orm_asc_october-2024 - 9

Ambulatory Surgery Centers
a short-active anesthetic
(remimazolam) and a potent
short-acting opioid
(oliceridine) provides effective
sedation and analgesia,
but with fewer
side effects (such as
nausea, vomiting, constipation,
and respiratory
depression) than their
relatively older counterShawn
Craddock,
DNP,
RN,
CNOR, NE-BC
parts. Both drugs were approved individually
in 2020, and the combination could
eventually rival established sedative-analgesic
combinations (eg, propofol and
fentanyl) for moderate sedation.
Midazolam
(Benzodiazepines)
Onset
2-3
minutes
Duration
5-10
minutes
More information about the remimazolam
and oliceridine combination can
be found in an article by Goudra and
Mason listed under the References. In
clinical trials, remimazolam significantly
decreased the incidence of hypotension
and respiratory depression and had a
faster recovery time compared to propofol.
Compared to midazolam, it had
a faster time to discharge and to return
to neuropsychiatric function. Oliceridine
(Olinvyk®) is approximately five times
more potent than morphine and has a
wider therapeutic window, as well as
an onset of 3 to 4 minutes. It also has
relatively lower respiratory depressant
Comments
Most commonly
used of the
benzodiazepines
thanks to its faster
onset of sedation,
more complete
amnesia, and
improved awakening
Fentanyl
(Opiates)
1-2
minutes
1-2 minutes Increases pain
threshold. Naloxone
is a strong antidote
Ketamine
1 minute
5-15
minutes
PSA doses maintain
a patent airway
and spontaneous
respiration
Etomidate
Dexmedetomidine
(Precedex)
Methohexital
(Barbiturates)
1-2
minutes
3-5
minutes
15-30
seconds
5-7 minutes Minimal
cardiovascular and
respiratory effects
15 minutes Does not cause
respiratory
suppression
Euphoria, confusion,
respiratory depression,
visual disturbances,
dyskinesia, hallucinations,
delirium
Recovery agitation,
transient airway
complications such as
laryngospasm, and emesis
Transiently lowers cerebral
blood flow and transient
adrenal suppression
Bradycardia, hypotension,
mild respiratory effects,
upper airway obstruction
possible
4-7 minutes Onset within seconds Respiratory depression,
transient hypotension
Alcohol and other drugs
(ie, cocaine, heroin) can
synergistically exacerbate
fentanyl's side effects. Lifethreatening
overdose
May cause emergence
phenomena (visual hallucinations,
disorientation). Contraindicated
in patients with increased blood
pressure or heart rate
Hypnotic effects only, no
analgesic properties
Use of other analgesics necessary
for the more painful procedures
Contraindicated in patients with
acute intermittent porphyria. No
analgesic properties (may even
reduce the pain threshold)
Side Effects
Hiccoughs, cough,
nausea, and vomiting.
Thrombophlebitis,
thrombosis, and pain
on injection. Hangover
effects with nighttime
administration
properties. As an analgesic, it can pair
well with benzodiazepines and other
intravenous anesthetics, such as propofol,
in moderate and deep sedation.
Other common PSA agents
Examples of other common intravenous
anesthetics are outlined in the table below,
based on articles by Benzoni and Cascella,
Ramos-Matos et al, Lingamchetty et al, and
NYSORA. The list of IV PSA agents and their
characteristics are by no means comprehensive.
Practitioners should consult clinical
indications, dosage, side effects, and
caution for each drug.
Caution
Neurocognitive alterations in
elderly patients
Alcohol or opioids greatly increase
the sedative and respiratorydepressant
effects, and the risk
for cardiovascular depression
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