Action
Consider pre-procedural adjuncts
- Ondansetron (Class III)
- Midazolam IV with ketamine (Class III)
- If opioids given 30-90 min before, need to delay PSA (Class III)
- Anticholinergics prior to ketamine PSA not indicated
Agent | Starting Dosage, Adult and Pediatric Patients | Onset
(min) | Duration
(min) | Advantages | Disadvantages |
Fentanvl | 1 mcg/kg IV | 1-2 | 30-40 | -Rapid onset
-Short duration
-Minimal CV effects | -Chest wall rigidity (when given rapidly in large doses)
-Analgesic properties only |
Remifentanil | 0.05-0.1 mca/ka/ min IV infusion with supplemental 0.5-1 mcg/kg IV boluses | <1-3 | 3-10 | -Short duration
-Can be titrated | -Respiratory depression
-Analgesic properties only |
Midazolam | 0.05-0.1 mg/kg IV | 1-5 | 60-120 | -Rapid onset
-Short duration
-Multiple routes | -Respiratory depression
-Moderate duration
-Sedative properties only |
Nitrous oxide | 30%-70% concentration | 1-2 | 3-5 | -Rapid onset
-Minimal CV effects | -Emesis
-Expansion of gas-filled structures |
Propofol | 0.5-1 mg/kg IV | <1 | 3-10 | -Rapid onset
-Antiemetic
-Short duration | -Hypotension
Respiratory depression
-Injection pain
-Sedative properties only |
Ketamine | 1-1.5 mg/kg IV
4-5 mg/kg IM
6-9 mg/kg IN (adults onlv) | ~1 (IV)
~5 (IM) | 10-15 (IV)
15-30 (IM) | -Preserved airway reflexes
-Predictable
-Provides analgesia and sedation | -Emergence phenomena
-Emesis
-Laryngospasm
-Hypertension, tachycardia
Increased secretions |
Ketamine-
propofol
(ketofol)
(adult patients oniv) | 1.1 admixture dosing
0.5 mg/kg ketamine IV and 0.5 mg/kg propofol IV, administered simultaneously IV | 1-3 | 10-15 | -Airway preservation
-Hemodynamic stability
-Rapid recovery
-Use together offsets hemodynamic
effects of each individual agent
-Provides analgesia and sedation | Same as for each individual
drug |
Etomidate | 0.15 mg/kg IV | <1 | 5-10 | -Rapid onset
-Minimal CV effects | -Respiratory depression
-Myoclonus
-Sedative properties only |
Decision
Are there any complications of the procedure?
Yes
- Provide airway support (bag-valve mask, OPA, NPA, supplemental oxygen, LMA reposition, etc)
- Provide hemodynamic support (IV fluids)
- Use reversal agents, if necessary
- If no improvement
- Admit to hospital
- Intubate if necessary
No
Discharge home if:
- Baseline mental status
- Ambulatory
- Sedation discharge instructions given
- Ride home available
- Tolerating PO intake (Class III)
Algorithm for Airway Rescue