Non IV sedation options

[caligas]

Had a “special” patient lose his mind in the recovery room, unfortunately after IV had been removed. I was alone at the outpatient center.

Tried to wait it out but it was getting dangerous and getting worse.

Ended up giving him IM Midaz. Was worried that this might make the situation worse but it definitely helped and we were able to get him his normal oral meds on board.

I also considered IM Ketamine and nasal fentanyl.

Any other ideas?

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[patriot6]

Dexmedetomidine

Haldol

 

[TheLoneWolf]

I have seen unmitigated dysphoric reactions with as little as 20 mg of IV ketamine, even with premedication. Agree on the IM or nasal midazolam.

 

[ProwlerturnGas]

Haldol FTW

 

[caligas]

Do you guys increase the dose for nasal meds?

 

[IlDestriero]

IM sux.
Settles them every time!

 

[caligas]

Haldol FTW

Great idea but I don’t think we have it at the outpatient center

 

[repititionition]

Great idea but I don’t think we have it at the outpatient center

If you have droperidol it’s grossly equipotent.

 

[GassYous]

Tell your nurse to hurry it up with the dc paperwork

 

[coffeebythelake]

I have seen unmitigated dyspric reactions with as little as 20 mg of IV ketamine, even with premedication. Agree on the IM or nasal midazolam.

I've seen this as well. 20 mg ketamine, normal sized woman, fairly short sedation case with propofol/fent/ketamine/versed, wouldn't "wake up" at the end of procedure and was just turning her head side to side for more than 1 hour until she "came out of it"

 

[IMGASMD]

B52?

 

[anbuitachi]

Had a “special” patient lose his mind in the recovery room, unfortunately after IV had been removed. I was alone at the outpatient center.

Tried to wait it out but it was getting dangerous and getting worse.

Ended up giving him IM Midaz. Was worried that this might make the situation worse but it definitely helped and we were able to get him his normal oral meds on board.

I also considered IM Ketamine and nasal fentanyl.

Any other ideas?

how much did you have to use?

 

[caligas]

how much did you have to use?

Just 2 mg IM and he improved dramatically

 

[kidthor]

Had a “special” patient lose his mind in the recovery room, unfortunately after IV had been removed. I was alone at the outpatient center.

Tried to wait it out but it was getting dangerous and getting worse.

Ended up giving him IM Midaz. Was worried that this might make the situation worse but it definitely helped and we were able to get him his normal oral meds on board.

I also considered IM Ketamine and nasal fentanyl.

Any other ideas?

I've had good success with intranasal fentanyl for pain/sedation - it's probably the least "complicated" of the choices due to predictable effect without too much downside - and works pretty fast. IM midazolam here was certainly a good choice.

 

[Iso4ane]

 

[Hork Bajir]

Never given IM Midaz, what’s the dosing range for an adult? Time to onset/peak and duration of effect?

 

[turkeyjerky]

Never given IM Midaz, what’s the dosing range for an adult? Time to onset/peak and duration of effect?

In the ED, we usually use 5-10 mg IM. Peak effect at about 15 min. I usually combine 5 mg IM midazo w/ 5 mg IM haloperidol. I would use droperidol if I had it, either as monotherapy or in combo w/ midaz depending on the circumstances (sympathomimetic vs etoh vs primary psych)

 

[caligas]

I've had good success with intranasal fentanyl for pain/sedation - it's probably the least "complicated" of the choices due to predictable effect without too much downside - and works pretty fast. IM midazolam here was certainly a good choice.

Yes, agree nasal fent would have probably worked, but he was also trying to bite so that was a factor.

 

[DocMcCoy]

Learned the good ol IM 5/2 Haldol Ativan as an intern from the ED guys for the bat sht crazies. Some combination of those hasn’t let me down yet.

 

[Twiggidy]

Had a “special” patient lose his mind in the recovery room, unfortunately after IV had been removed. I was alone at the outpatient center.

Tried to wait it out but it was getting dangerous and getting worse.

Ended up giving him IM Midaz. Was worried that this might make the situation worse but it definitely helped and we were able to get him his normal oral meds on board.

I also considered IM Ketamine and nasal fentanyl.

Any other ideas?

Out of pure curiosity and for teaching purposes for residents and young attendings on here, what was the patient's age and what was the primary anesthetic?

 

[caligas]

Out of pure curiosity and for teaching purposes for residents and young attendings on here, what was the patient's age and what was the primary anesthetic?

30 ish. Had GA with sevo for dental.

 

[Twiggidy]

30 ish. Had GA with sevo for dental.

Interesting. Young dudes can wake up wild, especially with gas and especially if there's "undisclosed recreation stuff" ("I drink 1 beer a week = I do 3 keg stands a week).

This is for the young folks/new folks. This young strapping dudes have to wake up comfortable (RR in the 6-8s or even lower) or they'll freak out and I personally TIVA these guys because I think the make up is smoother. I honestly think ISO wake ups are smoother but it may not always be available in ASCs. My theory? Sevo washes out so fast I personally feel like its someone jolting you awake like in boot camp so people (especially young folks and certain old men) wake up wild. I feel like the ISO wake up is smooth like waking from a 2:1 gummy.....allegedly

Just food for thought. Not attacking technique.

 

[hiyaman]

I've seen this as well. 20 mg ketamine, normal sized woman, fairly short sedation case with propofol/fent/ketamine/versed, wouldn't "wake up" at the end of procedure and was just turning her head side to side for more than 1 hour until she "came out of it"

Was this person drug abuser/pain patient?

 

[Arch Guillotti]

Learned the good ol IM 5/2 Haldol Ativan as an intern from the ED guys for the bat sht crazies. Some combination of those hasn’t let me down yet.

B52 - benadryl, haldol, ativan

 

[coffeebythelake]

N

Was this person drug abuser/pain patient?

No

 

[turkeyjerky]

B52 - benadryl, haldol, ativan

I would argue that we have better options. Esp in an outpatient case, where you're hoping to send the patient home eventually. This cocktail tends to produce very prolonged sedation, not unusual for someone to be knocked out for 6-8 hours ime. It's also relative slow to take effect, eg 15-20 min, which, in a truly dangerous situation, is either too long or puts the patient at risk for dose stacking. Also, the diphenhydramine is really unnecessary in acute treatment (psych hospitals include it in order to prevent dystonic reactions which rarely occur w/ initial dosing of haldol) and also leads to prolonged sedation.