procedural sedation ''conscious sedation''

[AlSomaliMD]

hye guys..
I've been reading a lot about procedural sedation ''conscious sedation'' recently in various web sites, bookss, etc. Seems like there's always some new controversy. Here are some issues that i would like to address...feel free to address only selected ones. These may not be quite so straightforward...

1. Is ketamine okay in adults? What about all the hubbub (?) regarding emergence in adults?
2. Is ketamine okay in patients with head injuries?
3. Which is better between propofol vs. etomodate ''which i have never seen in saudi arabia''? Are there circumstances in which one is preferred over another? Remember, we're talking about procedural sedation, not RSI ''Rapid sequence intubation''.
4. Do patients have to have an empty stomach for any drugs? Premedicate with antiemetics?
5. Recent controversy regarding supplemental oxygen, believe it or not, has surfaced. Some say that it's better to avoid supplemental O2 so you know earlier when the patient is hypoventilating. What do you think?

No. 5 is really intersting the most..

i cant wait for regards guys..

A. M. Al-Somali

Any other issues you want to raise?

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[deleted65604]

I've never seen ketamine used in adults. However, I have seen studies and videos of ketamine being combined with propofol. There was a podcast from those ER podcast guys.

The following are some googled and pasted articles on ketofol:

http://www.ketamine.com/ketofol.html
http://www3.interscience.wiley.com/journal/118497816/abstract?CRETRY=1&SRETRY=0
http://cat.inist.fr/?aModele=afficheN&cpsidt=1323382
http://www.ncbi.nlm.nih.gov/pubmed/18091596
http://www.aims.unc.edu/resources/knowledgebase/entry.aspx?id=1

Ketamine is contraindicated in head injury.

Etomidate is just as good as propofol. Some people think propofol is better because it doesn't cause adrenal suppression. Some people like etomidate in heart patients because it doesn't bottom out BP like propofol. Both are useful tools in the right situation. For conscious sedations in healthy patients, I'm tending toward propofol. For medically sick patients with low blood pressure, or heart issues, I use etomidate (telling admitting physicians that I gave the drug and to look for adrenal suppression).

It is reasonable to avoid oxygen in young healthy people, but I don't see the benefit in doing so. Transient hypercarbia for the 5-10 minutes that they are deeply sedated should have no adverse side effects in my opinion. It is easier to keep O2 sats high than to bag-up a hypoxic patient in the middle of a sedation. If they are sonorous, the RT, or nurse should do jaw thrust, and if they stop breathing adequately, they should get bagged whether they are hypoxic or not.

 

[AlSomaliMD]

great input doc thanks ...

 

[kungfufishing]

etomidate and propofol have fairly different properties and neither one is "better". Etomidate gives you less hemodynamic suppression but more myoclonus and probably more emesis. Propofol has a lot of great properties (fast, titratable, antiemetic, anticonvulsant) but also more cardiorespiratory depression and anecdotally is easier to oversedate with, although they wake up pretty fast, too. I use both about equally. I actually like ketamine some, started a study on ketafol while I was a resident. Low dose ketamine, in particular, has some really nice effects if combined with the propofol. I don't usually do the 1:1 ketafol as is often described, rather I use a 0.5 or even 0.25 mg/kg slug of ketamine up front and then titrate propofol boluses on top of that with anecdotally good results thus far. I usually only employ the addition of ketamine for things that are especially painful, in that if you can achieve the desired sedation effect with propofol or etomidate alone, why screw with it?

 

[matt_mt19]

Overnight last evening had a 45 y/o female (126kg) who put her left arm through a plate glass window, large, jagged, deep laceration, no OR available, ortho would like to explore and close, used versed then ketamine which was awesome. I use a smattering of fentanyl/propofol, fentanyl/versed, versed/ketamine, ketamine/propofol, depending on the patient/risk factors/length of procedure, etc.

 

[aphistis]

Ketamine: Perfectly fine in most adults, but be wary with patient populations predisposed toward psychiatric illness (e.g. VA facilities). You don't want grandpa reliving the war as he's waking up. Also, as others have said, a little ketamine helps counteract the cardiovascular effects of propofol in situations where you want to minimize hemodynamic swings.