Conscious Sedation
Art Wallace, M.D., Ph.D.
Professor of Anesthesiology and Perioperative Medicine
Chief of Anesthesia Service SF VAMC
Art.wallace@med.va.gov
wallacea@anesthesia.ucsf.edu
awallace@cardiacengineering.com
Objectives
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Discuss classes of sedatives
Discuss conscious sedation
Go over a few cases and suggest
management plans
Disclaimer
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Discuss off label use of FDA approved
medications
Consultant for Conmed Corporation.
Consultant to Nihon Kohden
Developer of ECOM.
Developer of AVD.
Developer of AVD-R.
Developer of perioperative beta blockade
and PCRRT.
Conscious Sedation: What is it?
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Conscious
Sedated
Not Unconscious
Responsive
Breathing
Stable Hemodynamics
Cooperative
Positive Memory
Does not develop PTSD
Conscious Sedation: What it isn’t
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Unconscious
General Anesthesia
Unresponsive
Hypoxic
Unstable Hemodynamics (tachycardia)
Disinhibition
Duct Tape and Leather Straps
PTSD Inducing
Anxiety
Components of Anesthesia
Memory
Autonomics
Consciousness
Pain
Placebo Effect
Movement
Conscious Sedation: Methods
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Local Anesthesia
No pharmacologic sedative agents
Audiovisual Distraction
Pharmacology
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Nitrous: MAC = 107%
Benzodiazepines (valium, midazolam)
Narcotics (fentanyl, morphine, demerol)
Barbiturates (methohexital, thiopental, propofol)
Tranquilizers (droperidrol)
Alpha-2 agonists (dexmedetomidine, clonidine)
Autonomic blockers (propranolol, atenolol)
Conscious Sedation: Requirements
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Privileges and Training
Monitoring
Oxygen
Resuscitative Equipment
Preoperative Evaluation
NPO
Recovery
Post OP Instructions
Follow UP
Controlled substances
Abuse potential
Risk of death, hypoxia, etc.
ASA Classification
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Non-linear scale of operative risk.
Highly correlated with perioperative outcome.
ASA 1 Nothing wrong with patient
ASA 2 One medical problem (CIG, HTN)
ASA 3 Systemic disease that will limit life (CAD,
COPD, DM)
ASA 4 Systemic disease that could limit life to a
year (CHF, U/A, ICU, Multiple Intubations for
COPD, ESRD)
ASA 5 Patient will die in 24 hours regardless of
medical care.
E: Emergency
What we worry about
Plastic Surgery Deaths: Looks to Die For
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Only a month after Olivia Goldsmith died
at Manhattan Eye, Ear and Throat, there’s
been another death during a face-lift.
Inside a hospital in crisis.
Olivia Goldsmith, the best-selling author of The
First Wives Club and ten other pop-feminist
novels, checked into the Manhattan Eye, Ear and
Throat Hospital on January 7 for what has been
described as minor plastic surgery—a chin-tuck.
Conscious Sedation:
No sedative pharmacologic agents
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Smooth talking, reassurance, and comfort
(Lamaze)
Who stops breathing from talk?
Conscious Sedation:
No sedative pharmacologic agents
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Audiovisual Distraction
Conscious Sedation: Nitrous
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MAC 107%
Little effect on memory
Laughing gas
Rapid onset and offset.
Limited potency
Patents have worn off, so no drug reps to push,
no free lunch and or pens.
How many drugs come from a pipe in the wall?
Conscious Sedation: Benzodiazepines
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Diazepam (Valium®) 2-10 mg IV/IM q 3-4
hours or 2-10 mg PO TID-QID (t1/2 = 2080 hours
Midazolam (Versed ®) 1 mg IV q 2-3 min
or 5 mg IM
Lorazepam (Ativan ®) 0.5 -2 mg PO/IM/IV
q 6-8 hours
Benzodiazepines and the World Economy
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1864 Barbiturates Barbital, Phenobarbitol (Bayer)
1893’s Methamphetamines (Japan, Germany) Pervitin,
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Fliegerschokolade ("flyer's chocolate") when given to pilots,
Panzerschokolade ("tanker's chocolate") when given to tank
crews.
1963 Benzodiazepines (chlordiazepoxide (Valium,
Librium (equilibrium))) (Hoffman La Roche)
1988 Selective Serotonin Reuptake Inhibitors (Prozac)
(Eli Lilly not Swiss)
Barbituates & Alcohol
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Marilyn Monroe was found dead in the bedroom of
her Brentwood, California home by her live-in
housekeeper Eunice Murray on August 5, 1962. She
was 36 years old at the time of her death.
Her death was ruled to be "acute barbiturate
poisoning"
Benzodiazepines Permeate Medicine
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Classical benzodiazepines
bromazepam (Lexotanil or
Lexotan)
clonazepam (Klonopin)
clorazepate (Tranxene)
chlordiazepoxide (Librium)
diazepam (Valium)
flurazepam (Dalmane)
lorazepam (Ativan or Temesta)
nitrazepam (Mogadon)
oxazepam (Serax)
temazepam (Restoril)
tetrazepam (Mylostan)
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Other benzodiazepines
alprazolam (Xanax)
estazolam (ProSom)
flunitrazepam (Rohypnol)
lormetazepam (Loramet)
mexazolam (Sedoxil)
midazolam (Dormicum)
triazolam (Halcion)
Mother's Little
Helper
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Written by Mick Jagger and Keith Richards, "Mother's
Little Helper" was recorded in Los Angeles from 3 to 8
December 1965.
The song deals with the widespread use of the
prescription drug Valium, invented by Polish chemist Leo
Sternbach. From the early 60's to the early 80's it was
one of the most heavily prescribed drugs in the US and
Europe. The song sheds a light on the darker
perspective of its use among housewives, intoning:
“Kids are different today, I hear ev'ry mother say
Mother needs something today to calm her down
And though she's not really ill, there's a little yellow pill
She goes running for the shelter of a mother's little helper
And it helps her on her way, gets her through her busy day”
“Life's just much too hard today / I hear ev'ry mother say / The pursuit of happiness
just seems a bore / And if you take more of those / you will get an overdose / No
more running for the shelter / of a mother's little helper
Valium has Permeated Our Culture
Buy valium without a prescription
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Happy
mother of
adopted
baby?
Benzodiazepines are Driven By
Economics
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Number one prescription in 1960-70’s
Major income source for Switzerland
Patent expired
Now what?
Conscious Sedation:
Reversal of Benzodiazepines
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Flumazenil (Romazicon ®) 0.2 mg IV q
min prn sedation. Max dose 3.0 mg per
series or 3 mg/hr.
If you reverse you have to monitor for resedation as flumazenil wears off.
Conscious Sedation: Narcotics
Drug
Dose
Onset
Offset
Metabolism
Meperidine
(Demerol)
100 mg
15 minutes
3 hours
200 minutes
Methadone
10 mg
30 minutes
6-12 hours
300 minutes
Morphine
10 mg
20 minutes
4 hours
210 minutes
Heroine
4 mg
3 minutes
4 hours
3 minutes
Hydromorphone 2 mg
(Dilaudid)
20 minutes
4 hours
180 minutes
Alfentanyl
1 mg
90 seconds
20 minutes
90 minutes
Fentanyl
100 mcg
240 seconds
40 minutes
240 minutes
Remifentanyl
100 mcg
15 seconds
5 minutes
5 minutes
Sufentanil
10 mcg
180 seconds
30 minutes
180 minutes
Redistribution
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There are only two answers in anesthesia:
Clinical: Consider ABC Airway, Breathing,
Circulation.
Pharmacologic: Must be Redistribution
Redistribution
Drug X mg
Volume of Distribution = Y liters
Final Concentration = X mg/liter
How do I get the drug to “go away” before it is metabolized?
Redistribution
100 mg Drug
20, 10, 5, 2.5, 1.25, 0.6, 0
20%
50, 25, 12, 6, 3, 1, 0
10, 5, 2, 1, 0
10%
10%
10%
10, 5, 2, 1, 0
10, 5, 2, 1, 0
50, 25, 12, 6, 3, 1, 0
Other
Drug disappears
from circulation
long before any is
metabolized
because it is
distributed in
tissues with high
blood flow.
50%
50, 25, 12, 6, 3, 1, 0
Fat
Bone
•Distribution of blood flow depends on exercise, pregnancy, digestion, etc.
•No Blood Flow – No drug
•Circulation time = 1 minute
Conscious Sedation: Narcotics
Drug
Dose
Onset
Offset
Metabolism
Meperidine
(Demerol)
100 mg
15 minutes
3 hours
200 minutes
Methadone
10 mg
30 minutes
6-12 hours
300 minutes
Morphine
10 mg
20 minutes
4 hours
210 minutes
Heroine
4 mg
3 minutes
4 hours
3 minutes
Hydromorphone 2 mg
(Dilaudid)
20 minutes
4 hours
180 minutes
Alfentanyl
1 mg
90 seconds
20 minutes
90 minutes
Fentanyl
100 mcg
240 seconds
40 minutes
240 minutes
Remifentanyl
100 mcg
15 seconds
5 minutes
5 minutes
Sufentanil
10 mcg
180 seconds
30 minutes
180 minutes
Conscious Sedation: Narcotics Toxicity
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Death
Respiratory arrest
Respiratory depression
CO2 retention
Nausea and Vomiting
Puritis (my nose itches)
Allergy
Constipation
Addiction
Diversion
Narcotic Toxicity and Diversion
On Oct, 25, 2013: 23,818 people reported to have side effects when taking
Oxycodone. Among them, 1,053 people (4.42%) have Death.
Time on Oxycodone when people have Death * :
<1
month
Death
1-6
months
6 - 12
months
69.77% 23.26% 0.00%
1-2
years
2-5
years
5 - 10
years
10+
years
2.33%
4.65%
0.00%
0.00%
Narcotic Toxicity and Diversion
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Growth in Overdose Deaths and Treatment Admissions,
2001-2006 "According to the Centers for Disease Control
and Prevention (CDC) National Center for Health
Statistics, unintentional overdose deaths involving
prescription opioids increased 114 percent from 2001
(3,994) to 2005 (8,541), the most recent nationwide
data available. Further, the number of treatment
admissions for prescription opioids as the primary drug
of abuse increased 74 percent from 46,115 in 2002 to
80,131 in 2006, the most recent data available,
according to the SAMHSA Treatment Episode Data Set
(TEDS)
"Moreover, the estimated cost of CPD diversion and
abuse to public and private medical insurers is $72.5
billion a year.
Conscious Sedation: Narcotics Reversal
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Narcan
Vial has either 0.4 or 1.0 mg
Can be titrated in 40 mcg doses to effect.
Can be given IV or IM
Duration 40 minutes: You must monitor
for resedation.
Can cause withdrawal phenomena
Conscious Sedation: Narcotics Reversal
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Narcan 0.4- 2 mg IV or IM
Naltrexone 50 mg po qd
If you reverse, now what?
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Monitor in conscious sedation area for
longer than half life of drug.
You are NOT mandated to admit to the
ICU.
We look at the use of reversal agents.
If you need to reverse, REVERSE.
Conscious Sedation: “Barbiturates”
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Sodium thiopental
Methohexital
Propofol (10 – 200 mcg/kg/min IV)
Conscious Sedation: Propofol
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Anti-emetic
Milk of Amnesia
Coffee Creamer that is also an aphrodisiac
Burning on injection
Must be kept sterile (like intralipid)
Really an anesthetic
Wears off by redistribution or metabolism.
No reversal
Less effective in patients with alcohol exposure.
Causes respiratory depression or arrest.
Can cause hemodynamic collapse or arrest.
Not for use by amateurs.
Propofol: Lots of
people play home
anesthesiologist.
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They end up dead.
No monitors, no IV,
not NPO, no
anesthesiologist.
Sedasys
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The FDA has given premarket approval to the Sedasys®
Computer-Assisted Personalized Sedation System,
developed by Ethicon Endo-Surgery Inc.
The device has the potential to “redefine sedation
delivery”, according to Ethicon’s press release, with
propofol sedation “personalized to the needs of each
patient, by precisely integrating drug delivery and
comprehensive patient monitoring.” The Sedasys device
is designed for “healthy” adult patients who undergo
colonoscopy and esophagogastroduodenoscopy (EGD)
procedures electively.
Sedasys
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Ethicon expects to introduce the system into clinical
practice on a limited basis in 2014 to address “the
growing preference for propofol sedation in
gastroenterology by more closely matching the skill level
of the sedation delivery team with the actual
requirements of less complex cases.”
According to the FDA’s overview, the Sedasys is a “firstof-a-kind device that will allow non-anesthesia
practitioners to administer propofol during colonoscopy
and EGD procedures.” It links clinical monitors to an IV
infusion pump, and will automatically modify or stop the
infusion if it detects “signs associated with oversedation”
such as oxygen desaturation.
Sedasys
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The goal here is to make colonoscopies and EGDs
cheaper by allowing people other than qualified
anesthesia practitioners to administer propofol.
The FDA has given everyone its blessing to ignore the
propofol package insert’s warning that propofol “should
be administered only by persons trained in the
administration of general anesthesia.”
The FDA appears to think it will be enough for GI teams
to take part in a “simulation-based moderate sedation
training program” that will provide “expert instruction in
the pharmacology of propofol and airway management.”
Sedasys
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Robotic anesthesiologist.
Controls propofol infusion
based on vital signs.
Sedasys
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I like robots.
Sedasys is a robot
anesthesiologist.
In the movies, they don’t
always turn out so well.
Conscious Sedation: Droperidrol
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Tranquilizer
Anti-emetic (0.625 mg IV PRN NAUSEA)
Innovar (fentanyl 50 mcg/cc + droperidrol 2.5 mcg/cc)
Neurolept Anesthesia (Benzodiazepine + Narcotic +
Droperidrol)
Droperidol currently carries a warning about cases of
sudden death at high doses (greater than 25 mg) in
patients at risk for cardiac arrhythmias.
QT prolongation
Prolonged QT may lead to torsades de pointes
Requires ECG pre and post and ECG monitoring post
use. Do not use in patients with prolonged QT.
Conscious Sedation:
Dexmedetomidine
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Alpha-2 agonist
1500 : 1 Alpha-2 to Alpha-1 ratio.
Responsive yet cooperative
Mental duct tape
No effect on memory
Zombie
Decrease epinephrine and
norepinephrine levels
O.2 to 0.7 mcg/kg/hour
Less delirium post sedation
Conscious Sedation:
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Make sure they are really conscious
Audiovisual Distraction works.
Less can be more: Disinhibition is a problem
Many experts agree that chronic breathing is good.
Measure the blood pressure, heart rate, oxygen
saturation
Beta blockers for heart rate control.
Monitor
Pulse oximeter is a poor man’s cardiac output monitor
Oxygen has been berry, berry, good to me.
Reversal:
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narcan for narcotics
Flumazenil for benzodiazepines
Monitoring has been very, very
good to us. Closed Claims Database
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1988: 50% reduction #1 in malpractice claims for
encephalopathy with anesthesia.
1992: 50% reduction #2 in malpractice claims for
encephalopathy with anesthesia.
1988: Pulse oximeter
1992: Capnography (Exhaled Carbon Dioxide sensor)
Malpractice $
Deaths from Anesthesia
1988 1992
Time
Conscious Sedation: Cases
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IV Drug Abuser
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What drug does he use?
How much does he use?
When did he use last?
Can we switch classes of agents?
Why throw more salt in the sea?
Conscious Sedation: Cases
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Alcoholic
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Is he drunk now?
Is he going into withdrawal?
Is he going to go into withdrawal?
When did he drink last?
Can we switch classes of agents?
Conscious Sedation: Cases
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Patient with dementia
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Is he going to fight with us?
Is he going to get agitated?
How do I make it comfortable for patient who
can’t understand?
How do I make it possible for physician to
work?
How do I sedate a violent patient?
Conscious Sedation: Cases
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VA Patient A
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HTN
CAD
COPD
BPH
GERD
Hiatal Hernia
Obesity
Hypercholesterolemia
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VA Patient B
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Patient A with diabetes
Please list diseases he doesn’t have, it will save time.
Conscious Sedation: Cases
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VA Patient B
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HTN, CAD, COPD, BPH, GERD, Hiatal Hernia, Obesity,
Hypercholesterolemia
HONDA: Hypertensive, Obese, Non Compliant,
Diabetic Alcoholic.
Monitor up the Wazoo!
Beta Blockers and/or Clonidine for anti-ischemia
prophylaxis.
Local or Regional Anesthesia
Do no harm
Conscious Sedation:
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Make sure they are really conscious : Less is more.
Local, Topical, Regional Anesthesia
Audiovisual Distraction
MONITOR!
Beta blockers for heart rate control.
Pulse oximeter is a poor man’s cardiac output monitor
Oxygen has been berry, berry, good to me.
Reversal:
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narcan for narcotics
Flumazenil for benzodiazepines