Pre-sedation Assessment - Prepping for Peace
- Goal: Ensure patient safety & successful sedation for imaging.
- Key Steps:
- History: Medical, surgical, anaesthetic history; allergies; medications; NPO status (last oral intake).
- Examination: Airway (e.g., Mallampati, neck mobility), CVS, RS, CNS. Assign ASA physical status.
- NPO Guidelines: Adherence critical. 📌 "2-4-6-8 Rule" as quick recall.
⭐ Current NPO: Clear liquids ≥2h, breast milk ≥4h, infant formula/non-human milk/light meal ≥6h, solids/fried/fatty meal ≥8h before elective procedures.
- Consent: Informed, written consent obtained.
- Investigations: Usually not indicated for healthy children (ASA I or II).
Pharmacological Agents - Potions & Protocols
Selection guided by procedure, patient status, and available expertise. Always ensure availability of resuscitation equipment and reversal agents.
- Titrate to effect for desired sedation level.
- Continuous monitoring of vitals (HR, RR, SpO2, BP) is mandatory.
- Strict adherence to NPO guidelines is crucial.
| Agent | Dose | Onset | Duration | Pros | Cons | Reversal (IV Dose) |
|---|---|---|---|---|---|---|
| Midazolam | PO: 0.25-1 mg/kg; IV: 0.05-0.1 mg/kg; IN: 0.2-0.5 mg/kg | IV: 1-3m | 30-60m | Anxiolysis, amnesia | Resp. depression, paradox. agitation | Flumazenil (0.01 mg/kg) |
| Fentanyl | IV: 1-2 mcg/kg | 1-2m | 30-60m | Potent analgesia | Resp. depression, chest rigidity | Naloxone (0.01-0.1 mg/kg) |
| Ketamine | IV: 0.5-2 mg/kg; IM: 2-5 mg/kg | IV: <1m | 10-40m | Dissociative, analgesia, bronchodilation, sympathomimetic | Emergence reactions, ↑secretions | Supportive (BZD for emergence) |
| Propofol | IV Bolus: 1-3 mg/kg; Infusion: 50-200 mcg/kg/min | <1m | 5-10m | Rapid onset/recovery, antiemetic | Hypotension, resp. depression, PRIS ⚠️ | Supportive |
| Chloral Hydrate | PO/PR: 25-100 mg/kg (max 2g) | 30-60m | 60-120m | Oral/rectal route | Paradoxical excitement, no analgesia, prolonged sedation, arrhythmogenic | Supportive |
Intra-sedation Monitoring - Guardian Duty
- Core Monitoring (Continuous):
- Pulse oximetry (SpO2 > 94%, alarm < 90%).
- Heart rate, rhythm.
- Respiratory rate, pattern, effort.
- Capnography (ETCO2): detects hypoventilation.
- Blood pressure (NIBP q5min).
- Level of consciousness.
- Essential Equipment:
- Oxygen source, delivery systems.
- Bag-Valve-Mask (BVM), suction.
- Airway adjuncts (OPA, NPA).
- Reversal agents, resuscitation drugs.
- Personnel: Dedicated trained individual (PALS certified) for monitoring.
⭐ Capnography is the most sensitive indicator of early respiratory depression, apnea, and airway obstruction.
Complications & Discharge - Crisis Control
- Complications:
- Respiratory: Hypoventilation, apnea, laryngospasm, desaturation (O₂↓).
- Cardiovascular: Hypotension, bradycardia, arrhythmias.
- GI: Vomiting (aspiration risk).
- CNS: Paradoxical agitation, prolonged sedation.
- Crisis Control (ABCs):
- Airway: Maneuvers, O₂, suction.
- Breathing: BMV, supplemental O₂, consider reversal.
- Circulation: IV fluids, vasopressors.
- Discharge (Aldrete Score ≥9):
- Vitals stable & age-appropriate (HR, RR, BP, SpO₂).
- Awake, alert, baseline neuro status.
- Tolerates oral intake.
- Responsible escort present.
⭐ Reversal Doses:
- Flumazenil (Benzos): 0.01 mg/kg IV (max 0.2 mg/dose; total 1 mg).
- Naloxone (Opioids): 0.01 mg/kg IV (<5y/<20kg); 0.1 mg/kg IV (>5y/>20kg). Max 2mg/dose.
High‑Yield Points - ⚡ Biggest Takeaways
- Strict NPO guidelines (e.g., 2 hrs clear liquids, 6 hrs solids) are vital to prevent aspiration.
- Dexmedetomidine is preferred for procedural sedation due to its favorable safety profile and arousable sedation.
- Midazolam (intranasal/oral) is effective for anxiolysis pre-procedure.
- Comprehensive monitoring (pulse oximetry, capnography, vitals) is mandatory throughout.
- Always ensure availability of reversal agents (flumazenil, naloxone) and emergency equipment.
- Pre-sedation risk assessment using ASA status is crucial for patient safety.
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