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Procedural Sedation and Paralysis - DRAFT

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Introduction

Procedural sedation and paralysis is a key skill for health care providers who will be dealing with trauma and life-threatening conditions.

Rapid sequence intubation (RSI) refers to pre-oxygenation, sedation, and paralysis prior to an intubation procedure. The technique is a quicker form of the process normally used to "induce" a state of general anesthesia.

The neuromuscular blocking agents paralyse all of the patient's skeletal muscles, most notably and importantly in the oropharynx, larynx, and diaphragm. Once the endotracheal tube has been passed between the vocal cords, a cuff is inflated around the tube in the trachea and the patient can then be artificially ventilated.

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Indications

Procedural sedation is used for painful or distressing procedures, including:

intubation
cardioversion
fracture or dislocated joint reduction

Paralysis is used when intubating a patient.

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Premedication

When performing endotracheal intubation, there are several adjunct medications available. No adjunctive medications, when given for their respective indications, have been proven to improve outcomes.

medication	dosage	onset	duration	uses	side effects
atropine		1-5 min	2-4 hours	reduces secretions inhibits bradycardia secondary to procedure in children	agitation paradoxical bradycardia tachycardia urinary retention
glycopyrrolate		1-2 min	4-6 hours	reduces secretions inhibits bradycardia secondary to procedure	tachycardia urinary retention
lidocaine		1-2 min	10-20 min	may decrease ICP may decrease pain with propofol	myocardial, CNS depression seizures at high doses
fentanyl				decrease sympathetic response analgesia
esmolol		seconds	10-20 min	cardiovascular protection with acute coronary syndrome, aortic dissection

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Sedation and Anaesthesia

medication	dosage	onset	duration	side effects	other
etomidate		<1 min	3-10 min	myoclonus cortisol inhibition nausea and vomiting	no analgesia maintains hemodynamic stability avoid with septic shock
fentanyl		1-3 min	30-60 min	chest wall rigidity
ketamine		30-60 sec	5-20 min	hypertension tachycardia increased secretions increased sympathetic tone, including ICP laryngospasm hallucinations	analgesic bronchodilator; used in asthma
midazolam		2-5 min	15-30 min	hypotension
propofol		30-60 sec	3-10 min	hypotension painful infusion (may be combined with lidocaine)	no analgesia decreases ICP
thiopental		20-40 sec	5-10 min	cardiac depression hypotension

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Paralysis (Neuromuscular Blockade)

medication

dosage

onset

duration

side effects

other

succinylcholine

45-60 sec

5-10 min

hyperkalemia
fasciculations
rhabdomyolysis
bradycardia
myalgias
intracranial, intraocular, intragastric pressure

depolarizing
avoid with renal failure, burns, crush injury, neuromuscular disease, hyperkalemia, or family history of malignant hyperthermia

rocuronium

60-90 sec

45-120 min

long duration of action

nondepolarizing

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Resources and References

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why avoid etomidate in septic shock?