Choice of drug regimen for procedural sedation and analgesia
The choice of drug regimen for procedural sedation and analgesia depends on the goals of treatment (eg level of sedation and analgesia required, need for amnesia or anxiolysis), patient factors (eg age, comorbidities), procedure factors (eg duration of procedure), and the level of sedation that can be safely delivered in the clinical setting. Factors influencing the choice of drug used for procedural sedation and analgesia summarises how these factors might influence the choice of drug used for procedural sedation and analgesia.
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Factor |
Consideration |
|---|---|
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patient age |
older patients are at an increased risk of adverse effects and require lower doses |
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patient comorbidities |
potential for drug interactions dose adjustment in patients with impaired cardiovascular, kidney, liver or respiratory function |
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patient’s level of distress |
patients who are significantly distressed about the procedure may require a regimen that includes anxiolytic or amnestic drugs (eg midazolam) |
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anticipated pain severity |
the analgesic properties of drugs commonly used for procedural sedation and analgesia vary; see Commonly used drugs for procedural sedation and analgesia onset and peak effect of analgesia—ensure pain relief is adequate at the onset and greatest intensity of procedural pain. postprocedural pain—analgesics with a longer duration of action may be needed [NB1] |
|
level of sedation required |
combination therapy may be required to achieve adequate analgesia and sedation |
|
duration of procedure |
the duration of action of the drug(s) used should be appropriate for the length of the procedure |
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clinical setting |
must meet the requirements for monitoring, staffing and equipment and physical facilities applicable to the drug regimen being used |
Note: NB1: If parenteral analgesia will be required to manage postprocedural pain, consider obtaining intravenous access during the procedure
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If sedation is required, drugs must be titrated cautiously to effect because it is easy to inadvertently proceed to a deeper level of sedation. See Commonly used drugs for procedural sedation and analgesia for a summary of commonly used drugs for procedural sedation and analgesia.
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Drug |
Role in procedural sedation and analgesia |
|---|---|
|
inhaled analgesics (methoxyflurane, nitrous oxide) |
very short acting (ie fast onset and offset of action) and useful for short procedures suitable for use in a wide variety of settings (eg sports fields, outpatient clinics) methoxyflurane provides analgesia and is unlikely to cause more than transient conscious sedation—it requires patient coordination to maintain effect methoxyflurane is not suitable for children younger than 5 years because deep sedation may occur nitrous oxide provides analgesia and anxiolysis—it may cause conscious sedation if delivered by a nonpatient-triggered system |
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opioids (fentanyl, oxycodone, morphine) |
provide analgesia and may cause sedation, but should not be used with the intent of causing sedation because of the risk of toxicity (eg opioid-induced ventilatory impairment)—sedation with doses used for analgesia is transient and reversible minimal effect on recall of the procedure in children, intravenous fentanyl and morphine are preferred to oxycodone because of greater experience with their use compared to oxycodone and morphine, fentanyl has the fastest onset and offset of action—it is preferred for short procedures and when postprocedural pain is not expected morphine and oxycodone have a slower onset of effect but a longer duration of action compared to fentanyl—they may be preferred if postprocedural pain is expected do not use morphine or oxycodone for procedures lasting less than 15 minutes if postprocedural pain is not expected—residual opioid effect unopposed by pain increases the risk of postprocedural opioid-induced ventilatory impairment |
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midazolam |
does not provide analgesia—must be combined with an analgesic (eg local anaesthetic, opioid, nitrous oxide) may be opioid-sparing when co-administered with an opioid; see Multimodal analgesia for acute pain provides anxiolysis and amnesia may cause conscious or deep sedation |
|
ketamine [NB1] |
provides analgesia and amnesia may cause conscious or deep sedation, which can inadvertently proceed to general anaesthesia compared to other drugs used for deep sedation, ketamine is associated with better maintenance of airway reflexes and respiratory drive in children, monotherapy with ketamine is preferred if a combination of drugs would otherwise be required to achieve the same effect has sympathomimetic effects at high doses—increased blood pressure and heart rate can be useful for patients with cardiovascular compromise |
|
propofol [NB1] |
provides amnesia but does not provide analgesia—may be opioid-sparing when co-administered with an opioid; see Multimodal analgesia for acute pain may cause conscious or deep sedation, which can inadvertently proceed to general anaesthesia infrequently used in children—regimens containing nitrous oxide, opioids, midazolam and ketamine are preferred |
Note: NB1: Do not use premixed preparations of propofol and ketamine (colloquially known as ‘ketofol’) because these preparations offer no benefits compared to administering each drug individually and are more difficult to titrate to effect.
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