the volume of gas inhaled with each normal breath
Tidal volume (TV)
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Areas of lung which are ventilated, but not perfused (no gas exchange occurs)
Dead space
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The presence of cO2 in expired gases thus provides status information about
- Ventilation
- Metabolism
- Circulation
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a physiologic problem caused by the pharmacodynamic effects of sedatives on the brain
Ventilatory depression
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An anatomic problem which occurs when the tongue, epiglottis and upper airway soft tissue "relax" during sedation and block the airway
Airway obstruction
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How to manage controlled T2D patients (not insulin dependent) the morning of conscious sedation.
- - Do not take normally scheduled AM dose of oral hypoglycemic
- - Fasting blood glucose reading is required before and after procedure
- ** Insulin dependent patients require consultation, depending on insulin meds instructions may change.
- Hypoglycemia symptoms can be masked under deep sedation
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What are the main parts of the pre-sedation patient selection ABC exam?
- Airway- mallampati, jaw, neck, mouth opening
- Access- IV
- Breath sounds- lungs
- BMI
- Cardiac- rate, rhythm, pacemaker, stents
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Fasting time on clear liquids
2 hours
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Fasting time on breast milk
4 hours
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Fasting time on non human milk
6 hours
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Fasting time on light meal
6 hours
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Fasting time on heavy fatty fried meals
8 hours +
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Contraindications for sedation
- ASA 3 or above
- BMI over 40
- Known difficult airway
- History of adverse/paradoxical reaction to sedation
- Drug abuse or methadone/suboxone maintenance
- Communication barrier
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2 quick tests to evaluate a difficult airway
- Mallampati score
- thyromental distance
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Which are the standards of monitoring?
- Oxygenation - sp02 monitor, supplement o2 1.2L per minute
- Ventilation - chest excursion, breathing bag, breathing sounds, most effective is Capnography
- Circulation - ekg monitors, BP, pulse
- and
- Temperature monitoring
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Peak pressure generated during systolic contraction
Systolic BP
* BP is not always an indicator of organ perfusion
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Lowest pressure during diastolic relaxation
Diastolic BP
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Pulse pressure is...
the difference between systolic and diastolic pressures
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The time weighted avg of arterial pressures during a pulse cycle is...
mean arterial pressure (MAP)
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Pulse over 140 is suspected to be
- SVT, supraventricular tachycardia
- Normal resting heart rate can be 45-95 or 60-100
- Athletes have lower resting heart rates
- Children have higher heart rates 70-88
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What are the 2 pieces of information we can get from Capnography?
- End tidal CO2 (normal is around 35-45)
- Respiratory rate (normal is around 12, but can be 8-24) and is a vital sign
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What does a high value in end tidal CO2 mean?
Person is hypoventilating and blood is becoming alkaline
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What does a rapid fall in ETCO2 mean?
indicator of pulmonary embolism, reduction in lung perfusion lessens ETCO2, decreased CO and BP
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At what level of Sp02 is hypoxemia
Under 90%, normal is 95-100%
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Which temperature monitoring technique is the best combination of economy, performance and safety?
Esophageal temperature
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Benzodiazepines work by which mechanism?
- limbic system and amygdala of the brain where fear arises.
- Act as allosteric agonists at specific GABA receptors.
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Effects of Benzodiazepines
- Anxiolysis
- Sedation
- Anteriograde amnesia
- Anticonvulsant
- muscle relaxation
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Anxiolytic of choice for IV sedation is.
- Midazolam/Versed (except in elderly, because of decreased liver function)
- Stable for cardiovascular when use as Sole agent.
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In patients who chronically take Cimetidine (tagamet) or Ranitidine (zantac) what happens with Benzodiazepines?
They are susceptible to Benzo overdose because H-2 blocking drugs increase sedative effect.
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2 MAIN patients contraindicated for Benzodiazepines
- Elderly (careful limited use)
- Pregnant (DO NOT USE, can cause cleft palate)
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When administering Midazolam, what increments are given and duration of action time is expected (by iV)
- Starting dose 0.5-1mg
- Titrate by 0.5mg increments
- Duration of action is 15-80 minutes by IV
Valium (not used as much) given in 2.5mg increments
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Reversal agente for Benzos
- Flumazenil/Romazicon (0.2mg) initial dose
- 1minute between doses until patient returns, 1mg Max
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Other sedation agent normally given with Benzos for IV sedation, what is their greatest risk?
- Narcotics, greatest risk is respiratory depression, (do NOT have Amnestic effects)
- eg: Morphine, Fentanyl and Demerol
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These agents interact with specific receptors in the endogenous opioid systems located at ALL levels of the pain pathways throughout the body
Opiods
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Fentanyl dosing is
- Starting dose is 25-50mcg
- 0/7-1mcg/kg
- Titrate in 25mcg increments
- Duration is 30-60 minutes IV
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What is the reversal agent for opiods and its dosing?
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General anesthesia agents include
- Ketamine (PCP, dissociative/analgesic)
- Propofol (milk of amnesia, respiratory depression, no reversal agents )
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Antiarrhythmic used to treat SVT, short duration, short duration to make the heart slow down
- Adenosine
- 6mg over 1-2 seconds (rapid)
- * Use Valsalva manuvers first
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Antiarrythmic used for vfib and vtach WITHOUT A PULSE and after trying epi and shocking.
- Amiodarone
- 300mg first dose and 150mg second dose
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Better broad spectrum antibiotic used IV effective against gram (-) and gram (+)
Ampicillin, 2g prophylaxis
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Aspirin dose in the kit and what is it used for
- 325mg used for MI
- Contraindicated for bleeding disorders or stroke
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Anticholinergic used for bradycardia, drowsiness and delirium
- Atropine
- 0/4 every 5 minutes, up to 3g for bradyarythmia
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IV antibiotic of choice for head and neck infections, for patient allergic to PCN,
- Clindamycin
- IV dose for adult is 600mg
- Contraindicated for colitis, liver disease and myasthenia gravis
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Synthetic glucocorticoid 16x stronger than prednisone
- Dexamethasone
- 0.1-0.2 mg/kg IV
- Increases blood glucose for 24 hours
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H1 receptor antagonist that blocks histamine effects on HI receptors
- Diphenhydramine, 25-50mg IV
- is a CNS depressant
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IV drug given IV for hypoglycemia and its dose
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Sympathomimetic adrenergic agonist to stimulate alpha and beta receptors and increase heart rate, not as good as epi
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Epinephrine used in anaphylaxis and given IM
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Epinephrine used in cardiac arrest
- 1mg IV FOR CARDIAC ARREST
- 1:10,000
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Medication given for ischemic heart pain, angina
- Nitroglycerin
- 0.4mg sublingual , repeat in 5 minutes if needed
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Antiemetic medication given IV
- Odansetron (ZOFRAN)
- 4mg dose
- ** Can cause arrythmia in QT interval
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Short acting B2 adrenergic receptor agonist for relief of bronchospasm in asthma and COPD
Albuterol
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Maximum flow through nasal cannula
- 4-5L/min
- Can give up to 44% oxygen
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This device can allow up to 90% oxygen flow to a patient as compared to 44% of an inferior one
- Oxygen face-mask, non rebreather
- 44% is the nasal cannula
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Oxygen-positive pressure ventilation bag can give ___% `
- 100%
- should be used when giving BLS
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Dosages of Epipen and EpiiPenJr
- 0.3 mg adult
- 0.15 mg pediatric dose
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Scoring system used before determining when to discharge patient post-sedation
- Aldrete score
- Score of 8 and above is recommended
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The gas pressure in the N2O cylinder will read approximately
750 psig until no more liquid remains to replace the gas
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