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Endoscopy –  Safe Sedation

Dr Alan Hope

Western Infirmary, Glasgow

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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.

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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 judge’s summing up besympathetic?

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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.

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Safe Sedation - principles

Preparation: anticipate and prevent

problems

Know your drugs

If in doubt –  don’t proceed, get advice 

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Safe Sedation – before you start

Check equipment: Suction, oxygen,ambubag, airways, defibrillator, tippingtable / trolley.

Monitors: ECG, SaO2 (alarm at 90%),NIBP, competent assistant

Drugs: including naloxone, flumazenil,

resuscitation drugs.Patient: ?hypovolaemic, reliable IV (expose

cannula), position.

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Safe Sedation - drugs

Benzodiazepines

Opioids Intravenous anaesthetic agents (propofol)

Nitrous oxide

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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 anendpoint (slurred speech), supervise for 1hrafter injection, accompanied home.

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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 to1-1.5mg/kg, depending on age, medication

(MAOIs!), renal function, body size,

conscious level, respiratory status.

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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.

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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

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Safe Sedation - summary

Know drugs, effects, side effects

Prepare: equipment, monitoring, antagonists

Don’t rush - slow titration of drugsHave a game-plan for clinical problems,

you may need to move quickly

You are responsible until patient has fullyrecovered from your sedation