Porphyria Educational Services
Vol. 2 No. 31
August 6, 2000
For many surgeries or medically procedures
today conscious sedation is used.
In terms of a porphyria patient undergoing the use of conscious sedation,
of proper anesthesia is mandated.
Conscious sedation is achieved
by administering pharmacological agents.
The most highly used way of
administration is intravenous (IV), although
medications may be given orally (P0), rectally, intramuscular (IM),
or nasally. The most commonly used agents are benzodiazepines, narcotics,
barbiturates, and certain hypnotics (such as chloral hydrate).
The pharmaceuticals used depend on the
type, duration and intensity of the procedure.
Physicians and nurses who do not have
privileges in anesthesiology should not administer
drugs classified as anesthetic agents, including but not limited to, ketamine,
pentothal, methohexital, propofol, etomidate and nitrous oxide, for the intent
Differences in patients' health status with
variable ability to metabolize medications
should be considered when selecting and administering the medications.
Any drug that is metabolized
through the liver should not be used in an acute
hepatic porphyria patient.
The anethesist is responsible for
validating the physician's order, obtaining the medications,
and assuring administration of medications according to the hospital's policy.
Such procedure includes the right medication in the right dose, to the
over the right time frame, through the right route.
The person administering the anesthesia must
adhere to all National, State and
Hospital guidelines when administering any IV medication.
Any inconsistencies between physician orders
and guidelines should be
resolved prior to administering the medications.
All medications, including reversal agents,
should be documented on the
appropriate patient permanent record.
Most usually non-anesthesia
personnel may administer only benzodiazepines such as diazepam
(Valium) and midazolam (Versed), and narcotics such as fentanyl (Sublimaze),
morphine, or meperidine (Demerol).
Conscious sedation is achieved using the same
delivery methods used for anesthesia and deep sedation.
Health care providers monitoring the sedated
patient must demonstrate a knowledge of anatomy,
physiology, dysrhythmia recognition, complications related to conscious
sedation, and a
knowledge of the pharmacology of the medications and the reversal agents.
Such health care professionals must also
have the skills necessary to assess,
diagnose, and treat any complications that may arise.
Midazolam (Versed) is a short acting
benzodiazepine CNS depressant.
It is indicated for conscious sedation prior to short diagnostic or surgical
either alone or with a narcotic. Versed may be administered IV, IM, P0,
nasally. The most common route of administration is IV.
Midazolam [Versed] should not be used on
patients with known benzodiazepine hypersensitivity or acute narrow-angle
glaucoma. Adverse reactions from IV administration include hiccups, nausea,
vomiting, over sedation, headache, coughing, and pain at the injection site.
Narcotics are also used during surgery or
medical procedure where pain can occur.
Narcotics are naturally occurring or synthetic
opioids that act to provide analgesia, sedation, and elevate the pain
threshold. They may be classified as agonists, mixed agonists-antagonists, or
partial agonists by their activity at the opioid receptors.
Fentanyl (sublimaze) is a synthetic opioid. It
is indicated for analgesic action of short duration in procedures such as
Reversal Agents are another factor which needs
to be considered in terms of the porphyric patient.
Reversal agents are drugs that counteract
the effects of other drugs. The reversal agent used for benzodiazepines is
flumazenil (Romazicon), and the reversal agent used for narcotics is naloxone
Flumazenil is a benzodiazepine antagonist. It
competes for receptor sites thereby reducing or reversing the effects of the
benzodiazepine. It should be used with extreme caution, and never in porphyria
patients whoexperience seizures.
Naloxone (Narcan) is a pure narcotic
antagonist. It competes for the receptor sites thereby reversing the effect of
the narcotic. It is important to note that all opioid effects are reversed in
Baseline vital signs, oxygen saturation level,
heart rhythm, and level of consciousness are the minimum assessment parameters
obtained and documented prior to sedation. During the medication
administration, the sedating period and the recovery phase, these parameters
should be monitored and documented at least every five minutes. The
anesthesist should immediately
report to the physician any variations from baseline.
Documentation of sedation and other
pharmaceutical in porphyria patients should include:
Dosages, route, time and effect of all drugs
used ;Type and amount of fluids administered, including blood and blood
products, monitoring devices or equipment used
Heart rate, rhythm, blood pressure, respiratory rate, oxygen saturation, and
level of consciousness
Interventions and the patients response to the interventions
Untoward or significant patient reactions and their resolution or outcome
The patient must be continuously monitored
from the start of conscious sedation until the time discharge criteria are
Michelle G. RNA, BS, MNS