IV Sedation Meds
IV sedation question/survey for everyone. I reveiewed my last 250 IV sedation cases to evaluate med dosages and time per procedure. In my practice, I use fentanyl and versed for sedation. Depending on the procedure, I sometimes give 8mg Decadron at the start of the case and Toradol at the conclusion of the case. I know some don't like to give Toradol due to bleeding concerns, but I have never had a problem with it. In my review I found that, on average, I am using about 8mg Versed and 125mcg Fentanyl per case. Average time per case is about 75 minutes. Sometimes longer, sometimes shorter depending on the case. How does this compare to others doing IV sedation?
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Med usage
While we all usually titrate the dose to what the patient needs, I usually use between 5-8mg Versed and 75-150mcg Fentanyl for most cases of about 2 hours duration. I rarely use more than 150mcg Fentanyl, but if I need more sedation I have given up to 19mg Versed in a 2-3 hour case. From what I have read/found there appears to be very little clear reference on what the actual max does of Versed is. Some say 10mg, but I have found no literature on any adverse outcome from going over this beyond oversedation....but if you titrate the dose to a reasonable level and to get there on a given patient requires 15mg of Versed, I see no problem with this.
Med Usage
For Sedation purposes;
run a midazolam infusion (or incremental bolus IV push)@ 1-15 mg/hr (200-300 mcg/kg/hr). This is assuming you have monitoring capable of measuring respiratory patterns & appropriate airway management skills. You are looking at 15 to 80 minutes duration so plan accordingly. For fentanyl, go with 0.7 – 2 mcg/kg (25 – 150 mcg). You will see a peak effect within 5-15 minutes, and duration of action 30-60 minutes. Make sure you are not trying to achieve analgesia with midazolam once the fentanyl has worn off. You will see lack of patient response/ respiratory depression first. If you have airway skill, I would increase the fentanyl dosage before I would elect to give more than 6 mg of midazolam per hour (assuming average 70 kg patient). Not going to get any additional amnestic effect after that dosage. Ideally, utilize propofol. Much smoother and faster recovery time.
- Patrick McCarty
www.zzzdmd.com
Propofol Pump
Propofol infusion pump is very nice. If I use propofol, I will only use it with the pump. To me, giving multiple boluses of propofol seems to produce too much variability. Sometimes patient is too deep...sometimes patient is too light. With the pump, you eliminate this problem.
Most of the time, I will give fentanyl (25-75mcg depending on size of patient and response) followed by versed (2-3mg depending on size of patient and response). In most cases, this seems to get the patient to Verill sign and then I give local anesthetic. I then give 1-2mg push of Versed and occasional fentanyl as needed depending on depth of patient sedation.