Versed and fentanyl for sedation

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medicine2wallstreet

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What are y'all's thoughts on the common practice and combination of versed and fentanyl for procedural sedation and Mac? This practice is incredibly pervasive in anesthesia. In my reading and understanding it seems like versed alone would be the much better agent as combining the two makes a patient much more prone to respiratory depression per benzodiazepine warnings. Yet we routinely give both. Is there any utility to fentanyl for minimal stimulation procedures aka less painful? I'm a resident currently but honestly I'm leaning towards only versed in my practice in the future given that respiratory events are the biggest closed claim in regards to Mac. I'm not spooked about getting sued is why I say that, just trying to find a way to perform tidier anesthesia. Or am I just imagining things that don't matter. Thanks.
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medicine2wallstreet said:
What are y'all's thoughts on the common practice and combination of versed and fentanyl for procedural sedation and Mac? This practice is incredibly pervasive in anesthesia. In my reading and understanding it seems like versed alone would be the much better agent as combining the two makes a patient much more prone to respiratory depression per benzodiazepine warnings. Yet we routinely give both. Is there any utility to fentanyl for minimal stimulation procedures aka less painful? I'm a resident currently but honestly I'm leaning towards only versed in my practice in the future given that respiratory events are the biggest closed claim in regards to Mac. I'm not spooked about getting sued is why I say that, just trying to find a way to perform tidier anesthesia. Or am I just imagining things that don't matter. Thanks.
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I think these sort of cookie cutter approaches to sedation, whether we're taking about people who always give versed and fentanyl, or who are thinking about practicing by only using versed, are pretty ill-advised.

The real answer is... it depends. Every patient is slightly different. Every procedure is slightly different. There will be some situations where only versed is appropriate, both are, or maybe neither are. Trying to come up with a recipe that you can use every time without fail is something better left to the nurses.
 
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vector2 said:
I think these sort of cookie cutter approaches to sedation, whether we're taking about people who always give versed and fentanyl, or who are thinking about practicing by only using versed, are pretty ill-advised.

The real answer is... it depends. Every patient is slightly different. Every procedure is slightly different. There will be some situations where only versed is appropriate, both are, or maybe neither are. Trying to come up with a recipe that you can use every time without fail is something better left to the nurses.
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Good point. I don't believe in singular dogma myself so doing so with this is poor form.
 
Lol OP is worried about mixing versed and fentanyl, meanwhile, IR recently sedated a pt for a fluoroscopy guided lumbar drain in a lady using 7.5 of versed and 335 of fentanyl all that without any airway equipment around aside from wall o2 and a bvm.
 
Versed is primarily for anxiolysis and amnesia. Fentanyl is primarily for pain. You would adjust your recipe based on the pain involved with the procedure and how long the procedure is.

Versed has a fast onset but a longer duration. High doses could make your patient pretty sedated for quite awhile, especially if older.

I don't use much versed in my practice, I prefer propofol with small doses of fentanyl for Mac
 
My thought is that it depends on who's doing the sedation.

If an anesthesiologist chooses fentanyl and/or midazolam for a case, it's probably an excellent solution for the specific case and circumstances at hand. Because if there was an obviously better solution, that's what the anesthesiologist would've done.

If a nurse "chooses" fentanyl and midazolam, because they're the only things policy permits (because they're "reversible") then odds are it's an inferior or maybe just adequate solution.


In general, I think one of my chief goals with short procedural sedation cases (rapid and complete emergence, preferably before they leave the procedure room) is more or less incompatible with the use of any midazolam or fentanyl at all. 99%+ of the GI work I do, for example, is straight propofol. I never found that adding fentanyl was worth the additional sedation and respiratory depression.
 
MirrorTodd said:
Lol OP is worried about mixing versed and fentanyl, meanwhile, IR recently sedated a pt for a fluoroscopy guided lumbar drain in a lady using 7.5 of versed and 335 of fentanyl all that without any airway equipment around aside from wall o2 and a bvm.
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IR by me does SIJ supervised by a doc, done by NP. 2 min 19sec of fluoroscopy.
 
Generally speaking, they want you there as opposed to RN in order to give the patient GA levels of sedation without the airway.

Versed tends to get the patients pretty sedated long after the procedure is done. So it's much less useful than prop and fent. Goal is that the patient is awake and happy asap after the procedure is done.

As you get used to Mac, you will get better at managing the resp depression and airway and be less concerned.
 
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NICMAN said:
Where's the Ketofol guy when you need him?
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God that clown was at the end of the douche spectrum. It's a continuum: there's people who refer to you as "my guy" on one end, those who brag about their ITE scores in the middle, then that dork at the opposite end of the spectrum.
 
Thank you. Just tryina ask a question and ol buddy wants to start name calling. Then I get shamed for clapping back. Anyways just curious if fentanyl decreases the margin for airway error in mac's in y'all's opinion.
 
To me propofol generally = GA without an airway. Versed/fentanyl = fake anesthesia (so long as you don’t give crazy amounts. The fake anesthesia is typically done on profoundly unhealthy podiatry patients, who are neuropathic, or IR and very unhealthy cath lab cases. GI is typically GA no airway. Hope that clears things up.
 
medicine2wallstreet said:
Thank you. Just tryina ask a question and ol buddy wants to start name calling. Then I get shamed for clapping back. Anyways just curious if fentanyl decreases the margin for airway error in mac's in y'all's opinion.
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Fentanyl will suppress breathing yea, but it will also provide better operating conditions than versed alone.

The trick with anesthesia is to combine different drugs and techniques to minimize the negative effects and amplify the effects that you are seeking.

Procedure details will influence your drug choice. Long vs short case, sustained discomfort vs very brief moments of intense pain, regional, comorbitiies, discharge plan, surgeon preference and personal skill.

The best part of residency, and sometimes the most frustrating part, is being forced to try new techniques even if you don't anticipate they will work as well as your own preferred method. This way you can see the pros and cons of each approach and tailor them to your goals
 
Only time I’ve used versed and fentanyl for sedation is during cataracts or some bogus ass sick off site case where I’m on anti death duty. Versed-fentanyl sedation is like a Toyota Yaris compared to a ferrari (propofol). It’s honestly bull crap we charge people full anesthesia price for it.

Like if you’re under versed-fent and I kicked you in the nuts, you would probably open your eyes and wince in pain like someone who was completely sober. You just wouldn’t remember it. As opposed to a prop kick to the groin with you looking much more comfortable. Under conscious sedation the goal is simply to make people amnestic despite how drastically they might react to stimuli. I’ve always thought if most people saw how people react under conscious sedation they would be much less likely to agree to it.
 
Ownage that is a phenomenal response and the insight I was looking for. Never thought about it like that.
 
Just give all of it. I typically give fent/midaz to start and then layer on propofol accordingly for my MAC cases. I do this because 1) fentanyl and midazolam are reversible 2) I get away with giving less propofol during the case 3) nobody wants to remember rolling into the OR and 4) the surgeons only care if the patient moves, and unless you want to blast them with propofol, judicious administration of opioid during sedation is great for having them lay still on the table.

If I have a patient that is really only a good candidate for some oxygen, a bit of fentanyl, and a little pat on the shoulder I’ll do that too.

As long as you’re diligent and have good airway management skills you should be fine. This is why I wish they made residents do a stint in Endo pushing propofol. It’s boring and robotic, but you really get a feel for GA without an ETT.
 
Steege305 said:
Just give all of it. I typically give fent/midaz to start and then layer on propofol accordingly for my MAC cases. I do this because 1) fentanyl and midazolam are reversible 2) I get away with giving less propofol during the case 3) nobody wants to remember rolling into the OR and 4) the surgeons only care if the patient moves, and unless you want to blast them with propofol, judicious administration of opioid during sedation is great for having them lay still on the table.

If I have a patient that is really only a good candidate for some oxygen, a bit of fentanyl, and a little pat on the shoulder I’ll do that too.

As long as you’re diligent and have good airway management skills you should be fine. This is why I wish they made residents do a stint in Endo pushing propofol. It’s boring and robotic, but you really get a feel for GA without an ETT.
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We have a lot of OMFS peeps rotating through. I've been trying to push for them to mostly do sedation stuff, since that is what they need to get good at. It's pointless for them to sit a six hour robotic hysterectomy day after day. At the very least, I've been having them give anxiolytic early in preop and giving more on the drive back so that they get used to the effects of the sedatives.
 
Steege305 said:
Just give all of it. I typically give fent/midaz to start and then layer on propofol accordingly for my MAC cases. I do this because 1) fentanyl and midazolam are reversible 2) I get away with giving less propofol during the case 3) nobody wants to remember rolling into the OR and 4) the surgeons only care if the patient moves, and unless you want to blast them with propofol, judicious administration of opioid during sedation is great for having them lay still on the table.

If I have a patient that is really only a good candidate for some oxygen, a bit of fentanyl, and a little pat on the shoulder I’ll do that too.

As long as you’re diligent and have good airway management skills you should be fine. This is why I wish they made residents do a stint in Endo pushing propofol. It’s boring and robotic, but you really get a feel for GA without an ETT.
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MAC in our mind = as long as we are there giving anesthesia, it’s called MAC. Dealers choice on how you want to manage it.

MAC in everyone else’s mind = GA with no airway.

I hate giving versed to old people. Had a 90 year old who had cataract with 1/1, apparently was dazed for weeks. I just sprinkled some fent on her, and she couldn’t be happier in PACU. I do find fent smooths out the respiratory part of my concerns. Certainly make them apneic with prop longer…….

The best advice when I first came out of residency and started at one of our endo center was, everyone (healthy) gets 20ml of prop right off the bat….. for EGD, that’ll make them apneic, then they can put the scope in without coughing. For Colon, if they are good, that’s all you need….

I found it to be generally true for endo center population……. Tried that once in our GI-CU. I was still very green. Wasn’t one of my finest moment.
 
IMGASMD said:
The best advice when I first came out of residency and started at one of our endo center was, everyone (healthy) gets 20ml of prop right off the bat….. for EGD, that’ll make them apneic...
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If that's the "best advice" you've ever gotten then I feel bad for you. So you slam a morbidly obese, sleep apneic with 20 mls of Propofol prior to their EGD? Ballsy.
 
I have yet to work in a facility where anesthesia (who writes the sedation rules) allows anything besides fentanyl and versed to be given for conscious sedation so it would appear that your colleagues are of the opinion that these are the only 2 safe drugs for that procedure to be given by a non-anesthesiologist.
 
Anesthesia_Dude said:
If that's the "best advice" you've ever gotten then I feel bad for you. So you slam a morbidly obese, sleep apneic with 20 mls of Propofol prior to their EGD? Ballsy.
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Our gastroenterologists only select the best/easiest Asa 1/2 patients for their GI centers. Everyone else get send to the hospital. For that patient population, i ain’t scared! Until I was….
Don’t feel bad for me. That’s just how we roll, son.
*in all seriousness, of course there’s some patient selection going on there…. Like I said GI center owned gastroenterologist, and one of the partner is the medical director. BMI over 40 is automatic no. Any history of difficult airway is a no. I still stand by my statement. Most of the time I am happier to slam propofol than fentanyl and versed…. Because I know when I start reaching for any other medication for the patient, there is something else going on, it ain’t a straight forward case.
 
medicine2wallstreet said:
My 82nd percentile on my Ca2 Ite would disagree with you. I'm asking a question among colleagues here. No reason to clown.
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Dude (or Dudette), This is SDN, 82nd percentile isn't the brag you think it is.

Anyways, most patients who aren't a nervous wreck, if you get rid of their pain, they don't really care what you do.
 
chessknt said:
I have yet to work in a facility where anesthesia (who writes the sedation rules) allows anything besides fentanyl and versed to be given for conscious sedation so it would appear that your colleagues are of the opinion that these are the only 2 safe drugs for that procedure to be given by a non-anesthesiologist.
Click to expand...

Propofol in one of the ED has to be given with two docs at bedside. One can do the procedure one is there for airway.
 
medicine2wallstreet said:
What are y'all's thoughts on the common practice and combination of versed and fentanyl for procedural sedation and Mac? This practice is incredibly pervasive in anesthesia. In my reading and understanding it seems like versed alone would be the much better agent as combining the two makes a patient much more prone to respiratory depression per benzodiazepine warnings. Yet we routinely give both. Is there any utility to fentanyl for minimal stimulation procedures aka less painful? I'm a resident currently but honestly I'm leaning towards only versed in my practice in the future given that respiratory events are the biggest closed claim in regards to Mac. I'm not spooked about getting sued is why I say that, just trying to find a way to perform tidier anesthesia. Or am I just imagining things that don't matter. Thanks.
Click to expand...
Sedation is very difficult.

It is difficult because right out the gate, you and the proceduralist probably have very different ideas about what should happen.

When someone books “MAC”, or the surgeon says, we can do this under MAC - you really need to define with them what that means.

In my estimation, propofol Is a HORRIBLE sedation drug because the line between them being responsive and disinhibited, and out, is very thin. It is a phenomenal drug for deep sedation and GA with natural airway, which is what most use it for. But to get them to a point where they are responsive and don’t try to reach down and help the surgeon is nearly impossible.

I suggest (when it is no longer on the shortage list) getting to know Alfentanil. I am shocked at how many anesthesiologists I meet that have never used it.

It is the perfect sedation drug (with or without midazolam). It works very quick, and leaves quickly.

The advantage of opioid sedation, is the brain isn’t scrambled. I have done alfenta sedation where they are out, and you tap them on the head and say “Hey Bob. Take a deep breath” - they open their eyes, take a deep breath, look at you blankly for a while, then close their eyes. When you do that to a sedated patient on propofol, they freak out, try to get up off the table, +|- on trying to punch you….
 
IMGASMD said:
Propofol in one of the ED has to be given with two docs at bedside. One can do the procedure one is there for airway.
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I get that--nobody thinks propofol should be able to be given by somebody who is generally not able to pay immediate attention at all times to the airway and monitors. I am thinking more of ketamine/precedex, both of which are vehemently prohibited everywhere I have worked for sedation by anesthesia and really limits options for people who actually do want to try to deliver an appropriate sedation but are chained to the 2 drugs mentioned by the OP.
 
A lot of hate on midazolam and fentanyl here. It is an excellent choice for mild or moderate sedation, patients don’t gets disinhibited, if given in divided and slow doses, respiratory depression can be avoided. Plus they are reversible. If your concerned just keep a stick of naloxone handy. Probably more airway complications are from upper airway obstruction rather than apnea from sedation and lack of vigilance on the providers part.
 
epidural man said:
Sedation is very difficult.

It is difficult because right out the gate, you and the proceduralist probably have very different ideas about what should happen.

When someone books “MAC”, or the surgeon says, we can do this under MAC - you really need to define with them what that means.

In my estimation, propofol Is a HORRIBLE sedation drug because the line between them being responsive and disinhibited, and out, is very thin. It is a phenomenal drug for deep sedation and GA with natural airway, which is what most use it for. But to get them to a point where they are responsive and don’t try to reach down and help the surgeon is nearly impossible.

I suggest (when it is no longer on the shortage list) getting to know Alfentanil. I am shocked at how many anesthesiologists I meet that have never used it.

It is the perfect sedation drug (with or without midazolam). It works very quick, and leaves quickly.

The advantage of opioid sedation, is the brain isn’t scrambled. I have done alfenta sedation where they are out, and you tap them on the head and say “Hey Bob. Take a deep breath” - they open their eyes, take a deep breath, look at you blankly for a while, then close their eyes. When you do that to a sedated patient on propofol, they freak out, try to get up off the table, +|- on trying to punch you….
Click to expand...

Alfentanil is the best drug for any sedation cases. It’s very forgiving, very quick on/off, and hemodynamically stable. I love using it!
 
dipriMAN said:
A lot of hate on midazolam and fentanyl here. It is an excellent choice for mild or moderate sedation, patients don’t gets disinhibited, if given in divided and slow doses, respiratory depression can be avoided. Plus they are reversible. If your concerned just keep a stick of naloxone handy. Probably more airway complications are from upper airway obstruction rather than apnea from sedation and lack of vigilance on the providers part.
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Nope. Just that if the procedure can be done with versed/fent then it can also be done with just local…
 
You can't get the right answer without asking the right question.

If you're asking a question that an OPD proceduralist wants to know the answer to. The answer is yes, Fentanyl causes respiratory depression.

If you're wanting to query Midazolam and Fentanyl for routine MAC/sedation... Why on earth are you not giving propofol/local?

If you're wanting to query the use of Midazolam +hold them down (instead of propofol) in the ASA7 community than the Fentanyl probably shouldn't even be in the equation.

I don't get it. What's the meat of the question?
 
GassYous said:
Not with my patient population
A lot of them can't even make it to the OR without some versed on board
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I think he's referring only to the pain of the actual procedure not requiring anything more than local if the anesthetic can be accomplished solely with versed/fent
 
vector2 said:
I think he's referring only to the pain of the actual procedure not requiring anything more than local if the anesthetic can be accomplished solely with versed/fent
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Yeah if you're nervous you can misinterpret pressure and touch for pain. I think versed/fent is very good for that.
 
dannyboy1 said:
Nope. Just that if the procedure can be done with versed/fent then it can also be done with just local…
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I don’t understand this response. Obviously almost any MAC case can be done with just local, because if it couldn’t we would give general or regional anesthesia.

There are times when I prefer midaz and fent, but I agree starting a prop infusion with deep sedation is usually easier and a quicker wake up.
 
Fent/Versed given all the time back in the day. Outpatient pain practice ASC in 2004. I was there for a discogram that took an hour on a workers comp patient that was on high dose opiates. 4 level disco. No anesthesiologist in center. PMR attending and 5 fellows all PMR. No CRNA. Just 3 RN's for the whole practice. Guy got 22:22 in that hour. Did not require an airway and thank goodness for that, because no one there trained outside ACLS. When I look back at the situation, I am amazed on what it takes to kill someone. Glad I was not the attending. Glad I was not the fellow doing the discogram. Glad he didn't die.
 
lobelsteve said:
Fent/Versed given all the time back in the day. Outpatient pain practice ASC in 2004. I was there for a discogram that took an hour on a workers comp patient that was on high dose opiates. 4 level disco. No anesthesiologist in center. PMR attending and 5 fellows all PMR. No CRNA. Just 3 RN's for the whole practice. Guy got 22:22 in that hour. Did not require an airway and thank goodness for that, because no one there trained outside ACLS. When I look back at the situation, I am amazed on what it takes to kill someone. Glad I was not the attending. Glad I was not the fellow doing the discogram. Glad he didn't die.
Click to expand...

22 versed/2200 fent?
on pump pain case?
 
Arch Guillotti said:
Probably 22 50 mcg doses of fent.

I have seen a pain pt. get at least 15 in just a few minutes and didn’t faze them one bi
Arch Guillotti said:
Probably 22 50 mcg doses of fent.

I have seen a pain pt. get at least 15 in just a few minutes and didn’t faze them one bit.
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Yup. 22mg versed and 22 - 50mcg boluses of fent.
 
Last edited:
medicine2wallstreet said:
What are y'all's thoughts on the common practice and combination of versed and fentanyl for procedural sedation and Mac? This practice is incredibly pervasive in anesthesia. In my reading and understanding it seems like versed alone would be the much better agent as combining the two makes a patient much more prone to respiratory depression per benzodiazepine warnings. Yet we routinely give both. Is there any utility to fentanyl for minimal stimulation procedures aka less painful? I'm a resident currently but honestly I'm leaning towards only versed in my practice in the future given that respiratory events are the biggest closed claim in regards to Mac. I'm not spooked about getting sued is why I say that, just trying to find a way to perform tidier anesthesia. Or am I just imagining things that don't matter. Thanks.
Click to expand...
Very unusual question and wording. Everything seems off with this
 
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