Intranasal Delivery for Procedural Sedation

Below are the indications for procedural sedation in the ED, using intranasal delivery of intranasal opiates and benzodiazepines.

Indications:

• Pediatric procedural sedation (minor procedures).
• Adult and pediatric minor painful procedures: Burn dressing changes; re-packing wounds such as abscesses; anytime you consider an intramuscular shot prior to a procedure.
• Combination therapy may work better than either alone due to variable patient responses to medications.

Opiates:

Fentanyl or sufentanil are most appropriate for intranasal delivery to treat pain and cause sedation.

A. Reasonable intranasal starting dose for painful procedures:

• Fentanyl: 3 mcg/kg (comes in 50 mcg/ml)
• Sufentanil: 0.2-1.0 mcg/kg (comes in 50 mcg/ml). Use bottle atomizer with pump rather than a syringe with this medication to get exact dose to 0.1 ml.

B. Be very wary of respiratory depression. Monitor patients with pulse oximetry and close observation whenever using these very powerful opiate medications. Be even more careful when used in combination with midazolam.

C. Titration to pain is possible. Repeat dosing (� dose) every 3-5 minutes until desired effect is achieved.

Benzodiazepines:

Midazolam is most appropriate for intranasal delivery. It results in mild somnolence with resultant reduction in anxiety and probably amnesia. It will not make the patient unconscious. Be aware that midazolam causes some nasal burning for 30-45 seconds when administered.

• Reasonable intranasal starting dose:
  • Midazolam 0.2 to 0.5 mg/kg
  • Use the higher dose if some somnolence preferred.
  • Use the lower dose if opiate is being used and be very wary of respiratory depression when used in combination.
• Use only concentrated midazolam (5 mg/ml).
• Maximum 10 mg (2 ml) (More will just run out nose.)

Source: Timothy Wolfe, MD, Associate Professor, Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City.

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