PSA should be done, in accordance with institutional guidelines, by a clinician or service proficient with the procedure and with equipment and trained personnel available to provide emergency airway and ventilatory support.
Monitor the patient throughout PSA, to ensure PSA safety (absence of respiratory depression or cardiovascular compromise) and effectiveness (relief of pain and anxiety):
Continue patient monitoring until the patient has fully recovered from the sedation.
To avoid oversedation, always wait at least 2 minutes after a midazolam dose before giving another dose—of midazolam or any other PSA drug.
PSA using midazolam and fentanyl
When used together, use smaller doses of each drug than when used alone and titrate carefully to avoid respiratory depression. Always wait at least 2 minutes after a midazolam dose before giving another PSA drug. Either drug may be given first; one strategy is to give midazolam first for primarily anxiety-provoking procedures and fentanyl first for more painful procedures.
Before and during the initial ketamine dose, converse with the patient about a happy or joyful topic (eg, a favorite person, place, or activity). This may reduce unpleasant emergence phenomena (confusion, anxiety, panic) following ketamine PSA.
PSA using nitrous oxide inhalation
A trained individual is required to administer or supervise nitrous oxide inhalation.
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