Pain is a noxious sensation transmitted by specialized nervous structures to the brain, where its perception is modified by cognition and emotion. 7 Analgesic and anesthetic techniques may modulate pain at the level of the peripheral nerves, spinal cord, thalamus, or cortex.
Analgesia is "relief of perception of pain without intentional production of a sedated state. Altered mental status may be a secondary effect of medications administered for this purpose."8 Agents for pain relief interrupt axonal action potential propagation (i.e., "local anesthetics"), modulate the inflammatory cascade (e.g., ibuprofen), or modulate central nervous system (CNS) responses to pain (e.g., enkephalins and opioids). 79
Anxiolysis is the reduction of apprehension without alterations in the level of consciousness. 8 A kind approach to the patient, a realistic and unhurried explanation of what may be expected, distracting conversation, and music have anxiolytic properties.
Neurolepsis is quiescence, indifference to surroundings, and reduced motor activity. Agents used for this purpose include haloperidol and droperidol.
Dissociation is characterized by amnesia, analgesia, sedation, and maintenance of muscle tone. Ketamine is the only commonly used dissociative agent.
Sedation is controlled reduction of environmental awareness.8 It is not so much a specific level of consciousness as it is a continuum, incorporating anxiolysis or light sedation at one extreme and general anesthesia at the other. The agent or agents chosen, the rate of delivery, the pharmacokinetics of CNS uptake and redistribution, the kinetics of metabolic and elimination pathways, and the degree of patient stimulation may result in varying degrees of sedation over time. The level of sedation is dynamic within a given patient and must be continually assessed to detect changes in its depth. Light or conscious sedation (CS) produces minimal depression in the level of consciousness and enables the patient to maintain a patent airway and respond appropriately to stimulation or commands. 8 Deep sedation produces marked depression of consciousness or unconsciousness and frequently results in loss of independent airway maintenance, protective reflexes, adequate respirations, and satisfactory hemodynamics.8
General anesthesia is the presence of "sensory, mental, reflex, and motor blockade and concurrent loss of all protective reflexes."10 PRINCIPLES OF CONSCIOUS SEDATION
The indications for CS include the treatment of severe pain, attenuation of the pain and anxiety associated with procedures, rapid tranquilization, and the need to perform a diagnostic procedure (Iable 3,3:.1...). No single regimen fits all patients and their clinical problems, so doses and agents should be individualized. The physician must integrate the nature of the planned procedure with an assessment of the patient's wishes and physical status, the physician's skills, the patient's intended disposition, the available resources, and a sound knowledge of the pharmacology of the available drugs to formulate a management plan.
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