PAGE CURRENTLY BEING UPDATED
You may find the updated medications within the Course Manual, or you may purchase our Sedation Handbook as a handy reference guide.
Medications commonly used in Moderate Sedation
Anesthetic Agents
Methohexitol (Brevital® )
Classification: Ultra short-acting IV barbiturate anesthetic.
Anesthesia: IV: Induction: 50-120 mg to start; 20-40 mg every 4-7 minutes. (doses must be titrated to effect).
- Onset: IV: Immediately
- Duration: Single dose: 10-20 minutes
- Supplied: 500 mg, 2.5 g, 5 gram (powder for reconstitution)
- Initial Dose: 0.25 mg/kg
0.25-0.5 mg/kg Titrate to effect
Onset: 5-7 min
-
- Peak Effect: 1-2 min
- Duration: 2-5 min
Lidocaine 1 mg/kg reduced the incidence of hiccoughs from 16% to 6%
Etomidate (Amidate)
Classification: Sedative Hypnotic:Ultrashort-acting nonbarbiturate hypnotic.
Sedation:
- Initial Dose: 0.1 mg/kg IV bolus.
- Additional Dose: 1 – 4 mg titrate to effect.
- Onset of action: 30-60 seconds.
- Peak Effect: 1-2 min (depends upon dose).
- Duration: 3 – 5 minutes ( terminated by redistribution).
- Supplied: 2 mg/ml (10 ml, 20 ml) injection.
Propofol (Diprivan)
Classification: Sedative hypnotic. Produces rapid hypnosis with minimal excitation.
| Route | Onset of Action | Peak Effect | Duration of Action |
|---|---|---|---|
| IV | 40 seconds | 1 minute | 5-10 minutes |
25 – 50mg (0.5 – 1 mg/kg) IV, administered in 10 mg increments over several minutes.
- Pain on injection is decreased with IV lidocaine, 0.1 mg/kg, added to the diprivan emulsion.
- Strict aseptic technique must be maintained in handling, as diprivan is preservative free and will support bacterial growth.
Diprivan injection should be prepared for single patient use only, just prior to the initiation of each procedure. Discard after opened for 6 hours.
0.5 – 1.0mg/kg infused slowly and titrated to desired effect.
Respiratory effects – respiratory depression, apnea, hiccup, bronchospasm, laryngospasm
- Cardiovascular effects – hypotension, arrhythmia, tachycardia, bradycardia, hypertension
- CNS effects – headache, dizziness, euphoria, myoclonic/clonic movement, seizures, and sexual illusions.
- GI effects – nausea, vomiting, abdominal cramps
Special considerations – this drug must be titrated to effect and administered slowly to prevent the occurrence of adverse reactions. Reduce dose in elderly, hypovolemic, and high-risk patients. Potentiation occurs when combined with narcotic analgesics and CNS depressants.
There is no pharmacologic reversal agent for Propofol.
Ketamine (Ketalar)
- Medication used especially for deep sedation in pediatric patients.
- Not a primary use drug.
- Administer drug only with previous experience or under the direction of a provider familiar with its use.
Mechanism of Action
Selectively interrupts cerebral pathways, causing dissociative anesthesia.
Dosage and Administration
| Route | Onset of Action | Peak Effect | Duration of Action |
| IV | < 60 seconds | 5-10 minutes | 5-15 minutes |
| IM | 3-8 minutes | 5-20 minutes | 12-25 minutes |
- Usually 0.25 to 1.0 mg/kg.
- Dose is based on patient response to medication.
- Rate of infusion should not exceed 50 mcg/kg/min.
Adverse Reactions:
- Respiratory effects– bradypnea, dyspnea, respiratory depression, apnea, bronchial smooth muscle relaxation, increased tracheo-bronchial tree secretions
- Cardiovascular effects– bradycardia, tachycardia, hypertension, hypotension, arrhythmias
- Musculoskeletal– enhanced skeletal tone
- CNS– uncontrolled muscle movements, visual illusions
- GI– vomiting, increased salivary secretions
- Special considerations– monitor patient for emergent reactions including vivid dreams, or hallucinations. Consider premedication (midazolam) to reduce potential for symptoms.
Nitrous Oxide (Kalinox)
Dosage and Effect: A 30% O2 – 70% N2O mixture is the most commonly used for sedation. In dentistry, nitrous oxide is typically used as an anxiolytic or as an anxiety-reducing agent with a 25% O2 – 75% N2O mixture administered through a nasal mask or nasal cannula.
Initial dose: Titrate to effect; start with 100% O2 and remind patient to breathe through the nose.
Onset of action: 2 – 5 minutes
Peak effect: Dose dependent
Duration of effect: 15-30 minutes
Reversal Agent: None; at end of procedure allow patient to breathe 100% O2 for 2-5 minutes to clear the lungs of nitrous oxide.
Benzodiazepines
Diazepam (Valium)
Classification: Benzodiazepine
Dosage / Administration:
| Route | Onset of Action | Peak Effect | Duration of Action |
| IV | 2 – 5 Minutes | 3 – 5 minutes | 15 – 60 minutes |
| Oral | 30 – 90 minutes | 60 minutes | 3 – 8 hours |
Adult Dose:
Administer in 1-2 mg increments every 2 minutes IV until desired effect is achieved. (Slurred speech). Generally 10 to 20 mg in 60 minutes.
Pediatric Dose:
0.1 – 0.3 mg/kg.
Adverse Reactions:
- Respiratory effects – Respiratory depression, apnea
- Cardiovascular effects – Bradycardia, hypotension
- CNS effects – Agitation, confusion, diplopia
- GI effects – hiccups
- Special Considerations – Phlebitis at site of injection, rash, urticaria, avoid extravasation as drug is caustic to tissue.
- May be diluted with normal saline only. Do not mix with any other drug.
- Midazolam is generally preferable to Diazepam due to Midazolam’s decreased duration and easier titratability.
Reversal agent:
Flumazenil (Romazicon) will reverse the respiratory effects of diazepam overdose.
Midazolam (Versed)
Classification: Benzodiazepine.
| Route | Onset of Action | Peak Effect | Duration of Action |
|---|---|---|---|
| IV | 1 – 5 minutes | 3 – 5 minutes | 2 – 6 hours |
| IM | 5 – 15 minutes | 30 – 60 minutes | 1 – 4 hours |
| Oral | 10 – 20 minutes | 30 minutes | up to 3 hours |
Midazolam (Versed) is a very potent short-acting drug that must be given slowly. Administration over at least two minutes is recommended.
Dilution: May dilute to desired concentration with D5W or Ns. Recommend concentration of 0.25 mg/ml, with administration rate no faster than 0.5 mg over 2 minutes.
Initial dose of 0.5mg IV over 2-minutes just before beginning of procedure. Must titrate to effect (slurred speech) by giving additional IV doses over 2 minutes. In general, do not exceed total dose of 3.0 mg, You may continue to titrate higher doses if needed to obtain effect. Wait at least 2 minutes after each administration of medication to determine effect.
Geriatric or patients with impaired pulmonary/hepatic function: Initial dose 0.25mg-0.5mg IV over 2 minutes. Maximum total dose is 2.0 mg. Titrate to effect.
0.025 – 0.05 mg/kg IV over 2 minutes. Maximum total dose 0.1 mg /kg. Titrate to effect.
Do not give midazolam to persons with known hypersensitivities to the drug.
- Do not give to patients with acute narrow-angle glaucoma and shock.
- Reduce dosage for patients with alcohol intoxication, or history of COPD.
Respiratory effects – Respiratory depression, apnea, coughing, bronchospasm
-
- Cardiovascular effects – Cardiac arrest, hypotension, bradycardia, PVC’s, Tachycardia
- CNS effect – Urticaria
- GI effects – Nausea, vomiting, uticaria, hiccups
- Special Considerations – Pain at injection site.
Reversal: Flumazenil (Romazicon) will reverse the respiratory effects of midazolam overdose.
Pediatric Sedation Using Midazolam (Versed): All of the above for Midazolam apply.
Pediatric:
0.025 – 0.05 mg/kg IV over 2 minutes. Maximum total dose 0.1 mg /kg. Titrate to effect.
Contraindications:
- Do not give midazolam to persons with known hypersensitivities to the drug.
- Do not give to patients with acute narrow-angle glaucoma and shock.
- Reduce dosage for patients with alcohol intoxication, or history of COPD.
Adverse Reactions:
- Respiratory effects – Respiratory depression, apnea, coughing, bronchospasm
- Cardiovascular effects – Cardiac arrest, hypotension, bradycardia, PVC’s, Tachycardia
- CNS effect – Urticaria
- GI effects – Nausea, vomiting, uticaria, hiccups
- Special Considerations – Pain at injection site.
Reversal: Flumazenil (Romazicon) will reverse the respiratory effects of midazolam overdose.
Emergency Medications
Diphenhydramine hydrochloride (Benadryl Injection)
Initial dose: 10 – 50 mg up to 100 mg if required; administer intravenously at a rate generally not exceeding 25mg/minute or inject deep intramuscularly, not to exceed 400 mg/day.
Additional doses: Single doses up to 100 mg may be used as needed.
Onset of action: 2-3 minutes
Peak effect: 60-90 minutes
Duration of effect: More than 240 minutes
Reversal Agent: None
Atropine (Atropine Sulfate)
Initial dose: Adult – 0.4 mg – 1.0 mg intravenous; Child >5 kg (11 lbs.) – 0.01 – 0.2 mg/kg, minimum dose 0.1 mg
Additional doses: 0.4-0.6 mg
Onset of action: 45 – 60 seconds
Peak effect: 2 minutes
Duration of effect: 1-2 minutes
Reversal Agent: None
Glucagon (GlucaGen)
Onset of action: 1 minute
Duration of effect: 9-17 minutes -OR- Dose: 2 mg*
Onset of action: 1 minute
Duration of action: 22-25 minutes *Use of 2mg dose produces a higher incidence of nausea and vomiting than do lower doses.
Reversal Agent: None
DILAUDID® Hydromorphone HCl
Action and Clinical Pharmacology:
Hydromorphone has a strong analgesic action and antitussive activity. Small doses of Hydromorphone produce effective and prompt relief of pain usually with minimal nausea and vomiting. Generally, when given parenterally, hydromorphone’s analgesic action is apparent within 15 minutes and remains in effect for more than 5 hours. The onset of action of oral Hydromorphone is somewhat slower, with measurable analgesia occurring within 30 minutes. When sleep follows the administration of Hydromorphone, it is due to relief of pain, not to hypnosis. Hydromorphone is approximately 8 times more potent on a milligram basis than morphine. In addition, hydromorphone is better absorbed orally than is morphine; the former is approximately 20 to 25% as active orally as i.m. Hydromorphone has greater antitussive potency than codeine on a weight basis; however, its dependence liability is also greater than that of codeine. After absorption hydromorphone is metabolized by the liver to the glucuronide conjugate which is then excreted in the urine.
Indications And Clinical Uses:
Relief of moderate to severe pain.
Contra-Indications:
Intracranial lesion associated with increased intracranial pressure, status asthmaticus, and pulmonary edema.
Precautions:
May be habit-forming. Hydromorphone is a narcotic with an addiction liability similar to that of morphine and for this reason the same precautions should be taken in administering the drug as with morphine. Pregnancy: As with all narcotics, hydromorphone should be used in early pregnancy only when expected benefits outweigh risks. If necessary, hydromorphone may be givenby IV route but the injection should be given very slowly. Rapid IV injection of narcotic analgesic agents, including hydromorphone, increases the possibility of adverse effects, such as hypotension and respiratory depression. As with any narcotic analgesic agent, the usual precautions should be observed and the possibility of respiratory depression should be kept in mind. If a patient shows signs of hypersensitivity to hydromorphone the treatment must be stopped. Dilaudid injection has been reported to be physically or chemically incompatible with solutions containing sodium bicarbonate and thiopental sodium. Children: Hydromorphone suppositories are not recommended for use in children.
Adverse Reactions:
Nausea, vomiting, dizziness, somnolence, anorexia and constipation may occur. Pain at injection site; local tissue irritation and induration following s.c. injection, particularly when repeated in the same area.
Symptoms and Treatment of Overdose:
Symptoms: Serious overdose with hydromorphone may be characterized by respiratory depression (a decrease in respiratory rate and/or tidal volume, Cheyne-Stokes respiration, cyanosis), extreme somnolence progressing to stupor or coma, skeletal muscle flaccidity, cold and clammy skin, and sometimes bradycardia and hypotension. In severe overdosage, apnea, circulatory collapse, cardiac arrest and death may occur. Treatment: If significant respiratory depression occurs, it may be antagonized by naloxone as recommended by the manufacturer. Employ other supportive measures as indicated.
Dosage:
Orally for adults, 2 to 4 mg every 4 to 6 hours as required. The usual adult parenteral dose for pain relief is 2 mg by s.c. or i.m. routes every 4 to 6 hours as necessary, If necessary, hydromorphone may be given i.v., but the injection should be given very slowly. Severe pain can be controlled with 3 to 4 mg every 4 to 6 hours as necessary. Rectal suppositories (3 mg) provide long-lasting relief and are especially useful at night. The oral liquid may be diluted in fruit juice or other beverage, if desired.
I.V.: Initial: Opiate-naive: 0.2-0.6 mg every 2-3 hours as needed; patients with prior opiate exposure may tolerate higher initial doses. Dilute 2mg one ml ampoule into 9cc’s of saline which is 0.2mg per ml.
Note: More frequent dosing may be needed.
Meperidine Hydrochloride (Demerol)
Binds with opiate receptors in the CNS, altering perception of and emotional response to pain.
| Route | Onset of Action | Peak Effect | Duration of Action |
|---|---|---|---|
| IV | 1 – 5 minutes | 5 – 7 minutes | 2 – 4 hours |
| IM | 10 – 15 minutes | 30 – 50 minutes | 2 – 4 hours |
| Oral | 15 – 45 minutes | 60 – 90 minutes | 2 – 4 hours |
Adult: 25 mg slow IVP. Slowly titrate in 25 mg increments to individual patient response. Total dose for nursing administration, 100 mg in 60 minutes. Reduce dosage and rate of administration in patients who are elderly, debilitated, having renal or hepatic disease, or who have hypothyroidism. Contraindicated in patients on MAO inhibitors. Severe and even fatal reactions have been known to occur.
Pediatric: 1 – 1.5 mg/kg. Titrate dose to individual response. Max. dose 100mg.
Respiratory effects – severe respiratory depression and arrest. Use with caution in patients with COPD, asthma, corpulmonale, decreased respiratory function, hypoxia or hypercapnia. Cardiovascular effects – orthostatic hypotension, bradycardia, tachycardia, palpitations, syncope, shock, cardiac arrest.
CNS effects – euphoria, dysphoria, weakness, sedation, convulsions, agitation, tremors, uncoordinated muscle movements, transient hallucinations, disorientation, visual disturbances. GI – dry mouth, constipation, biliary spasm, nausea and vomiting.
Integumentary – flushing, pruritis/local tissue irritation (histamine release), uticaria, skin wheals, local irritation
GU – urinary retention
Special considerations – this drug must be titrated to effect and administered slowly to prevent the occurrence of adverse reactions.
Reversal: Naloxone (Narcan) will reverse the respiratory and cardiovascular effects of Demerol overdose.
Fentanyl Citrate (Sublimaze)
Binds with opiate receptors in CNS, altering perception of and emotional response to pain.
| Route | Onset of Action | Peak Effect | Duration of Action |
| IV | 3 – 5 minutes | 5 – 15 minutes | 30 – 60 minutes |
| IM | 5 – 8 minutes | 15 – 20 minutes | 1 – 2 hours |
| Transmucosal | 5 – 15 minutes | 1 – 2 hours | 1 – 2 hours |
Dosage/Administration
Adults: 25-100mcg slow IV injection into IV infusion line over 1-2 minutes is required. Titrate 25 mcg at a time. Total recommended dose for nursing administration, 200 mcg for healthy young adult. Reduce dosage and rate of administration in patients who are elderly, debilitated or have renal or hepatic disease.
Pediatric: 0.5 – 2 mcg/kg. Titrate to individual response.
Adverse Reactions
Respiratory effects – potent respiratory depression, apnea. Use with caution with patients with COPD or other respiratory compromise.
Cardiovascular effects – hypotension, bradycardia, tachycardia, palpitations, syncope, shock, cardiac arrest.
CNS effects – euphoria, dysphoria, weakness, sedation, agitation, tremors, seizures, use with caution with patients with increased intracranial pressure.
GI effects – nausea, vomiting, delayed gastric emptying, biliary tract spasm.
Musculoskeletal – may cause muscular rigidity of the thorax to the point that ventilation (spontaneous or controlled) is impossible. Muscle relaxant can be used for treatment, but is only to be given by anesthesia; therefore, treat with Narcan.
Special considerations – this drug must be titrated to effect and administered slowly to prevent the occurrence of adverse reactions. DO NOT mix with barbiturates.
Reversal Agent: Naloxone (Narcan) will reverse the respiratory and cardiovascular effects of Fentanyl overdose. Reversal brought on too rapidly may cause nausea, sweating, and hypertension.
Morphine Sulfate
Binds opiate receptors in CNS, altering perception of and emotional response to pain.
| Route | Onset of Action | Peak Effect | Duration of Action |
| IV | 5 – 10 minutes | 20 minutes | 4 – 5 hours |
| IM | 10 – 30 minutes | 30 – 60 minutes | 4 – 5 hours |
| Oral | < 60 minutes | 1 – 2 hours | 6 – 12 hours |
Dosage/Administration
Adults:
- Give 2 – 10 mg IV.
- Must give slowly and titrate to individual response.
- Assess patient continuously for signs and symptoms of pain and give additional doses for increasing pain levels.
- Decrease dosage if giving to elderly or debilitated patients and in patients with renal or hepatic disease.
- Dilute with 5 ml of sterile water or NS and give slowly.
- May repeat every 15 minutes.
- Total dosage 10 mg in 60 minutes.
Pediatrics: 0.05 – 0.1 mg/kg IV, titrated to effect.
Adverse Reactions
- Respiratory effects – respiratory depression, bronchospasm, laryngospasm.
- Cardiovascular effects – hypotension, hypertension, bradycardia, arrhythmias
- CNS effects – euphoria, dysphoria, somnolence, syncope
- GI effects – nausea, vomiting, constipation, biliary tract spasm
- GU – urinary retention
- Integumentary – pruritis/local tissue irritation, urticaria, skin wheals
- Musculoskeletal – chest wall rigidity
Reversal Agent: Naloxone (Narcan) will reverse the respiratory and cardiovascular effects of MS overdose.
Other Sedation Medications
Promethazine (Phenergan)
One time dose: 12.5- 25 mg IV; 25 – 50 mg IM
Onset of action: 20 minutes
Peak effect: 4 – 6 hours
Duration of effect: Up to 12 hours
Reversal Agent: None
Droperidol (Inapsine)
Initial dose: 0.625 – 1.25 mg IV (slow)
Additional doses: Additional 1.25 mg 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
Reversal Agent: None
Reversal Agents
Flumazenil (Romazicon)
(Specific Benzodiazepine antagonist)
Classification: Reversal Agent
Dosage / Administration:
| Route | Onset of Action | Peak Effect | Duration of Action |
| IV (bolus or infusion) | 1 – 2 minutes | 6 – 10 minutes (but 80% of the maximum response is seen within 3 minutes.) Call anesthesia if there is no desired clinical response with the administration of the initial 1 mg. | 45 – 90 minutes |
Adverse Reactions:
- Nausea, vomiting, sweating, hot flashes, agitation, headache, injection site pain
- Do not use Flumazenil in patients who chronically take Benzodiazepines
May precipitate:
- Tremors
- Profuse sweating
- Hypotension
- Seizure activity
Reversal agent: None
Naloxone Hydrochloride (Narcan)
Classification: Reversal Agent
Description:
- A pure opioid antagonist with no agonist activity.
- It reverses respiratory depression, hypotension, hypercapnia, sedation, and euphoria associated with the administration of narcotics.
Dosage / Administration:
| Route | Onset of Action | Peak Effect | Duration of Action |
| IV | 1 – 2 minutes | 5 – 15 minutes | 30 – 45 minutes |
Dosage/Administration
NARCAN injection is available as a sterile solution for intravenous, intramuscular and subcutaneous administration in three concentrations:
- 02 mg of naloxone hydrochloride per ml
- 4 mg of naloxone hydrochloride per ml
- 1 mg of naloxone hydrochloride per ml
pH is adjusted to 3.5 ± 0.5 with hydrochloric acid.
Adult:
Initial dose: 0.04 mg – 2 mg titrated in small increments. Dilute 0.4 mg amp of Narcan to 10cc total volume. This will be 0.04 mg or 40 mcg per cc. Give this reversal 1cc at a time, with at least 2-3 minutes between doses. This titration will allow one to bring the patient up to a safe respiratory rate without reversing analgesia or causing severe CV problems. If no response is observed after 2 mg has been administered, the diagnosis of narcotic induced toxicity should be questioned. Total dosage for nursing administration – 2 mg.
Pediatric:
Initial dose: 0.01 mg. If initial dose does not result in desired clinical reversal, administer a subsequent dose of 0.01 mg. If this does not result in desired effect, administer 0.1mg/kg. Total dosage for nursing administration in pediatric patients is: 0.2 mg/kg.
Adverse Reactions:
Respiratory effects – pulmonary edema
- Cardiovascular effects– hypotension, hypertension, arrythmias, ventricular tachycardia, ventricular fibrillation
- CNS effects – excitement, tremors, seizures, reversal of analgesia.
- GI– nausea, vomiting
Special considerations
Titrate slowly to desired effect. Complete reversal from higher doses will result in total reversal of analgesia with other effects including hypertension, excitation, tachycardia. Monitor the patient closely in the post-procedure period for re-sedation. Additional doses of Naloxone may be required.
Reversal agent: None