Sedation

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The aim of providing sedation is to reduce anxiety, agitation and pain so as to tolerate unpleasant  medical procedures or intervention while the patient retains control of airway, breathing and blood  pressure.  This  procedural  sedation  and  analgesia  is  commonly  used  in  emergency  units,  radiological /diagnostic units, dentistry and for certain endoscopic and gynaecological procedures. 

Minimal Sedation/Anxiolysis (no analgesic effect is required) 

A:  diazepam  (IV)  0.1mg/kg  (In  a  60kg  patient,  give  boluses  of  2mg  every  minute;  may require up to 10mg)  

OR   

C: nitrous oxide inhaled 20 to 50%, in oxygen (will also provide some analgesia) 

OR 

D: midazolam (IV) 0.05mg/kg (In a 60 kg patient, give boluses of 1 mg every minute; may require up to 3mg) 

Medicines for moderate sedation & analgesia: If analgesia is required, one of the above is usually combined with an opiate. However, ketamine  has analgesic activity and can be used on its own or combined with a benzodiazepine. 

B: ketamine (IV) 0.5mg/kg. Repeat doses of 0.5mg/kg as required, every 5-10minutes 

OR 

C: morphine(IV) 0.1mg /kg in increments of 2mg every 5minutes 

OR 

S: fentanyl (IV) 0.25µg/kg   

Alternative medicines 

D: propofol (IV) 0.5mg/kg. Repeated as 0.25mg/kg boluses every 5minutes as required 

OR 

S: etomidate (IV) 0.1mg/kg. Repeat doses of 0.05 mg/kg (IV) every 5minutes, as required. But it is more likely to cause myoclonus  

Medicines for Deep Sedation & Analgesia: This is usually achieved with either higher doses of  medications used for moderate sedation, or by combining an opiate, a benzodiazepine, and either  Propofol or Etomidate. When agents are combined, lower doses may be adequate. 

Supplemental Analgesia: Simple analgesics can be given before or after the procedure: 

A: paracetamol (PO): 1g 4-6 hourly when required to a maximum of 4doses per 24hours. 

Maximum dose: 15mg/kg/dose. Maximum dose: 4 g in 24 hours. 

OR 

A: ibuprofen (PO) 400mg 8hourly with meals after the procedure. 

Note - Sedation in intensive care 

• Indications for sedation in intensive care needs to be defined for each patient, and may include one or more of anxiolysis, analgesia, agitation control, or to help patients tolerate uncomfortable situations or procedures (e.g. intubation and ventilation) 
• Sedation requirements fluctuate rapidly so, it warrants regular review 
• Adequate pain control is often more efficacious than sedatives for reducing agitation. Delirium should be considered and managed appropriately

Short–term and long–term sedation 

Medicines for short–term sedation (less than 24 hours) 

C: midazolam (IV) 0.05–0.2mg/kg/hour. 

OR 

D: propofol (IV) 0.5mg/kg/hour.  

Due  to  high  fat  solubility,  midazolam  also  becomes  ‘long  acting’  after  infusions  of  more  than  24  hours 

Medicines for longer–term sedation (72 hours or more)   

C: lorazepam (IV) 0.1mg/kg/hour. 

OR 

D: midazolam (IV) 0.2mg/kg/hour.  

Lorazepam (0.1 mg/kg/hour) is as effective (and as easy to wean) as midazolam 0.2 mg/kg/hour) but  more difficult to titrate. 

Supplemental analgesia 

C: morphine (IV) 0.1–0.2mg/kg/hour.   

OR 

S: fentanyl (IV) 1 µg/kg/hour (also becomes long acting after prolonged infusion due to fat solubility)