Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center...

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Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center Evansville, Indiana

Transcript of Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center...

Page 1: Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center Evansville, Indiana.

Sedation in the GI Suite

Curt Mardis, MDStaff Anesthesiologist

St Mary’s Medical CenterEvansville, Indiana

Page 2: Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center Evansville, Indiana.

Objectives

• Review the pharmacodynamics of medications used for sedation– Mention common side effects

• Review the pharmacokinetics of these same medications

• Review the antidotes for medications• Review fundamentals of airway

management• Review rescue medications

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Basic nomenclature

• Pharmacodynamics– What a drug does to the body– Study of the biochemical and physiological effects of

drugs on the body

• Pharmacokinetics– What the body does to a drug– Studying the fate of substances administered

externally to a living organism– Include pharmaceutical agents, hormones, nutrients,

and toxins

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Midazolam (Versed)

• Benzodiazepine• Enhances effect of GABA on GABA A receptors• Used to treat acute seizures• Induce sedation and amnesia before medical

procedures

Page 5: Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center Evansville, Indiana.

Midazolam (Versed)

• Potent anxiolytic and amnestic medication

• Anticonvulsant and sedative properties

• Most commonly used benzo for sedation, because of very fast recovery time

• Less commonly used for induction and maintenance of anesthesia

Page 6: Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center Evansville, Indiana.

Midazolam drawbacks

• Tolerance

• Withdrawal syndrome

• Paradoxical effects can occur, especially at high doses– Children– Elderly

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Midazolam and lethal injection

• Manufacturer of pentobarbital has disallowed its use for lethal injection

• Florida used midazolam to execute a prisoner in 2013

• Ohio used midazolam in 2014

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Flumazenil

• GABA A receptor antagonist• Antidote to benzo overdose• Antidote to overdose of non-

benzodiazepine sleep enhancers– Zolpidem– Zaleplon– Zopiclone

• 200 mcg IV every 2 min, up to 3 mg/hour

Page 9: Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center Evansville, Indiana.

• Strong agonist at mu-opioid receptors

• Potent synthetic opioid analgesic with rapid onset, short duration of action

• Commonly used in procedures for analgesia

• 50-100x more potent than morphine

Fentanyl

Page 10: Sedation in the GI Suite Curt Mardis, MD Staff Anesthesiologist St Mary’s Medical Center Evansville, Indiana.

Fentanyl

• Side effects– Nausea– Constipation– Dry mouth

• Less nausea than morphine• Less histamine-induced itching than

morphine• Responsible for many fatal overdoses, due

to respiratory depression

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Naloxone (Narcan)

• Opioid antagonist• Antidote to opioid overdose

– Fentanyl– Morphine– Heroin

• Naloxone can be administered IV, IM, SQ, or via nasal mucosa

• Start at 80 mcg, then 4 mcg/kg/hour gtt

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Propofol (Diprivan)

• Potentiates GABA A receptor activity

• Acts as a sodium channel blocker

• Diprivan: diisopropyl IV anesthetic

• Anti-emetic

• Rapid onset and recovery

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Propofol Adverse Effects

• Vasodilation

• Decreases SVR

• Hypotension

• Apnea

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Propofol and lethal injection

• Missouri Supreme Court– Propofol for lethal injection is constitutional

• First execution was scheduled for October 2013, but halted

• European Union threatened to limit drug’s export to United States

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Epinephrine

• Useful medication in emergency

• Non-specific agonism at adrenoreceptors

• Increases heart rate and blood pressure

• Increases coronary perfusion pressure

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Atropine

• Competitive antagonist at muscarinic acetylcholine receptors

• Dilates pupils

• Increases heart rate

• Antidote to vagal responses