Sedation Slang

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mikecwru said:
Well, hopefully you mean milligrams, not ccs. Because even I would say that's a hefty dose.

mike

Yeah - long night. That many cc's would rival a small motorcycle's motor. I've edited my post and stand embarrassed. :oops:

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BKN said:
I guess I'll finally chime in. We started out in the 70's using smaller doses per Tenesma's comments. There was a fear that we would run into folks with cholinesterase deficiencies and get prolonged block. Further getting a CT wasn't as easy or quick and we often wanted the patient back with us real soon so we could follow the exam. We don't care as much today about that.

It was fine most of the time, but these were unprepared airways and not much like the OR. We weren't as good as the gasmen and we weren't putting them on gas immediately.

So, sometimes we didn't get full intubating conditions. Sometimes we got them, but they didn't last long enough to do the job. So the dose went up. Haven't seen anybody with the prolonged block and I really don't care if they're relaxed for 20 minutes versus 5.

One of my friends in med school (an orthopod) has the enzyme deficiency (found after his brother couldn't be extubated)... I've been waiting to intubate him.

mike
 
bartleby said:
Not exactly. Higher doses of haldol, particularly when given with benzodiazepines, can cause some respiratory depression. Don't forget that regardless of what you do or do not administer to the patient, many of them (particularly those behaving badly enough to require sedation in the first place) have pretreated themselves with various and sundry street drugs and pills from their own stash prior to gracing your ED with their presence.

Benzos cause respiratory depression, Haldol does not. I've used Haldol drips with daily doses over a gram in patients with severe medical comorbidity, and never had a problem with respiratory depression.
 
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You should review the ASA guidelines for procedural sedation. Whether the intended consequence is sedation for a procedure, or anxiolysis+analgesia for an acutely agitated patient, the end result is the same. You will have a patient who may become deeply sedated, lose protective airway reflexes, and require ALS-level care. The reason for the more stringent ASA definitions or what consitutes "procedural sedation" is that the level of sedation required to perform painful procedures on most people is quite deep, and may approach a plane of general anesthesia. Too many EM docs approach this with a very cavalier attitude. This is in no way a question of semantics. If you are using a benzodiazepine and a narcotic in efficacious dosages, you are procedurally sedating, and your patient deserves 1:1 nursing, CR and pulse ox monitors, and the immediate availability of advanced airway mgmt supplies/personnel.
 
KidDoc29 said:
You should review the ASA guidelines for procedural sedation. Whether the intended consequence is sedation for a procedure, or anxiolysis+analgesia for an acutely agitated patient, the end result is the same. You will have a patient who may become deeply sedated, lose protective airway reflexes, and require ALS-level care. The reason for the more stringent ASA definitions or what consitutes "procedural sedation" is that the level of sedation required to perform painful procedures on most people is quite deep, and may approach a plane of general anesthesia. Too many EM docs approach this with a very cavalier attitude. This is in no way a question of semantics. If you are using a benzodiazepine and a narcotic in efficacious dosages, you are procedurally sedating, and your patient deserves 1:1 nursing, CR and pulse ox monitors, and the immediate availability of advanced airway mgmt supplies/personnel.


Hmmm. In that case, I can think of more than one patient with anxiety and chronic lower back pain in the medical history who are effectively being prescribed self procedural sedation.
 
Solitary use of either haldol or benzodiazepines are not the issue. It is the use of haldol accompanied by benzos or illicit drugs which is the issue, and this is well documented in the literature.

Doc Samson said:
Benzos cause respiratory depression, Haldol does not. I've used Haldol drips with daily doses over a gram in patients with severe medical comorbidity, and never had a problem with respiratory depression.
 
Tenesma said:
wow - 150mg of Succinylcholine... your patients must all be 500 lbs!!!!!

wouldn't it be more appropriate to dose it correctly? (0.6mg/kg)
that dose is already somewhat of an overdose considering the saturation of acetylcholine receptors.

I couldn't read any further so this may have already been address - apologies if it has.

The paralytic dose of succinycholine is 1 - 1.5 mg/kg IV. The nice thing is that there really is no such thing as an overdose of succ. There is, however, a problem with underdosing and not achieving adequate paralysis.

And since none of us practice in fascist regimes... of course that succ is accompanied simultaneously by an induction agent.
 
bartleby said:
Solitary use of either haldol or benzodiazepines are not the issue. It is the use of haldol accompanied by benzos or illicit drugs which is the issue, and this is well documented in the literature.

I am unaware of any studies that show that haldol decreases respiratory drive in combination with benzos any more than the benzo alone would. I am familiar with the literature that demonstrates increased sedation with the combo, but why would dopamine blockade suppress respiration? Any references you could point me to?
 
There is no good recent data in this regard, as most sedation studies have rather small n and almost none have a benzo only arm for treating acute agitation.

The waters become muddied quite quickly here, as it is not so much a matter of pure antagonism of the respiratory drive and subsequent hypoventilation which occurs classically in the case of a patient who is oversedated with an opioid agent. The issue is that as people become increasingly sedated by any agent (even one which does not directly influence respiratory drive) they will fail to maintain their upper airway reflexes and tone before they lose the desire to breath. In an oversedated patient one is just as bad as the other in a practical sense.

Doc Samson said:
I am unaware of any studies that show that haldol decreases respiratory drive in combination with benzos any more than the benzo alone would. I am familiar with the literature that demonstrates increased sedation with the combo, but why would dopamine blockade suppress respiration? Any references you could point me to?
 
bartleby said:
There is no good recent data in this regard, as most sedation studies have rather small n and almost none have a benzo only arm for treating acute agitation.

The waters become muddied quite quickly here, as it is not so much a matter of pure antagonism of the respiratory drive and subsequent hypoventilation which occurs classically in the case of a patient who is oversedated with an opioid agent. The issue is that as people become increasingly sedated by any agent (even one which does not directly influence respiratory drive) they will fail to maintain their upper airway reflexes and tone before they lose the desire to breath. In an oversedated patient one is just as bad as the other in a practical sense.

But there's a ceiling effect with Haldol... using it in combination with a benzo should actually reduce the risk of respiratory compromise based on the numerous studies that show that the combination of Haldol + Benzo allows for better sedation with lower doses of each drug than needed when used alone.
 
Anuwolf said:
Wow did this actually happen? After reading this... I nearly cried. Because I could not understand why people can do such thing and to piss off a doctor so much that he goes beyond and did what he did to protect his fellow doctors and nurses and the rest of the staffs.

And I bet you cry the cops shoot rabid dogs too.....have you actually worked in a hospital before because it doesn't seem like you have a clue as to what goes on in actual practice and have no where near the requisite thick skin for medicine.....

Anuwolf said:
When I was at the psychiatric hospital....

Ah....it is much clearer now.

socuteMD said:
And just to clarify, Haldol is not a sleep aid. It is a high-potency typical antipsychotic.

Ah....the Saturday night special....

Vitamin K = Ketamine (gotta love the glassy eyeballs when the brain unhooks from the body. I've always wondered where they go to).

Trust me, a low dose makes you go to a place where Salvador Dali did the interior decorating. Emergence reactions are a b-tch. Speaking from experience here.....

I agree that an acute subdural hematoma is dangerous, but I thought you meant that subdurals in general are acute, which I didn't know about.

Any brain bleed can be dangerous but the way it was explained to me is that subdurals tend to progress much slower (relatively speaking) because they tend to be venous bleeds rather than the arterial bleeds involved with subarachnoid or epidural hematomas.

And since none of us practice in fascist regimes... of course that succ is accompanied simultaneously by an induction agent.

:smuggrin:
 
EMResident said:
The nice thing is that there really is no such thing as an overdose of succ.

Actually there are some rather serious adverse reactions to high succinylcholine doses, the foremost being malignant hyperthermia. Don't worry though, we all get your point in this context.
 
Actually I believe malignant hyperthermia is not a side effect of sux OD. Hyperkalemia secondary to rhabdomyolysis however is, particularly in pediatric cases. An interesting note though (and I have no idea why I remember this) but if you give more than a recommended dose of succinylcholine to someone you may well see a blockade like what you would see with a non-depolarizing agent, as opposed to the typical depolarizing block you normally see.
 
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