Just curious if you have a preference for moderate / conscious sedation medications, and if you would share some experiences (good and bad) in the comments section about what has worked and what has not worked for you in the past.

The impression I get is that everyone loves ketamine for pediatric patients, and most people administer propofol for adult patients. Is this your practice? Do you use a one drug fits all approach for every patient, or does it depend on the procedure?

Have any of you had experience with alfentanil, remifentanil or Dexmedetomidine ? Was it good? bad?

Do you always give opiate medications prior to the actual sedation?

What are some of the reactions your patients have had to different sedation agents?

This is pure opinion, I think it will be nice to see what the rest of our colleagues are preferentially using in the ED for conscious sedation.  The greatest benefit would be from comments, but if you are too lazy, at least vote in the poll!


2 thoughts on “Sedation

  1. I prefer ketofol, in a 1:1 mixture of ketamine and propofol. I like to mix the two medications in a 20mL syringe, 10mL of each drug with the concentration of 10mg / mL. <very important to look at the concentration, as ketamine does exist in a 100mg / mL formulation). I feel the stimulatory effect of ketamine on the cardiovascular system counteracts the hypotension that is so often seen with propfol. Also, I think the anti-emetic effect of propofol counteracts the post sedation nausea and vomiting associated with ketamine. I generally do give an opiate medication about 30 minutes prior to when the sedation will start. I will generally initially administer about 0.6mg/kg of each medication (so for an 80kg patient, i would start with 50mg ketamine and 50 mg propofol pushed slowly, or 10mL of the mixture. If more sedation is required, I will push 2mL every 1-2 minutes until I am happy with the level of sedation).

    For procedures I expect to be "quick," such as I&D of a large abscess, simple wrist or ankle dislocation, or electrical cardioversion, I have a preference of etomidate at a dose of 0.1-0.15mg/kg. I don't like to use this for shoulder or hip dislocations, as there is the potential that the reduction will take longer than the effect of the etomidate, and while the general consensus is that a single dose of etomidate does not lead to adrenal insufficiency, I am not comfortable giving multiple doses of etomidate.

    For pediatric patients I do think ketamine is king, and I will try to get them to have some odt zofran before hand. If the patient lets the RN insert an IV, I will usually give a small dose of a benzo in the hopes of preventing an emergence reaction, although I know the literature on that is not great.

    Sometimes if it is a simple laceration or a simple abscess that's needs an I&D in a pediatric patient, I have had about a 70% success rate with giving either oral versed alone or a combination of oral versed and oral diphenhydramine.

    I have limited experience with precedex – during my PICU rotation in residency this was sometimes used for sedation of children for MRI's, which worked okay, but I did not think they were deeply sedated enough to perform any procedures on.

    My craziest post sedation reaction occurred after ketofol. A middle aged patient was convinced I was a vampire who was going to abduct them to Transylvania for an hour after waking up from the sedation. The patient would not let me in the room to speak unless a security guard was standing between us. after an hour the patient had no recollection of her vampire fear.

    I did have an adverse event after midazolam for an electrical cardioversion. Adenosine failed to convert the SVT so midazolam was given and the electrical cardioversion was successfull in terms of putting the patient back into a normal sinus rhythm, however the patient also became apneic and hypotensive. The patient was on chronic benzodiazepines so I did not risk romazicon and ended up having to intubate the patient.

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