Sedation

- GA is a plane of unawareness
- Phases of anaesthesia: light deep

General anaesthesia
- Patient unable to maintain their own airway
- Airway assistance needed
- Some extent of haemodynamic support needed

Before reaching the plane of anaesthesia, there is the plane of sedation.

Sedation can be as mild as conscious sedation(patient can still talk and is responsive, but is more calm and cooperative) patient
becomes more and more drowsy GA
Can start in sedation and end up in GA
Once patient is in GA plane, different management of patient ie anaesthesiologist needed for a/w management and haemodynamic
management.
Safe sedation spectrum can be done by a normal doctor who has had some training in that area.
Need to ensure the patient does not drift off into GA plane.

Sedation needed for: endoscopy, MRI in children etc

Complications: cardiac arrest

CASE
- Patient is hypoxaemic
Oxygen sat is low
- Bradycardic

100mg IV pethidine
5mg IV midazolam
- Fairly large doses of each drug

Why patient is hypoxaemic and bradycardic?

- Pethidine and midazolam contributing to respiratory depression
- Synergistic effect of benzodiazepine and opioid
- Opioids are cardiovascular-stable ie no direct effect on CV effect
Opioids only cause hypotension in very compromised patients
- When combining benzo and opioid may use less than 50% of the doses

When patients saturation begins to fall,

- Initially the body’s response is tachycardia but when it continues to spiral downwards, patient’s HR begins to slow down
- Patient is in critical hypoxemia
- Next thing that will happen is cardiac arrest.
- Patient in the case is about the arrest
- If they continue with debridement, the monitor will show asystole.

The drugs did not cause direct CV effect. They caused resp depression but as it worsened, it lead to a profound CV depression.
Eventually will lead to death.

If atropine given, HR will increase but it will not solve the initial problem ie hypoxemia.

MANAGEMENT
ABC
- Assess a/w and breathing
The 2 main problems that can be contributing to the patient’s hypoxemia:
 Upper a/w collapse/ obstruction
Tongue collapse
Soft tissue collapse
 Partial obstruction snoring, noisy breathing ie turbulence at vocal cord
Head tilt, chin lift, jaw thrust, put in Guedel a/w should resolve obstruction
 Total obstruction a/w collapse
Check for air flowing at the mouth. Feel with hands
Check for chest wall movement
In airway obstruction: Paradoxical breathing- abdo and chest moves in opposite directions ie see-saw movement
When you feel at the mouth no air flow

If patient is obstructed, giving oxygen will not help because he is still obstructed.
 Open a/w and give supplemental O2
Jaw thrust
Open a/w
Oxygenate

Call for equipment:

Oropharyngeal airway
Face mask
Oxygen

 If patient is breathing
 if apneic, oxygen will not help, you need to ventilate the patient
 Open a/w and mask ventilate
Use ambu bag
 Call for equipment:
Oropharyngeal airway
Ambu bag

Assess patient
 If no air flow but chest wall is moving obstruction do head tilt, chin lift, jaw thrust
 If no air flowing and no chest wall movement apnea use ambu bag

NO ATROPINE
- HR will resolve when you deal with hypoxemia

NO REVERSAL AGENT
- Ie naloxone and flumazenil
- Since patient is critical
- May have cardiac arrest soon
- Reversal agent will not immediately solve the hypoxemia
- Do ABC
- It can be given simultaneously but it will only have a short duration.

IF ALL THE ABOVE FAILS

- Manage circulation start compressions

Management for patient may include intubating patient, admitting to ICU and monitoring patient.

ALTERNATIVE APPROACH
- Lower doses of both drugs
- Monotherapy
- Use local anaesthetic instead to do procedure ie infiltrative LA
For diabetic foot patient may have peripheral neuropathy and minimal LA needed
- Regional eg nerve block
- Titrating drugs to produce desired effects instead of bolus dosing

Other drugs for sedation

- Ketamine
 Potent analgesic
 Broad therapeutic index
 Safer to work with
 Low risk of resp complications
 Not commonly used because
 Side effects: hallucinations, delirium
 [Recreational drug]

- Propofol
 Need to have a/w management
 Only used by anaesthesiologist
 Narrow margin of safety

- Fentanyl
 Rapid acting
 Short duration
 But very potent can cause resp depression
 Cannot use unless you are trained in a/w management

Essential monitors for sedation:

- Sp02
- BP
- ECG
Need someone to observe the patient eg respiration, looking at monitor

Some places use Capnograph as one of the essential monitors but not available in Trinidad, except in ICU, OR and emergency dept.

Extra:
Sedatives are also used to reduce fractures
No airflow by mouth but chest moving -> obstruction
Upper airway or central apnoea? (know difference)
No chest wall movement -> ventilate
Reversal agents are short acting -> patient can become sedated again so it is done at a later stage
LA is the safest thing for this patient
3 persons: the one doing the procedure, the one assisting that person doing the procedure and someone monitoring the patient for
airway obstruction etc.