Sedation conscious

To induce conscious sedation before a diagnostic or therapeutic procedure in the hospital setting... 

Midazolam (Versed), a short-acting benzodiazepine CNS depressant, is used as a preanesthetic drug to relieve anxiety for induction of anesthesia for conscious sedation before minor procedures, such as endoscopic procedures and to supplement nitrous oxide and oxygen for short surgical procedures. When the drug is used for induction anesthesia, the patient gradually loses consciousness during a period of 1 to 2 minutes. 

Benzodiazepines have a wide array of clinical uses. In addition to relieving anxiety, they can be used to treat epilepsy, alcohol withdrawal, insomnia, agitation, and perhaps impulsivity. They can also be used as muscle relaxants or to produce conscious sedation during certain medical procedures such as cardiac catheterization and colonoscopy. 

Naloxone is used for rapid opioid detoxification in conjunction with anesthetic agents for conscious sedation. 

Benzodiazepines. Safer than the barbiturates but acting in a similar manner, the benzodiazepines have largely replaced barbiturates since their introduction in the 1960s. Other uses of benzodiazepines include treatment for epilepsy, alcohol withdrawal, several anxiety disorders, agitation, and impulsivity, as muscle relaxants, and as conscious sedation during certain medical procedures. 

Reversal of conscious sedation or in general anesthesia The recommended initial dose is 0.2 mg (2 mL) administered IV over 15 seconds. If the desired level of consciousness is not obtained after waiting an additional 45 seconds, a further dose of 0.2 mg (2 mL) can be injected and repeated at 60 second intervals where necessary (up to a maximum of 4 additional times) to a maximum total dose of 1 mg (10 mL). Individualize the dose based on the patient s response, with most patients responding to doses of 0.6 to 1 mg. 

Hypoventilation Monitor patients who have received flumazenil for the reversal of benzodiazepine effects (after conscious sedation or general anesthesia) for resedation, respiratory depression or other residual benzodiazepine effects for an appropriate period (120 minutes or less) based on the dose and duration of effect of the benzodiazepine employed, because flumazenil has not been established as an effective treatment for hypoventilation due to benzodiazepine administration. Flumazenil may not fully reverse postoperative airway problems or ventilatory insufficiency induced by benzodiazepines. In addition, even if flumazenil is initially effective, such problems may recur because the effects of flumazenil wear off before the effects of many benzodiazepines. 

Benzodiazepines are useful as orally administered premedications. They are also used intravenously in doses that produce conscious sedation rather than hypnosis. Sedated patients tolerate unpleasant procedures (e.g., wound repair, bronchoscopy, angiography) while maintaining cardiorespiratory function and the ability to respond to tactile stimulation or verbal commands. 

Flumazenil Romazicon) is a benzodiazepine antagonist that specifically reverses the respiratory depression and hypnosis produced by the benzodiazepine receptor agonists. Its block of the amnesic effect of the agonists is less reliable. Flumazenil is particularly useful when an overdose of benzodiazepines has occurred. It is also employed when a benzodiazepine has been used to produce conscious sedation and rapid recovery of psychomotor competency is desirable. To avoid resedation, flumazenil may require administration by intravenous infusion. 

Rapid recovery and its antiemetic properties make propofol anesthesia very popular as an induction agent for outpatient anesthesia. Propofol can also be used to supplement inhalational anesthesia in longer procedures. Both continuous infusion of propofol for conscious sedation and with opioids for the maintenance of anesthesia for cardiac surgery are acceptable techniques. 

Reversal of conscious sedation or general anesthesia IV Initially, 0.2 mg (2 ml) over 15 sec may repeat dose in 45 sec then at 60-sec intervals. Maximum 1 mg (10-ml) total dose. 

Conscious sedation for diagnostic, therapeutic, and endoscopic procedures IV 1-2.5 mg over 2 min. Titrate as needed. Maximum total dose 2.5-5 mg. 

Conscious sedation during mechanical ventilation IV Initially, 0.02-0.08 mg/kg. May repeat at 5-15 minute intervals or continuous infusion rate of 0.04-0.2 mg/kg/hr and titrated to desired effect. 

Other Uses in Geriatric Patient Conscious sedation, status epilepticus... 

Conscious sedation implies that patients have a depressed level of consciousness but nevertheless have intact protective reflexes, the ability to maintain their airway, and the ability to respond appropriately to requests and physical stimulation (Kennedy and Luh-mann, 1999). Sedative agents familiar to psychiatrists that are used in this manner for procedures include chloral hydrate, given orally or rectally in a dose of 25 to 100 mg/kg midazolam, given intramuscularly or intravenously in a dose of 0.05 to 0.15 mg/kg, rectally in a dose of 0.3 to 0.5 mg/kg, or orally in a dose of 0.2 to 0.75 mg/kg and midazolam, which is felt to be preferable to diazepam for this purpose (Kennedy and Luhmann, 1999). Midazolam is also available in a nasal spray (Ljungman et ah, 2000). 

Reflex sympathetic Dystrophy Conscious sedation for procedures Gabapentin Chloral hydrate Midazolam 25-100 mg/kg po or rectally 0.05-0.15 mg/kg IM or IV 0.3-0.5 mg/kg rectally 0.2-0.75 mg/kg po 11-year-old girl with refractory reflex sympathetic dystrophy Also available in a nasal spray Tong and Nelson, 2000 Kennedy and Luhmann, 1999 Ljungman et al., 2000... 

It is indicated for preoperative sedation, conscious sedation prior to short diagnostic or endoscopic procedures, induction of general anaesthesia prior to administration of other anaesthetic agents. 

Midazolam Slow onset and recovery flumazenil reversal available Used in balanced anesthesia and conscious sedation provides cardiovascular stability and marked amnesia... 

A specialized form of conscious sedation is occasionally required in the ICU, when patients are under severe stress and require mechanical ventilation for prolonged periods. In this situation, sedative-hypnotic drugs or low doses of intravenous anesthetics, neuromuscular blocking drugs, and dexmedetomidine may be combined. 

As an anesthetic, nitrous oxide has many legitimate uses. In dentistry it is used to calm patients and lower their anxiety (a process known as conscious sedation). 

A special form of conscious sedation is sometimes needed in the ICU, when patients are under... 

Droperidol is used as an adjunct in conscious sedation for endoscopic procedures. In one study, basal biliary sphincter pressures measured in 35 patients before and after droperidol were 56 and 48 mmHg the basal pancreatic sphincter pressures measured in 22 patients before and after droperidol were 92 and 67 mmHg (24). However, in another study basal pressures of the biliary sphincter and of the pancreatic sphincter were not significantly altered by droperidol (25). 

Glaser JW, Blanton PL, Thrash WJ. Incidence and extent of venous sequelae with intravenous diazepam utilizing a standardized conscious sedation technique. J Periodontol 1982 53(11) 700-3. 

Midazolam nasal spray 2 mg/kg has been compared with a citric acid placebo for conscious sedation in children undergoing painful procedures (52). Citric acid was added to the placebo, so that the sensation of nasal burning caused by midazolam did not unblind the observers. Parents and nurses judged the procedure to be more comfortable with midazolam, but the children rated the discomfort of the procedure similar in the two groups. Anxiety was significantly reduced by midazolam. There was nasal discomfort in 43% of the midazolam group. The authors concluded that midazolam intranasal spray effectively reduces anxiety, but that its use may be limited by nasal discomfort. 

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