Procedural
sedation
PATIENT
CONTROLLED
ANALGESIA(PCA)
Dr.Muntadher
Alwaali( Anesthesiologist and
Intensivist , FICMS)
INDRODUCTION
Given the continued increase in the
complexity of invasive and non invasive
procedures , healthcare practitioners are
faced with a large number of patients
.requiring procedural sedation
Effective sedation and analgesia during
procedures not only provides humanitarian
relief of suffering , but also frequently
facilitates successful and timely completion
of the procedure , nursing management ,
blunting autonomic and hemodynamic
…response
INDRODUCTION
The American College of Emergency
Physicians(ACEP) defines procedural
sedation as (( a technique of administering
sedatives or dissociative agents with or without
analgesics to induce a state that allows the
patient to tolerate unpleasant procedures while
.maintaining cardiorespiratory function
Procedural sedation and analgesia(PSA) is
intended to result in a depressed level of
consciousness that allows the patient to
maintain oxygenation and airway control
.independently
?…HOW TO EVALUATE SEDATION & ANALGESIA
Sedation Scales , is it beneficial to
? use them
Provide a semi quantitative “score” and-
standardize treatment endpoints , help to
.avoid over sedation and under sedation
Allow review of efficacy of sedation-
.Facilitate sedation studies-
The ASA has defined four levels
of sedation : Anxiolysis, mild
sedation, moderate sedation
level 4 corresponds to general
THE RICHMOND What is
AGITATION–SEDATION our
SCALE(RAAS)
?…WHAT ABOUT PAIN
Signs of Pain: Hypertension,
,Tachycardia
Lacrimation , Sweating, Pupillary
dilation
VISUAL
ANALO
G
SCALE(
VAS)
IS THERE ANY COMPONENTS TO
?.…COVER
Pain •Anxiety •Delirium/agitation •
AGITATION : BEFORE GOING TO TREAT
Causes of The Correctable
Agitation not to Causes of
Nursing :Full •
:Agitation
:be Overlooked
Hypoxia , • bladder ,
Uncomfortable bed
Hypercarbia,
position , Noise ,
Hypoglycemia Inability to
Pneumothorax communicate
Myocardial • Intensivist : •
ischemia Ventilator problems ,
Abdominal pain • ETT problems
Drug and alcohol • Patient : Mental •
EUROPEAN SOCIETY OF ANAESTHESIOLOGY
AND EUROPEAN BOARD OF
ANAESTHESIOLOGY GUIDELINES FOR
PROCEDURAL SEDATION AND ANALGESIA IN
ADULTS
Hinkelbein, Jochen; Lamperti, Massimo; Akeson, Jonas;
Santos, Joao; Costa, Joao; De Robertis, Edoardo; Longrois,
Dan; Novak-Jankovic, Vesna; Petrini, Flavia; Struys, Michel
M.R.F.; Veyckemans, Francis; Fuchs-Buder, Thomas*;
†Fitzgerald, Robert
Patient
comorbidit
ies
GUIDELIN
ES
)ESAI(
Skills
Requireme
nts
personne
l
WHAT TYPE OF COMORBIDITIES AND
PATIENTS REQUIRE EVALUATION AND
MANAGEMENT OF PSA BY AN
?ANAESTHESIOLOGIST
a. Severe cardiovascular diseases
b. Documented/risk of Obstructive
Sleep Apnoea (OSA)
c. Morbid obesity
d. Chronic renal failure
e. Chronic hepatic disease
f. Elderly patients((older than 70 years)
g. American Society of
Anesthesiologists’ (ASA) physical status
3 or 4 patients
WHAT ARE THE REQUIREMENTS TO PROVIDE
WELL TOLERATED AND SAFE PROCEDURAL
?SEDATION AND ANALGESIA
Adequate upper airways evaluation
Adequate monitoring and
anesthesia environment (standard
monitoring , anesthesia machine ,
O2 source …)
Immediate access to equipment for
.resuscitation
A difficult airway equipment should
be readily available wherever PSA is
.performed
MINIMAL SKILLS FOR TRAINING FOR NON-
ANAESTHESIA PROVIDERS DEDICATED TO
PROCEDURAL SEDATION AND ANALGESIA
All personnel in charge of the
procedural sedation and analgesia
should be certified for
cardiopulmonary resuscitation and
.monitoring of the patient
Minimal requirements are competence at
intravenous cannulation; advanced airway
management; diagnosis and management
of respiratory and haemodynamic
depression
CHARACTERISTICS OF AN IDEAL
: SEDATION AGENTS
Analgesia •
Anxiolysis and Sedation with •
ease of orientation and
arousability
Hemodynamic stability and lack •
of respiratory depression
Rapid onset, titratable, with a •
.short elimination half-time
: PHARMACOLOGICAL OPTIONS
Short acting benzodiazepine ( eg : --
midazolam) : produces hypnosis( in high
doses) , sedation , anxiolysis and anterograde
.amnesia
Opioid analgesic ( eg : fentanyl , morphine , --
.… )
Morphine is a potent analgesic agent and --
may cause drowisness , anxiolysis , and
.euphoria , lasts 3-4 hours
Fentanyl is a 50-80 times more potent an --
analgesic than morphine and has little hypnotic
or sedative activity , a small IV dose has
.duration of action 30-60 minutes
: PHARMACOLOGICAL OPTIONS
Combination ? ………(synergistic effect) --
Propofol : hypnotic , either in boluses or --
IVI
Ketamine result in dissociative state , it is --
good analgesic , cause mild respiratory
stimulation and relatively preserves airway
reflexes but it does have frequent association
with emergence delirium, increase secretion,
..sympathetic stimulation
Dexmedetomidine(an alpha 2 agonist) is--
another recent addition that provide sedation ,
analgesia and anxiolysis without causing
.respiratory depression
PATIENT CONTROLLED
: ANALGESIA(PCA)
First developed as a research
.tool
First pump ,Cardiff Palliator
.was introduced in UK in 1976
In the late 1980 ,
improvement in syringe pump
technology allowed PCA to
become available in general
This
.use
device allows self-
administration of analgesia. The
patient is able to administer a
pre- determined dose of
: OPIOID ANALGESICS
PCA opioids produces modest improvements in
pain relief compared to the same opioids given
.conventionally
The most commonly used opioids is morphine ,
.fentanyl , pethidine
.Dexmedetomidine and ketamine also can be used
The inherent safety of PCA lies in the fact that
.excessive doses of opioids will not be delivered
Patients titrates their plasma opioids
concentration to remain in the analgesic
window(above the minimum analgesic
concentration and below the minimum toxic
.concentration)
: ADVANTAGES
The advantages of this method of
:analgesia are
Gives the patient autonomy over their pain •
.control
.Minimizes delays in analgesia administration •
Reduces nursing time involved in analgesia •
.administration
Minimizes the side effects of the opioids •
which are related to higher drug
.concentrations
Patients report more satisfaction than those •
.having conventional analgesia
PATIENT SELECTION
:Patients SHOULD be considered for PCA
For treatment of severe acute pain ( after major surgery , during •
.conscious sedation)
If they are unable to absorb oral analgesia •
If they need frequent subcutaneous injections to control acute pain •
(e.g. 3 injections within 6 hours)
If they are mentally alert and understand how to use the PCA pump •
In the following patients CAUTION should be exercised before
prescribing PCA
Patients with renal impairment •
Patients with hepatic impairment •
Patients with head injury •
The following patients are NOT SUITABLE for PCA
Patients in medical wards •
Physically unable to use PCA handset •
For the management of chronic pain •
Confused •
THE PCA
PRESCRIPTION/PREPARATION
Titrate IV analgesia until patient comfortable prior to •
.commencing PCA (loading dose)
Patient Bolus Dose •
Lockout interval. This is a predetermined period •
during which the patient cannot initiate
doses and plays a key part in increasing the safety of
PCA
Continuous (background) infusion this should ** •
only be used after consultation with the anaesthetist
or the acute pain team. The addition of a continuous
infusion may increase the risk of side effects and
reduce the safety of the PCA technique. If a
continuous infusion is being used, the patient must be
.nursed in critical care
PCA REGIMES
Drug and dose PCA variable
Morphine 0.05-0.1 mg/kg Loading dose
Fentanyl 1-50 mic./kg
Pethidine 25-100 mg or
1-2mg/kg
Tramadol 50-100 mg or 1-2
mg/kg
Morphine 1mg Bolus dose
.Fentanyl 20 mic
Pethidine 10mg
Tramadol 10mg
Varies , depending on pump Concentration
used and hospital protocols
.min 5-15 Lockout interval
Morphine 0.01-0.04 mg/kg/h Background infusion
Fentanyl 0.2-2 mic/kg/h ( < 50
mic/h)
In elderly
Pethidine 15/25patients
mg/h these doses may*
REQUIREMENTS FOR THE SAFE MANAGEMENT OF
PCA
Trained medical staff •
All areas must have Naloxone immediately •
available
All patients should receive supplementary •
.oxygen for the duration of the infusion
Anti-emetics must be prescribed, consider •
laxatives (after discussion with medical staff)
Blood products or antibiotics should not be •
administered through the same line
If the patient requires IV fluids they should be •
administered through the anti-reflux valve on
the administration set. IV fluids are not
required to maintain the patency of the cannula
Be cautious with the administration of drugs •
TROUBLESHOOTING PCA
Management Problem
Administer anti-emetics routinely and/or prn , change Nausea/vomiting
to alternative opioid , consider other possible
causes(ex : ileus)
.Assess sedation score and res. Sys Sedation/
Consider device malfunction(failure of antireflux respiratory
valve) depression
Oxygen therapy
Consider reducing the dose or stop PCA
Consider giving naloxone ( 100-400 mic. repeated
doses)
Mild , tolerable ? Consider the dose Pruritus
Sever ? Ondansetron , alternative opioid ,
antihistamine ( be careful of oversedation)
Consider other causes e.g. hypoxia, sepsis, alcohol or Confusion
benzodiazepine
withdrawal
PCA may need to be discontinued due to patient
TROUBLESHOOTING PCA
Consider reducing the dose or stop Hypotension
PCA
Look for other causes of hypotension,
e.g. hypovolaemia, cardiac
Complications
Check line connections and device Inadequate analgesia/breakthrough
malfunction pain
Consider other causes for new or
increasing pain e.g. development of a
Complication
Consider adding other type of
analgesic or changing opioid
Catheterize Urinary retention
Discourage use of PCA for discomfort Decreased bowel
.from resumption of peristalsis motility/colicky pain
If treatment is needed consider
peppermint water/capsules
If pain becomes severe request
.surgical review
