Sedation and Analgesia for Diagnostic and Therapeutic Procedures Edited by Shobha Malviya, MD Norah N. Naughton, MD Kevin K. Tremper, MD , P h D HUMANA PRESS HUMANA PRESS Humana Press Totowa, New Jersey SEDATION AND ANALGESIA FOR DIAGNOSTIC AND THERAPEUTIC PROCEDURES Edited by SHOBHA MALVIYA, MD, N ORAH N. NAUGHTON, MD, and KEVIN K. TREMPER, MD, PhD Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI Contemporary Clinical Neuroscience © 2003 Humana Press Inc. 999 Riverview Drive, Suite 208 Totowa, New Jersey 07512 humanapress.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. All authored papers, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher. 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The fee code for users of the Trans- actional Reporting Service is: [0-89603-863-7/03 $20.00]. Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1 Library of Congress Cataloging-in-Publication Data Sedation and analgesia for diagnostic and therapeutic procedures / [edited by] Shobha Malviya, Norah N. Naughton and Kevin K. Tremper. p. ; cm (Contemporary clinical neuroscience) Includes bibliographical references and index. ISBN 0-89603-863-7 (alk. paper) E-ISBN 1-59259-295-3 1. Anesthesia. 2. Analgesia. I. Malviya, Shobha. II. Naughton, Norah N. III. Tremper, Kevin K. IV. Series. [DNLM: 1. Anesthesia. 2. Analgesia. 3. Diagnostic Techniques and Procedures. WO 200 S4466 2003] RD81 .S39 2003 617.9'6 dc21 2002032817 Disclaimer: Some images in the original version of this book are not available for inclusion in the eBook. DEDICATION In memory of my parents Mr. Laxmi Narain Goel and Mrs. Janak Dulari Goel who gave me the privilege of learning. To my husband Vinay, and our children Samir and Sanjana with whom I continue to learn. Shobha Malviya, MD To Bridget, Julie, Michael, and Pat: your presence makes my dreams possible. Norah N. Naughton, MD v vii PREFACE Pharmacologically induced sedation has become pervasive throughout medical practice to accomplish diagnostic and minor therapeutic procedures effectively and humanely. As diagnostic techniques and technical proce- dures become more complex, the need for sedation in patients with varied co-morbid conditions, in diverse settings produces a series of questions regarding safety and effectiveness. The administration of sedation and anal- gesia for diagnostic and therapeutic procedures has therefore evolved into a unique discipline that is practiced by clinicians with varying skills and train- ing. Disparities in sedation practices have led regulatory agencies to man- date that patients receive the same standard of care regardless of the location in which the care is provided within an institution. To ensure that the stan- dard of care is of high quality, institutions are required to develop guidelines for the practice of sedation, ensure that these guidelines are followed, and provide quality data and outcome measures. In addition, practitioners who administer sedatives and analgesics specifically for a diagnostic and/or a therapeutic procedure require specific credentials for this practice. It is the intent of Sedation and Analgesia for Diagnostic and Therapeutic Procedures to review sedation and analgesia from a wide variety of per- spectives starting with the basic neurobiology and physiology of the sedated state, proceeding through clinical guidelines and practices, and concluding with a section on quality-outcome measures and processes. The practical aspects of this book have been further emphasized by incorporating a series of tables and figures in each chapter that highlight protocols, regulatory requirements, recommended dosages of pharmacologic agents, monitoring requirements, and quality assurance tools. The target audience for this text spans multiple disciplines that range from investigators, physicians, and nurses to hospital administrators. The editors are indebted to all the authors for contributing their knowledge, time, and effort. Special thanks are due to Dr. Ralph Lydic who conceived this project and to Ms. Terri Voepel-Lewis, MSN, RN for her invaluable assis- tance throughout the development of this text. Finally, we thank Mrs. Colleen Rauch and Mrs. Melissa Bowles for their administrative assistance. Shobha Malviya, MD Norah Naughton, MD Kevin K. Tremper, MD, PhD ix CONTENTS Dedication v Preface vii Contributors xi 1 Opioids, Sedation, and Sleep: Different States, Similar Traits, and the Search for Common Mechanisms 1 Ralph Lydic, Helen A. Baghdoyan, and Jacinta McGinley 2 Practice Guidelines for Pediatric Sedation 33 David M. Polaner 3 Practice Guidelines for Adult Sedation and Analgesia 53 Randolph Steadman and Steve Yun 4 Procedure and Site-Specific Considerations for Pediatric Sedation 77 Shobha Malviya 5 Adult Sedation by Site and Procedure 105 Norah N. Naughton 6 Pharmacology of Sedative Agents 125 Joseph D. Tobias 7 Opioids in the Management of Acute Pediatric Pain 153 Myron Yaster, Lynne G. Maxwell, and Sabine Kost-Byerly 8 Patient Monitoring During Sedation 191 Kevin K. Tremper 9 Assessment of Sedation Depth 219 Lia H. Lowrie and Jeffrey L. Blumer 10 Nursing Perspectives on the Care of Sedated Patients 243 Terri Voepel-Lewis 11 Recovery and Transport of Sedated Patients 263 Loree A. Collett, Sheila A. Trouten, and Terri Voepel-Lewis 12 Quality Assurance and Continuous Quality Improvement in Sedation Analgesia 275 J. Elizabeth Othman Index 297 [...]... descriptive data that now characterize sedation From: Contemporary Clinical Neuroscience: Sedation and Analgesia for Diagnostic and Therapeutic Procedures Edited by: S Malviya, N N Naughton, and K K Tremper © Humana Press Inc., Totowa, NJ 1 2 Lydic, Baghdoyan, and McGinley During sedation, the effects of pharmacological agents are superimposed on a patient’s emotional state and level of arousal A patient’s... sleep and sedation can be bizarre and hallucinoid For each of the foregoing examples, however, there are qualitative differences between the traits characterizing states of sleep and states of sedation The remainder of this chapter highlights data consistent with the working hypothesis that the similarities between sedation and natural sleep are mediated by common neurobiological mechanisms 3 SEDATION AND. .. concerning the cellular and molecular mechanisms that cause sedation Improved anesthetic drugs are a key factor contributing to enhanced anesthetic safety (166) Therefore, basic and clinical sedation research are essential for continued advances in patient safety and comfort Opioids, Sedation, and Sleep 21 ACKNOWLEDGEMENT Supported by NIH grants HL57120, MH45361, HL40881, HL65272, and the Department of... relationships for midazolam for EEG-derived parameters and saccadic peak velocity Br J Clin Pharmacol 36, 109–115 13 Roelofse, J A., Louw, L R., and Roelofse, P G (1998) A double blind randomized comparison of oral trimeprazine-methadone and ketaminemidazolam for sedation of pediatric dental patients for oral surgical procedures Anesth Prog 45, 3–11 14 Ramsay MAE, Savege, T M., Simpson, B R J., and Goodwin,... Anesthesiology/Critical Care Medicine and Pediatrics, The Johns Hopkins Hospital, Baltimore, MD STEVE YUN, MD • UCLA School of Medicine, Center for Health Sciences, Los Angeles, CA Opioids, Sedation, and Sleep 1 1 Opioids, Sedation, and Sleep Different States, Similar Traits, and the Search for Common Mechanisms Ralph Lydic, PhD, Helen A Baghdoyan, PhD, and Jacinta McGinley, MB, FFARCSI 1 INTRODUCTION Sedation is an area... defining “procedural sedation (16), “monitored anesthesia care” (17), “conscious versus deep sedation (18), and sedation/ analgesia (2)? Practice guidelines recommend monitoring the level of consciousness during sedation (2,19) Therefore, a clear understanding of the similarities and differences between sedation and natural sleep are directly relevant to any objective assessment of arousal level Aldrich... directly relevant for sedation analgesia Opioids administered to intensive care unit (ICU) patients have been shown to contribute to the sleep deprivation and delirium that characterize ICU syndrome (30) Despite these differences between sleep and sedation, the two states share remarkable similarities For example, NREM sleep is characterized by slow Opioids, Sedation, and Sleep 5 eye movements and REM sleep... sedation and analgesia in the emergency department Ann Emerg Med 31, 663–677 17 Novak, C I (1998) ASA updates its position on monitored anesthesia care Am Soc Anes News 62, 22–23 18 Coté, C J (1994) Sedation for the pediatric patient Paediatr Anaesth 41, 31–53 19 Holzman, R S., Cullen, D J., Eichhorn, J H., and Philips, J H (1994) Guidelines for sedation by nonanesthesiologists during diagnostic and therapeutic. .. Lapham, A English, and M A Norat REFERENCES 1 Lydic, R and Baghdoyan, H A (eds) (1999) Handbook of Behavioral State Control: Cellular and Molecular Mechanisms, CRC Press, Boca Raton, FL 2 Gross, J B., Bailey, P L., Caplan, R A., Connis, R T., Coté, C J., Davis, F G., et al (1996) Practice guidelines for sedation and analgesia by nonanesthesiologists Anesthesiology 84, 459–471 3 Lydic, R and Biebuyck, J... predictor for the conscious processing of information during propofol sedation and hypnosis (59) In a study of 72 healthy volunteers, the developers of BIS measured: i) blood concentrations of propofol, midazolam, and alfentanil, and end tidal concentrations of isoflurane; ii) sedation level, and iii) recall (60) None of the subjects in this study who received alfentanil lost 8 Lydic, Baghdoyan, and McGinley . practice. It is the intent of Sedation and Analgesia for Diagnostic and Therapeutic Procedures to review sedation and analgesia from a wide variety of per- spectives. Angeles, CA Opioids, Sedation, and Sleep 1 1 From: Contemporary Clinical Neuroscience: Sedation and Analgesia for Diagnostic and Therapeutic Procedures Edited