Versed has anterograde amnesia, meaning you, ideally, don’t remember things that happen after it’s given. This is dose dependent and not guaranteed, but it’s nice when it works.
But the big thing, from my perspective, is that it’s short acting. Unlike, say, a colonoscopy, in many ER procedures the pt is in fair bit of pain. After we remove that pain stimulus, what was the perfect dose may now be too much. If the drug lasts another 4 hours that’s a big problem, if it lasts another 20 minutes, not so much.
Ah - in my own experience, it does indeed work that way.
I think they gave me Versed and Fentanyl when I had my cataract surgery - but at a MUCH lower dose, so there wasn’t any amnestic effect. For other surgeries, yep: room tilts, then I’m in recovery.
OK, this is not a procedural sedation story, but, some years ago I had a woman with a lower extremity fracture. We had her juiced up on morphine and she was cruising until a cramp hit. She told me she gets those a lot at night, but usually walks them off. Well, that wasn’t an option. So, I’ve got her foot in both hands, leaning my full 200# of weight to counteract the muscle, and I can feel the bones crutching, and she’s screaming, as one does.
Now, in that case, we gave her Diazepam because it has good anti-spasmodic effects. But, after we’d broken the spasm, splinted the fracture and stopped messing with it, her respirations started to fall. We do have a reversal agent for diazepam, but we don’t like to use it in general, and really didn’t want the cramps to come back in this case, so we used narcan instead to reverse some of the morphine and she did great.
I had some of that earlier this week for diagnostic spinal injections. After I got onto the procedure table, I heard my doc ask for sedation - think he said something about “standard,” whatever that may be. (Perhaps a standard dose of the two meds used for an “average” adult without titrating for a specific weight?) I felt someone at the IV port on my hand, then vaguely recall rolling off the table onto a gurney. Then I was fully awake in recovery. It’s the light switch aspect that I find fascinating. No periods of grogginess after getting versed and fentanyl.
I’ve also had MAC, or Managed Anesthesia Care. AFAIK, it’s essentially sedation but administered by a dedicated anesthesiologist rather than a nurse or doc before they treat or do whatever’s needed, and they’re qualified and equipped to immediately kick over to general anesthesia if needed. No idea what would happen to require that transition. I was a bit groggy after some hand surgery where I know I was given MAC.
However, I’m a real bear to get out of general anesthesia. When I start to come out of it in the PACU, there will be quite a while of hearing “Open your eyes!” and “Breathe!” PACU time is not cheap - I’m sure my insurance would appreciate if I came out faster, but that’s unlikely.
My husband had some combination of Good Drugs and an epidural for his knee surgery in 2018. Not full general anesthesia which required intubation. He was the last patient in the recovery area (at a stand-alone surgery center, not a hospital) so they had me back with him as soon as they could - and I remember there was a lot of “remember to breathe!” as he was actually desaturating a little. It was definitely more than light procedural sedation.
I’m kind of curious as to what the cutoff is for wanting intubation versus what he had. I vaguely remember that before another one of his surgeries, they talked about doing something that did not require it - we even asked about it here at the time and I think the consensus was he had some kind of laryngeal mask airway.
Is the deciding factor that they’re using strictly IV stuff versus gas? Something else? I would assume that gas anesthesia requires intubation so the gas isn’t leaking out and making the staff groggy - that would seem to be a Very Bad Idea.
As a side note: when the anesthesiologist for the knee surgery said “epidural”, I kinda freaked a bit - as epidurals simply do not work well for me. Had it been ME they were talking about, I’d have bolted as fast as I could manage.
Which brings to mind the old saw:
Q. What is the definition of an anaesthesiologist?
A. A doctor half asleep next to a patient half awake.
Intubation is needed once the anaesthetic process leaves a patient needing mechanical ventilation. Under far enough and you don’t breathe on your own.
There are other useful attributes - like stopping a patient aspirating something nasty whilst under. Which could be a bad day for the patient.
ETT vs an LMA. the LMA is usually offered as a can’t miss choice, although, TBH, I don’t see them used much in the ER. With the exception of short-term vs long-term procedures, I’m not sure what criteria they might consider for different types of anesthesia. I would assume things like a pts prior history of complications or certain injuries would be among them, but things like ‘where I went to school,’ or ‘my favorite mentor did it this way’ still come into play.
PACU time is not cheap - I’m sure my insurance would appreciate if I came out faster, but that’s unlikely.