Your favorite conscious sedation...

i would argue that an unresponsive patient hardly fits into the realm of "conscious sedation".... i have a lot of issues with etomidate being used for conscious sedation, it has all the same inherent issues that diprivan/propofol has.

could you elaborate on your "issues" about using etomidate for concious sedation. I've seen both etomidate and propofol used frequently and without problems.


thanks

My favorite med for "Moderate Sedation" is Ketamine... fast, safe, used worldwide without difficultly. I generally reserve it for the younger patients- mostly b/c of concerns re: emergence.

My next fav is Propofol... fast, safe. Easy to titrate.

I haven't tried Etomidate for sedation- starting to use it for induction.

I generally avoid the opiate, BZD combo because patients take WAY too long to wake up, and we end up watching them for hours.

QuinnNSU said:

The nurse looked at me and said "I gave him the Etomidate." UGH!

Anyways, lesson learned (and my attending told me to do this from now on, as its his policy) is to draw up your Etomidate and push it yourself.

Q, DO

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Oh my. That needs to go into the stupid nurse file. Seriously though, you gotta get off the versed/MSO4 thing and get into ketamine and propofol. They're miracle drugs. I hardly use anything else for procedural sedation.

Because we have about a billion clinical faculty, I can say I have seen a ton of approaches. I have to say without a doubt Etomidate has been the most predictible and easiest to use (knock on wood). I hate the opiate versed combo for its absolute lack of predictable results...I was disappointed with Propofol. The truth is that you learn from the attendings...if you see alot of approaches then you can pick and choose.
Ketamine for kids is fantastico.

Go Pacers.

I agree. We only use fentanyl/versed and I hate it. It is very unpredictable and for anything even remotely difficult (a four hundred pound hip dislocation) often times the sedation isn't adequate to the procedure and now your stuck.

Unfortunately anesthesia has control over propofol in our institution. We are working on having etomidate approved as concious sedation. We did a great journal club on it. I will try and track down the articles and post them. Basically etomidate looks safe with very few side effects and shorter recovery times.

I think propofol is a great drug but has to be treated with respect but it works great everytime I have used it!

Etomidate is a wonderful med. Just a few caveats though...I notice that it causes a good amount of myoclonic activity in a few patients (~15-20%). I make sure to let the nurses as well as any family that is in the room that this may happen, that it is a common reaction, it is not harmful, and it is NOT a seizure, so this way no one freaks out during the procedure....Also be prepared for vomiting...I've never seen it (n>100), but it is listed as a common reaction...Otherwise I use it for all kinds of procedures including DCCV, shoulders, hips, mandibular reductions, etc...It has a very rapid onset, and lasts about 5 min, so if you are doing a longer procedure, I would recommend ketamine...It lasts longer, about 20-30 min IV, 30-45 min IM. If using it for a kiddo, make sure to give atropine (for secretions), and tell the family that the eyes are going to twitch, so they don't freak out...There is plenty of literature out there, mostly from Loma Linda's Dr Green...It is safe, effective...I don't combine it with Versed. After the procedure, I turn the lights down and have mom hold/comfort the patient until they are awake. It really reduces the emergence phenomenon...Just don't use ketamine to get head CT's to r/o bleeds. It can raise ICP, so if the patient does actually have a bleed and they have a bad outcome...It will be hard to defend why you gave them the med that potentiated their bad outcome....PO versed or PR thiopental works well in this situation....
Propofof is great as well for short procedures, but at my current facility, it is restricted to anesthesia....I am working on a protocol to make it available to us....I used it a lot at my old job...Nice med...Just have to titrate it more so than Etomidate....Well, I blabbed enough....
MArk

It is counter intuitive....It seems that there is good muscle relaxation early on. I notice that the myoclonus, if it happens, tends to happen in the last minute or 2 of sedation. It tends to be pretty mild....So far, I've been able to reduce every shoulder that I've used Etomidate for. So be efficient. Have your sheets wrapped around you and your counter traction helper, and as soon as the patients eyes glaze over, start-a-tuggin!
Mark

Knock on wood...no myoclonus yet. I have had the salivation problem with Ketamine (not me, the patient).

I vote for etomidate. I've used it since brevital went into the sunset. I have seen the myoclonus several times. I have had to bag a hand full of pts but never had to tube anyone.

DocWagner said:

Knock on wood...no myoclonus yet. I have had the salivation problem with Ketamine (not me, the patient).

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You can pretreat with glycopyrolate before ketamine. That's what we do for our asthmatic intubations.

I haven't had much conscious sedation experience directly. We don't start doing a lot of them until second year. I have been mostly doing the procedures that the conscious sedation is for. Our main institution does not allow propofol (anesthesia turf war) but at the Cleveland Clinic, we can use propofol and it works pretty well. The most common things I see used are ketamine in kids and fentanyl/versed in adults. I have asked to use etomidate for sedation once and the attending I asked was nervous about it (ironically, during the sedation for a cardioversion, the lady started puking blood and I tubed her c etomidate anyway).

mike

I use Tylenol ES and a stick.

lloydchristmas said:

I use Tylenol ES and a stick.

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My preference is etomidate for deep sedation or low dose benzos for procedures that need anxiolysis. I've had two cases (within days of each other) where etomidate was inadequate. Everybody's different. This one early teen had a shoulder dislocation, and I ended up giving him a total dose of etomidate that would have been more than adequate for RSI, and he was still awake and even more agitated. Weird. One hit of fentanyl, and he was out for the required 5 minutes (plus a few). Other than those, etomidate has been my mainstay, though I trained where we used only fentanyl/versed, and I've used propofol some as well (just for variety).