Medications commonly used in Moderate Sedation

Anesthetic Agents

Classification: Ultra short-acting IV barbiturate anesthetic.

Anesthesia: IV: Induction: 50-120 mg to start; 20-40 mg every 4-7 minutes. (doses must be titrated to effect).

  • Onset: IV: Immediately
  • Duration: Single dose: 10-20 minutes
  • Supplied: 500 mg, 2.5 g, 5 gram (powder for reconstitution)
  • Initial Dose: 0.25 mg/kg

0.25-0.5 mg/kg Titrate to effect

Onset: 5-7 min

    • Peak Effect: 1-2 min
    • Duration: 2-5 min

Lidocaine 1 mg/kg reduced the incidence of hiccoughs from 16% to 6%

Classification: Sedative Hypnotic:Ultrashort-acting nonbarbiturate hypnotic.
Sedation:

  • Initial Dose: 0.25-0.5 mg/kg
  • Additional Dose: 1-4 mg titrate to effect
  • Onset of action: 30-60 seconds.
  • Peak Effect: 1-2 min (depends upon dose)
  • Duration: 3-10 minutes ( terminated by redistribution).
  • Supplied: 2 mg/ml (10 ml, 20 ml) injection.

Classification: Sedative hypnotic. Produces rapid hypnosis with minimal excitation.

Route Onset of Action Peak Effect Duration of Action
IV 40 seconds 1 minute 5-10 minutes
 25 – 50mg (0.5 – 1 mg/kg) IV, administered in 10 mg increments over several minutes.
  • Pain on injection is decreased with IV lidocaine, 0.1 mg/kg, added to the diprivan emulsion.
  • Strict aseptic technique must be maintained in handling, as diprivan is preservative free and will support bacterial growth.

Diprivan injection should be prepared for single patient use only, just prior to the initiation of each procedure. Discard after opened for 6 hours.

0.5 – 1.0mg/kg infused slowly and titrated to desired effect.

Respiratory effects – respiratory depression, apnea, hiccup, bronchospasm, laryngospasm

  • Cardiovascular effects – hypotension, arrhythmia, tachycardia, bradycardia, hypertension
  • CNS effects – headache, dizziness, euphoria, myoclonic/clonic movement, seizures, and sexual illusions.
  • GI effects – nausea, vomiting, abdominal cramps

Special considerations – this drug must be titrated to effect and administered slowly to prevent the occurrence of adverse reactions. Reduce dose in elderly, hypovolemic, and high-risk patients. Potentiation occurs when combined with narcotic analgesics and CNS depressants.

There is no pharmacologic reversal agent for Propofol.

  • Medication used especially for deep sedation in pediatric patients.
  • Not a primary use drug.
  • Administer drug only with previous experience or under the direction of a provider familiar with its use.

Mechanism of Action

Selectively interrupts cerebral pathways, causing dissociative anesthesia.

Dosage and Administration

Route Onset of Action Peak Effect Duration of Action
IV Immediate 15 – 30 Seconds 5-10 minutes
  • Usually 0.25 to 1.0 mg/kg.
  • Dose is based on patient response to medication.
  • Rate of infusion should not exceed 50 mcg/kg/min.

Adverse Reactions:

  • Respiratory effects– bradypnea, dyspnea, respiratory depression, apnea, bronchial smooth muscle relaxation, increased tracheo-bronchial tree secretions
  • Cardiovascular effects– bradycardia, tachycardia, hypertension, hypotension, arrhythmias
  • Musculoskeletal– enhanced skeletal tone
  • CNS– uncontrolled muscle movements, visual illusions
  • GI– vomiting, increased salivary secretions
  • Special considerations– monitor patient for emergent reactions including vivid dreams, or hallucinations. Consider premedication (midazolam) to reduce potential for symptoms.

Dosage and Effect:

Initial dose: Titrate to effect

Onset of action: 2-3 minutes

Peak effect: Dose dependent

Duration of effect: 15-30 minutes

Reversal Agent: None

Benzodiazepines

Classification: Benzodiazepine

Dosage / Administration:

Route Onset of Action Peak Effect Duration of Action
IV 1 – 5 Minutes 3-5 minutes 2-4 hours
Oral 15-60 minutes 60 minutes 3-6 hours

Adult Dose:

Administer in 1-2mg increments every 2 minutes IV until desired effect is achieved. (Slurred speech). Generally 10 to 20 mg in 60 minutes.

Pediatric Dose:

0.1 – 0.3 mg/kg.

Adverse Reactions:

  • Respiratory effects – Respiratory depression, apnea
  • Cardiovascular effects – Bradycardia, hypotension
  • CNS effects – Agitation, confusion, diplopia
  • GI effects – hiccups
  • Special Considerations – Phlebitis at site of injection, rash, urticaria, avoid extravasation as drug is caustic to tissue.
  • May be diluted with normal saline only. Do not mix with any other drug.
  • Midazolam is generally preferable to Diazepam due to Midazolam’s decreased duration and easier titratability.

Reversal agent:

Flumazenil (Romazicon) will reverse the respiratory effects of diazepam overdose.

Classification: Benzodiazepine.

Route Onset of Action Peak Effect Duration of Action
IV 1 minute 3-5 minutes 15min. – 6hours
IM 5-15 minutes 15-60 minutes 2-6 hours
Oral < 10 minutes 30 minutes 2-6 hours
Midazolam (Versed) is a very potent short acting drug that must be given slowly. I administration over at least two minutes is recommended.

Dilution: May dilute to desired concentration with D5W or Ns. Recommend concentration of 0.25 mg/ml, with administration rate no faster than 0.5 mg over 2 minutes.

Initial dose of 0.5mg IV over 2-minutes just before beginning of procedure. Must titrate to effect (slurred speech) by giving additional IV doses over 2 minutes. In general, do not exceed total dose of 3.0 mg, You may continue to titrate higher doses if needed to obtain effect. Wait at least 2 minutes after each administration of medication to determine effect.

Geriatric or patients with impaired pulmonary/hepatic function: Initial dose 0.25mg-0.5mg IV over 2 minutes. Maximum total dose is 2.0 mg. Titrate to effect.

0.025 – 0.05 mg/kg IV over 2 minutes. Maximum total dose 0.1 mg /kg. Titrate to effect.

Do not give midazolam to persons with known hypersensitivities to the drug.

  • Do not give to patients with acute narrow-angle glaucoma and shock.
  • Reduce dosage for patients with alcohol intoxication, or history of COPD.

Respiratory effects – Respiratory depression, apnea, coughing, bronchospasm

    • Cardiovascular effects – Cardiac arrest, hypotension, bradycardia, PVC’s, Tachycardia
    • CNS effect – Urticaria
    • GI effects – Nausea, vomiting, uticaria, hiccups
    • Special Considerations – Pain at injection site.

Reversal: Flumazenil (Romazicon) will reverse the respiratory effects of midazolam overdose.

Pediatric Sedation

Classification: Benzodiazepine.

Route Onset of Action Peak Effect Duration of Action
IV 1 minute 3-5 minutes 15min. – 6hours
IM 5-15 minutes 15-60 minutes 2-6 hours
Oral < 10 minutes 30 minutes 2-6 hours

Dosage / Administration

Midazolam (Versed) is a very potent short acting drug that must be given slowly. I administration over at least two minutes is recommended.

Dilution: May dilute to desired concentration with D5W or Ns. Recommend concentration of 0.25 mg/ml, with administration rate no faster than 0.5 mg over 2 minutes.

Pediatric:

0.025 – 0.05 mg/kg IV over 2 minutes. Maximum total dose 0.1 mg /kg. Titrate to effect.

Contraindications:

  • Do not give midazolam to persons with known hypersensitivities to the drug.
  • Do not give to patients with acute narrow-angle glaucoma and shock.
  • Reduce dosage for patients with alcohol intoxication, or history of COPD.

Adverse Reactions:

  • Respiratory effects – Respiratory depression, apnea, coughing, bronchospasm
  • Cardiovascular effects – Cardiac arrest, hypotension, bradycardia, PVC’s, Tachycardia
  • CNS effect – Urticaria
  • GI effects – Nausea, vomiting, uticaria, hiccups
  • Special Considerations – Pain at injection site.

Reversal:

Reversal: Flumazenil (Romazicon) will reverse the respiratory effects of midazolam overdose.

Drug is used primarily in pediatric patients.

Description:

A pure sedative hypnotic with no analgesic properties. It may produce a state of disinhibition with an agitated response to noxious stimuli. It is used as an adjunct for painful therapeutic procedures. Most effective in children less than 4 years of age. See table for more information.

Dosage and Route of Administration:

Oral: 25-100 mg/kg up to 1g dose (max of 2g in 2 divided doses)

Onset: 15-30 Minutes

Peak effect: 30-60 minutes

Duration: 60 minutes (residual sedation may persist for 10 or more hours in toddlers, but 20 hours or more in neonates)

Adverse reactions

  • Desaturation, respiratory depression and airway obstruction, agitation, ataxia, vomiting, cardiac arrhythmias.
  • Increased risk of direct and indirect hyperbilirubinemia and kernicterus in newborns.
  • Metabolic acidosis with repeat administration particularly in neonates.
  • Not recommended for repeat use in neonates.
  • Single use will produce prolonged sedation in preterm infants and full-term infants< 1 month of age.

Drug interactions

  • Cautious use with other sedatives or opioids – may increase the risk of respiratory complications.
  • May alter the rate of metabolism of warfarin or warfarin-related anticoagulants.

Contraindications

  • Preterm and term neonates (repeat dosing).
  • Should not be used on a chronic basis
  • Patients with significant hepatic or renal disease
  • Patients with cardiac dysrhythmias
  • Patients who have previously exhibited an idiosyncrasy or hypersensitivity to the drug
  • Oral dose contraindicated in patients with gastritis
  • Patients with Porphyria

Antagonist: None

Emergency Medications

 

 

Dosage:

Initial dose: 25-50 mg up to100mg if required

Onset of action: 2-3 minutes

Peak effect: 60-90 minutes

Duration of effect: More than 240 minutes

Reversal Agent: None

Dosage:

Initial dose: 0.4-0.6 mg

Additional doses: 0.4-0.6 mg

Onset of action: 45-60 seconds

Peak effect: 2 minutes

Duration of effect: 1-2 hours

Reversal Agent: None

Dose: 0.25-0.5 mg

Onset of action: 1 minute

Duration of effect: 9-17 minutes -OR- Dose: 2 mg*

Onset of action: 1 minute

Duration of action: 22-25 minutes *Use of 2mg dose produces a higher incidence of nausea and vomiting than do lower doses.

Reversal Agent: None

 

 

Analgesic – Antitussive

Action and Clinical Pharmacology:

Hydromorphone has a strong analgesic action and antitussive activity. Small doses of Hydromorphone produce effective and prompt relief of pain usually with minimal nausea and vomiting. Generally, when given parenterally, hydromorphone’s analgesic action is apparent within 15 minutes and remains in effect for more than 5 hours. The onset of action of oral Hydromorphone is somewhat slower, with measurable analgesia occurring within 30 minutes. When sleep follows the administration of Hydromorphone, it is due to relief of pain, not to hypnosis. Hydromorphone is approximately 8 times more potent on a milligram basis than morphine. In addition, hydromorphone is better absorbed orally than is morphine; the former is approximately 20 to 25% as active orally as i.m. Hydromorphone has greater antitussive potency than codeine on a weight basis; however, its dependence liability is also greater than that of codeine. After absorption hydromorphone is metabolized by the liver to the glucuronide conjugate which is then excreted in the urine.

Indications And Clinical Uses:

Relief of moderate to severe pain.

Contra-Indications:

Intracranial lesion associated with increased intracranial pressure, status asthmaticus, and pulmonary edema.

Precautions:

May be habit-forming. Hydromorphone is a narcotic with an addiction liability similar to that of morphine and for this reason the same precautions should be taken in administering the drug as with morphine. Pregnancy: As with all narcotics, hydromorphone should be used in early pregnancy only when expected benefits outweigh risks. If necessary, hydromorphone may be given i.v. but the injection should be given very slowly. Rapid i.v. injection of narcotic analgesic agents, including hydromorphone, increases the possibility of adverse effects, such as hypotension and respiratory depression. As with any narcotic analgesic agent, the usual precautions should be observed and the possibility of respiratory depression should be kept in mind. If a patient shows signs of hypersensitivity to hydromorphone the treatment must be stopped. Dilaudid injection has been reported to be physically or chemically incompatible with solutions containing sodium bicarbonate and thiopental sodium. Children: Hydromorphone suppositories are not recommended for use in children.

Adverse Reactions:

Nausea, vomiting, dizziness, somnolence, anorexia and constipation may occur. Pain at injection site; local tissue irritation and induration following s.c. injection, particularly when repeated in the same area.

Symptoms and Treatment of Overdose:

Symptoms: Serious overdose with hydromorphone may be characterized by respiratory depression (a decrease in respiratory rate and/or tidal volume, Cheyne-Stokes respiration, cyanosis), extreme somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, and sometimes bradycardia and hypotension. In severe overdosage, apnea, circulatory collapse, cardiac arrest and death may occur. Treatment: If significant respiratory depression occurs, it may be antagonized by naloxone as recommended by the manufacturer. Employ other supportive measures as indicated.

Dosage:

Orally for adults, 2 to 4 mg every 4 to 6 hours as required. The usual adult parenteral dose for pain relief is 2 mg by s.c. or i.m. routes every 4 to 6 hours as necessary, If necessary, hydromorphone may be given i.v., but the injection should be given very slowly. Severe pain can be controlled with 3 to 4 mg every 4 to 6 hours as necessary. Rectal suppositories (3 mg) provide long-lasting relief and are especially useful at night. The oral liquid may be diluted in fruit juice or other beverage, if desired. I.V.: Initial: Opiate-naive: 0.2-0.6 mg every 2-3 hours as needed; patients with prior opiate exposure may tolerate higher initial doses. Dilute 2mg one ml ampoule into 9cc’s of saline which is 0.2mg per ml. Note: More frequent dosing may be needed.

 

Binds with opiate receptors in the CNS, altering perception of and emotional response to pain.

Route Onset of Action Peak Effect Duration of Action
IV 1 minute 5-20 minutes 2-4 hours
IM 1 – 5 minutes 30-50 minutes 2-4 hours
Oral 15-45 minutes 60 minutes 2-4 hours

Adult: 25 mg slow IVP. Slowly titrate in 25 mg increments to individual patient response. Total dose for nursing administration, 100 mg in 60 minutes. Reduce dosage and rate of administration in patients who are elderly, debilitated, having renal or hepatic disease, or who have hypothyroidism. Contraindicated in patients on MAO inhibitors. Severe and even fatal reactions have been known to occur.

Pediatric: 1 – 1.5 mg/kg. Titrate dose to individual response. Max. dose 100mg.

Respiratory effects – severe respiratory depression and arrest. Use with caution in patients with COPD, asthma, corpulmonale, decreased respiratory function, hypoxia or hypercapnia. Cardiovascular effects – orthostatic hypotension, bradycardia, tachycardia, palpitations, syncope, shock, cardiac arrest.

CNS effects – euphoria, dysphoria, weakness, sedation, convulsions, agitation, tremors, uncoordinated muscle movements, transient hallucinations, disorientation, visual disturbances. GI – dry mouth, constipation, biliary spasm, nausea and vomiting.

Integumentary – flushing, pruritis/local tissue irritation (histamine release), uticaria, skin wheals, local irritation

GU – urinary retention

Special considerations – this drug must be titrated to effect and administered slowly to prevent the occurrence of adverse reactions.

Reversal: Naloxone (Narcan) will reverse the respiratory and cardiovascular effects of Demerol overdose.

 

Binds with opiate receptors in CNS, altering perception of and emotional response to pain.

Route Onset of Action Peak Effect Duration of Action
IV 5-15 minutes30-60 minutes
IM 5-8 minutes 15-20 minutes 1-2 hours
Transmucosal 5-15 minutes 20 – 30 minutes 1-2 hours

Dosage/Administration

Adults: 25-100mcg slow IV injection into IV infusion line over 1-2 minutes is required. Titrate 25 mcg at a time. Total recommended dose for nursing administration, 200 mcg for healthy young adult. Reduce dosage and rate of administration in patients who are elderly, debilitated or have renal or hepatic disease.

Pediatric: 0.5 – 2 mcg/kg. Titrate to individual response.

Adverse Reactions

Respiratory effects – potent respiratory depression, apnea. Use with caution with patients with COPD or other respiratory compromise.

Cardiovascular effects – hypotension, bradycardia, tachycardia, palpitations, syncope, shock, cardiac arrest.

CNS effects – euphoria, dysphoria, weakness, sedation, agitation, tremors, seizures, use with caution with patients with increased intracranial pressure.

GI effects – nausea, vomiting, delayed gastric emptying, biliary tract spasm.

Musculoskeletal – may cause muscular rigidity of the thorax to the point that ventilation (spontaneous or controlled) is impossible. Muscle relaxant can be used for treatment, but is only to be given by anesthesia; therefore, treat with Narcan.

Special considerations – this drug must be titrated to effect and administered slowly to prevent the occurrence of adverse reactions. DO NOT mix with barbiturates.

Reversal Agent: Naloxone (Narcan) will reverse the respiratory and cardiovascular effects of Fentanyl overdose. Reversal brought on too rapidly may cause nausea, sweating, and hypertension.

 

Binds opiate receptors in CNS, altering perception of and emotional response to pain.

Route Onset of Action Peak Effect Duration of Action
IV 5-20 minutes4-7 hours
IM 5-10 minutes 30-60 minutes 4-7 hours
Oral Within 1 hour 1-2 hours 6-12 hours

Dosage/Administration

Adults:

  • Give 2 – 10 mg IV.
  • Must give slowly and titrate to individual response.
  • Assess patient continuously for signs and symptoms of pain and give additional doses for increasing pain levels.
  • Decrease dosage if giving to elderly or debilitated patients and in patients with renal or hepatic disease.
  • Dilute with 5 ml of sterile water or NS and give slowly.
  • May repeat every 15 minutes.
  • Total dosage 10 mg in 60 minutes.

Pediatrics: 0.05 – 0.1 mg/kg IV, titrated to effect.

Adverse Reactions

  • Respiratory effects – respiratory depression, bronchospasm, laryngospasm.
  • Cardiovascular effects – hypotension, hypertension, bradycardia, arrhythmias
  • CNS effects – euphoria, dysphoria, somnolence, syncope
  • GI effects – nausea, vomiting, constipation, biliary tract spasm
  • GU – urinary retention
  • Integumentary – pruritis/local tissue irritation, urticaria, skin wheals
  • Musculoskeletal – chest wall rigidity

Reversal Agent: Naloxone (Narcan) will reverse the respiratory and cardiovascular effects of MS overdose.

 

Other Sedation Medications

 

Dosage:

One time dose: 12.5- 50 mg

Onset of action: 2-5 minutes

Peak effect: Unknown

Duration of effect: More than 120 minutes

Reversal Agent: None

 

 

Dosage:

Initial dose: 1.25-2.5 mg via IM or slow IV

Additional doses: Additional 1.25 mg doses may be administered to achieve the desired effect

Onset of action: 3-10 minutes

Peak effect: 30 minutes

Duration of effect: 120-240 minutes

Reversal Agent: None

 

Reversal Agents

 

(Specific Benzodiazepine antagonist)
Classification: Reversal Agent

Dosage / Administration:

 

Route Onset of Action Peak Effect Duration of Action
IV (bolus or infusion) 1-2 minutes 6-10 minutes (but 80% of the maximum response is seen within 3 minutes.)Call anesthesia if there is no desired clinical response with the administration of the initial 1 mg. 45-90 minutes

 

Adverse Reactions:

  • Nausea, vomiting, sweating, hot flashes, agitation, headache, injection site pain
  • Do not use Flumazenil in patients who chronically take Benzodiazepines

May precipitate:

  • Tremors
  • Profuse sweating
  • Hypotension
  • Seizure activity

Reversal agent: None

 

Reversal Agent for Narcotics

Classification: Reversal Agent

Description:

  • A pure opioid antagonist with no agonist activity.
  • It reverses respiratory depression, hypotension, hypercapnia, sedation, and euphoria associated with the administration of narcotics.

Dosage / Administration:

 

Route Onset of Action Peak Effect Duration of Action
IV 1-2 minutes 5-15 minutes 1 – 4 hours

Dosage/Administration

NARCAN injection is available as a sterile solution for intravenous, intramuscular and subcutaneous administration in three concentrations:

  1. 02 mg of naloxone hydrochloride per ml
  2. 4 mg of naloxone hydrochloride per ml
  3. 1 mg of naloxone hydrochloride per ml

pH is adjusted to 3.5 ± 0.5 with hydrochloric acid.

Adult:

Initial dose:  0.04 mg – 2 mg titrated in small increments. Dilute 0.4 mg amp of Narcan  to 10cc total volume.  This will be 0.04 mg or 40 mcg per cc. Give this reversal 1cc at a time, with at least 2-3 minutes between doses.  This titration will allow one to bring the patient up to a safe respiratory rate without reversing analgesia or causing severe CV problems.  If no response is observed after 2 mg has been administered, the diagnosis of narcotic induced toxicity should be questioned.  Total dosage for nursing administration – 2 mg.

Pediatric:

Initial dose: 0.01 mg. If initial dose does not result in desired clinical reversal, administer a subsequent dose of 0.01 mg. If this does not result in desired effect, administer 0.1mg/kg. Total dosage for nursing administration in pediatric patients is: 0.2 mg/kg.

Adverse Reactions:

Respiratory effects – pulmonary edema

  • Cardiovascular effects– hypotension, hypertension, arrythmias, ventricular tachycardia, ventricular fibrillation
  • CNS effects – excitement, tremors, seizures, reversal of analgesia.
  • GI– nausea, vomiting

Special considerations

Titrate slowly to desired effect. Complete reversal from higher doses will result in total reversal of analgesia with other effects including hypertension, excitation, tachycardia.  Monitor the patient closely in the post-procedure period for re-sedation. Additional doses of Naloxone may be required.

Reversal agent: None

 

© 2017 Sedation Certification. All rights reserved.

Click Me
There are no products