{"type":"rich","version":"1.0","provider_name":"Transistor","provider_url":"https://transistor.fm","author_name":"Board Pearls","title":"Chapter 29, Ep 2 of 4: Sedation Depth and Agents","html":"","width":"100%","height":180,"duration":577,"description":"Episode two frames procedural sedation around one trade: the depth you want versus the depth your team can rescue from. The ASA continuum sets the rescue rule, the practitioner must be able to manage a patient one level deeper than intended, and ASA physical status predicts who tolerates endoscopist-supervised moderate sedation versus who needs anesthesia. Midazolam and fentanyl carry the easy case at the cost of multiplicative respiratory depression; propofol buys fast onset and offset for the complex case at the cost of no antagonist. The alternative agents each solve one problem the standard pair cannot.\n \nTopics covered\n\nThe intended-versus-rescuable depth trade\nASA sedation continuum and the rescue rule\nASA physical status classification\nMidazolam plus fentanyl pharmacology and dosing\nMultiplicative benzodiazepine-opioid respiratory depression\nPropofol kinetics and staffing implications\nEtomidate, ketamine, and dexmedetomidine\n \n \nKey decisions\n\nQualify to rescue one level deeper than the intended target, because a moderate-sedation plan reliably drifts into deep sedation in a subset of patients.\nCarry ASA class one and two patients with endoscopist-supervised midazolam and fentanyl for routine EGD and colonoscopy, and involve anesthesia for class three and above.\nTitrate midazolam in one milligram increments (0.5 to 2 mg initial) every two to five minutes and fentanyl in twenty-five to fifty microgram increments, waiting for peak effect at three to five minutes before redosing.\nChoose propofol for long, complex, ASA three-plus, or high-aspiration-risk cases, with airway-trained personnel immediately available because it has no antagonist and produces predictable apnea.\nPick etomidate (0.1 to 0.2 mg/kg) for the hemodynamically unstable patient such as active hemorrhage with severe aortic stenosis, accepting six to twenty-four hours of adrenal suppression and avoiding it in sepsis.\nReach for ketamine when propofol-induced apnea is unacceptable or IV access is...","thumbnail_url":"https://img.transistorcdn.com/-FuAdDBcPDLhEoUmroZKtOBRvuBn_FHPpYlh41hOnU4/rs:fill:0:0:1/w:400/h:400/q:60/mb:500000/aHR0cHM6Ly9pbWct/dXBsb2FkLXByb2R1/Y3Rpb24udHJhbnNp/c3Rvci5mbS9iNzlh/ZTU4Y2MzNWExMjQ5/MjA5OWMwMmI3ZTk5/NGFiZS5wbmc.webp","thumbnail_width":300,"thumbnail_height":300}