Medications

Medications


Medication Considerations   Opioids   Benzodiazepines   Reversal Agents   Anesthetic Agents   Other Drugs   Pregnancy Considerations   Other Considerations  Sources

 

 

Medication Considerations during Sedation

Incremental Dosing

  • Recommended procedure for moderate sedation
  • Initial bolus
  • Titrate to desired level of sedation based on pharmacodynamics properties of specific agent

Synergistic Effects

  • Combination of drugs from different classes often have synergistic effects e.g. benzodiazepines and opioids
  • The administration of one drug can reduce the amount of a second drug in a different class
  • Ideally each component should be administered alone to reach targeted effect i.e. pain or anxiety

Reversal Agents

  • Antagonists for opioids and benzodiazepines
  • Reverses respiratory depression and sedation only
  • Can result in pain, hypertension and tachycardia
  • Must be immediately available wherever moderate sedation is administered
  • Patient specific approach is advised utilizing other modalities such as stimulation, supplemental oxygen, artificial airway, jaw thrust, bag-mask ventilation Use of reversal agents requires extended recovery period for observation of signs of resedation

Oxygen

  • Should be considered for moderate sedation
  • Especially for elderly or high risk
  • Must be available at all times

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Opioids

Medications: Meperidine (Demerol) Dosing for Endoscopic Sedation:
  • Initial Dose: 25-50mg over 1-2 minutes
  • Additional doses: doses of 25mg can be administered every 2-5 minutes
  • Onset of action: 3-6 min
  • Peak effect: 6-7 min
  • Duration of effect: 1-3 hours
  • Use with caution in renal patients, hepatic patients and elderly
  • Causes respiratory depression and hypotension
  • Pregnancy: C
  • Lactation: Probably safe

Pediatric

  • Initial dose (<50kg): 1mg/kg
  • Additional doses: 1mg/kg can be administered every 2-4 minutes to max dose of 3mg/kg
Reversal Agents:Naloxone

Medications: Fentanyl (Sublimaze)

Dosing for Endoscopic Sedation:

  • Initial dose: 50-100mcg
  • Additional doses: doses of 25mcg can be administered every 2-5 minutes
  • Onset of action: 1-2 minutes
  • Peak effect: 3-5 minutes
  • Duration of effect: 30-60 minutes
  • Pregnancy: C
  • Lactation: Safe
  • Causes respiratory depression and hypotension
  • Reduce dose by 50% in elderly

Pediatric (Children over age 12)

  • Initial dose: 0.5-1mcg/kg (maximum dose 50mcg)
  • Maximum dose: 5mcg/kg or 250mcg (whichever is less)
Reversal Agents:Naloxone

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Benzodiazepines

Medications: Diazepam (Valium) Dosing for Endoscopic Sedation:
  • Initial dose: 5-10mg over 1 minute
  • Onset of action: 2-3 min
  • Peak effect: 3-5 min
  • Duration of effect: 6 hours
  • Pregnancy: D
  • Lactation: Possibly unsafe
  • Reduce dose in elderly or debilitated patients
  • Causes respiratory depression and coughing

Pediatric

  • Moderate (conscious) sedation for procedures:
    • Oral: 0.2-0.3mg/kg (maximum dose: 10mg) 45-60 minutes prior to procedure
  • Adolescents: Moderate (conscious) sedation for procedures:
    • Oral: 10mg
    • IV: 5mg; may repeat with 2.5mg if needed
Reversal Agents: Flumazenil 

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Medications: Midazolam (Versed)

Dosing for Endoscopic Sedation: 

  • Initial dose: 1-2mg
  • Additional doses: 1mg administered at 2-minute intervals
  • Onset of action: 1-2 minutes
  • Peak effect: 3-4 minutes
  • Duration of effect: 15-80 minutes
  • Pregnancy: D
  • Lactation: Possibly unsafe
  • Reduce dosage in patients over 60 or with ASA>3
  • Causes respiratory depression and hypotension; can cause seizures with rapid administration
  • BLACK BOX WARNINGS: appropriate use, respiratory depression, individualized dosage

Pediatric

  • Infants less than 6 months*: limited information available for this age group; recommendations unclear
  • Infants and children ages 6 months to 12 years:
    • Initial dose: 0.05mg/kg (maximum dose 2.5mg)
    • Additional doses: 0.05mg/kg (maximum dose 2.5mg) at 3 minute intervals until maximum dose is reached
    • Maximum dose: 0.3mg/kg or 15mg, whichever is less
Reversal Agents: Flumazenil

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Reversal Agents

Medications:Naloxone (Narcan)
Dosing for Endoscopic Sedation: 
  • Initial dose: 0.2-0.4mg
  • Additional doses: 0.2-0.4mg administered intravenously every 2-3 minutes until desired response is attained. Supplemental dose may be necessary after 20-30 minutes
  • Onset of action: 1-2 minutes
  • Peak effect: 5 min
  • Duration of effect: 30-45 minutes
  • Patient should be monitored for 2 hours for signs of resedation
  • Reverses opioids only
  • Pregnancy: B
  • Lactation: Safety unknown

Pediatric

  • Initial dose in children is 0.01 mg/kg body weight given I.V
  • If this does not result in the desired degree of clinical improvement, a subsequent dose of 0.1 mg/kg body weight may be administered
Reversal Agents:N/A
Medications:Flumazenil (Romazicon)
Dosing for Endoscopic Sedation:
  • Initial dose: 0.2mg administered intravenously over 15 seconds
  • Additional doses: If desired consciousness is not reached within 45 seconds, up to 4 additional doses 0.2mg can be administered at 60 second intervals up to maximum dose
  • Onset of action: 1-2 minutes
  • Peak effect: 3 minutes
  • Duration of effect: 10-15 minutes
  • Repeat treatment: If resedation occurs, repeated doses can be administered at 20 minute intervals. No more than 1mg (given as 0.2mg/min) should be administered at any one time. No more than 3mg should be given in any one hour
  • Patient should be monitored for 2 hours for signs of resedation
  • Reverses benzodiazepines only
  • BLACK BOX WARNING: seizure risk
  • Pregnancy: C
    Lactation: Safety unknown

Pediatric (children aged 1-17 years)

  • Pediatric patients greater than 1 year of age, the recommended initial dose is 0.01 mg/kg (up to 0.2 mg) administered intravenously over 15 seconds.
  • If the desired level of consciousness is not obtained after waiting an additional 45 seconds, further injections of 0.01 mg/kg (up to 0.2 mg) can be administered and repeated at 60-second intervals where necessary (up to a maximum of 4 additional times) to a maximum total dose of 0.05 mg/kg or 1 mg, whichever is lower
Reversal Agents:N/A

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Anesthetic Agents

MedicationsPropofol(Diprivan)

Dosing for Endoscopic Sedation:

  • Initial dose: 10-40mg
  • Additional doses: IV dose of 25-75mcg/kg per minute; or incremental IV bolus doses of 10-20mg
  • Onset of action: less than 30-45 seconds
  • Peak effect: 1-2 minutes
  • Duration of effect: 4-8 minutes
  • Causes respiratory depression and hypotension
  • Requires anesthesia assistance in many states
  • Reduce dosage in elderly or debilitated patients
  • Contraindicated in patients with egg allergy
  • Pregnancy: B
  • Lactation: Probably safe

Pediatric

  • Initial dose: 1-2mg/kg bolus administered over 30 seconds
  • Additional doses: 300-350mcg/kg/hour continuous infusion following initial dose
  • 0.5-1mg/kg IV administered at 3-5 minute intervals as needed; alternatively continuous IV infusion of 50-150mcg/kg per minute
Reversal Agents: None

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Other Drugs

Medications:Ketamine (Ketalar) Dosing for Endoscopic Sedation:
  • Initial IV dose: 0.5mg/kg
  • Additional doses: Titrate to effect
  • Onset of action: Less than 1 minute
  • Peak effect: 1 minute
  • Duration of effect: 15-30 minutes
  • Generally used for pediatric sedation
  • BLACK BOX WARNING: emergence reactions, psychological disturbances
  • Pregnancy: B
  • Lactation: Probably safe

Pediatric

  • Initial IV dose: 0.5-1mg/kg (max bolus dose 70mg) via slow infusion (over 60 sec)
  • Additional doses: 0.25-0.5mg/kg as necessary to maximum of 2mg/kg
Reversal Agents:None
MedicationsNitrous Oxide (Kalinox) Dosing for Endoscopic Sedation:
  • Initial dose: titrate to effect
  • Onset of action: 2-3 minutes
  • Peak effect: Dose dependent
  • Duration of effect: 15-30 minutes
  • No reversal agent
  • Pregnancy: B
  • Lactation-Safety unknown

Pediatric

  • Same as adult
Reversal Agents: Medications:Diphenhydramine (Benadryl Injection) Dosing for Endoscopic Sedation:
  • Initial dose: 25-50mg up to100mg if required
  • Onset of action: 2-3 minutes
  • Peak effect: 60-90 minutes
  • Duration of effect: More than 240 minutes
  • Anticholinergic and sedative properties
  • Pregnancy: B
  • Lactation: Probably safe

Pediatric (children other than premature infants and neonates)

  • One time dose: 1.25mg/kg

Reversal Agents:None


Medications: Promethazine (Phenergan) Dosing for Endoscopic Sedation:
  • One time dose: 12.5- 50mg
  • Onset of action: 2-5 minutes
  • Peak effect: Unknown
  • Duration of effect: More than 120 minutes
  • Pregnancy: -C
  • Lactation-Possibly unsafe
  • BLACK BOX WARNING: unsafe in children <2 years; use with caution in children >2 years due to respiratory depression; severe tissue injury if extravasation occurs

Pediatric

  • 12.5-25 IV x 1 dose

Reversal Agents:None

Medications: Droperidol (Inapsine) Dosing for Endoscopic Sedation:
  • Initial dose: 1.25-2.5mg slow IV
  • Additional doses: Additional 1.25mg doses may be administered to achieve the desired effect
  • Onset of action: 3-10 minutes
  • Peak effect: 30 minutes
  • Duration of effect: 2-4 hours
  • BLACK BOX WARNING: proarrhythmic effects
  • Pregnancy: C
  • Lactation: Safety unknown

Reversal Agents:None

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Pregnancy Considerations

  • Smallest effective doses should be used
  • Greatest risk is during first trimester
  • Should also be avoided close to time of delivery
  • FDA categorizes drug safety for pregnancy
  • Consultation with obstetrician and/or anesthesiologist is recommended
  • Meperidine alone is recommended
  • Midazolam should be avoided

Safety in Pregnancy of Commonly Used Medications for Endoscopic Sedation

Drug:Meperidine FDA Category:B Comments:
  • Does not appear to be teratogenic in two major studies
  • Preferred over fentanyl and morphine
Drug: Fentanyl

FDA Category:C Comments:

  • Appears to be safe in humans when given in low doses typical for endoscopy
  • Not teratogenic but was embryocidal in rats
  • Rapid onset of action and shorter recovery time than meperidine
Drug:Naloxone

FDA Category:B Comments:

  • Does not appear to be teratogenic
  • Contradicted in mothers who are dependent on opiates because it can precipitate opiate-withdrawal symptoms
  • To be used only in cases of respiratory depression, hypotension, or unresponsiveness under close monitoring
  • Risk of resedation as drug is metabolized
Drug:Benzodiazepines

FDA Category:D
Comments:

  • Diazepam should not be used for sedation in pregnant women
  • Sustained use of diazepam in pregnancy has been linked to cleft palate and neurobehavioral disorders
  • Midazolam has not been reported to be associated with congenital abnormalities
  • Midazolam is the preferred benzodiazepine when meperidine is inadequate
  • Midazolam use in the first trimester should be avoided
Drug:Flumazenil

FDA Category:C
Comments:

  • Little is known about safety profile
  • Not teratogenic but produces neurobehavioral changes in male rats exposed in utero
Drug:Propofol

FDA Category:B
Comments:

  • Safety in first trimester has not been established
  • When administered to a pregnant patient, it is recommended that this drug be administered by an anesthesiologist due to narrow therapeutic index and need for close monitoring
Drug:Glucagon

FDA Category:B
Comments:

  • Not contraindicated in pregnancy

FDA Pregnancy Categories

The FDA-assigned pregnancy categories as used in the Drug Formulary are as follows:

Category A

  • Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).

Category B

  • Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.

Category C

  • Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Category D

  • There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Category X

  • Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.
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Other Considerations

Pediatric Considerations:

  • Anesthesia assistance is standard of care for sedating the pediatric populations

Elderly Considerations:

  • Use fewer agents at lower doses with more time in between doses
  • Choose agents that have a short half-life, minimal active metabolites and limited side effects

Obstructive Sleep Apnea Considerations:

  • Sedation relaxes the muscle tone of the upper airway and increases airway resistance resulting in a reduction of the diameter of the airway
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Sources

Cohen, L.B., DeLegge, M.H., Aisenberg, J. et al. (2007). AGA Institute Review of Endoscopic Sedation, Gastroenterology, 133:675-701.

Briggs, G.G., Greeman, R,K,, Yaffe, S.J (2011). Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk. 9th ed. Philadelphia: Lippincott Williams & Wilkins.

Kost, M. (2004). Moderate Sedation/Analgesia: Core Competencies for Practice, 2nd Ed. St. Louis, MO: Saunders. 116.

Ludwin, D.B., Shafer, S.L. (2008). CON: The black box warning on droperidol should not be removed (but should be clarified). Anesthesia & Analgesia.106:1418–20. Epocrates Online. Retrieved from: https://online.epocrates.com/noFrame/?ICID=eolepocratesheaderbutton

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