Opioid-Sparing Approach to Anesthesia and Procedural Sedation

Core Multimodal Regimen

The American College of Emergency Physicians recommends implementing a multimodal opioid-sparing approach using acetaminophen 1000mg IV, ketorolac 15-30mg IV, ketamine 0.5 mg/kg IV, and dexmedetomidine 0.5-1 mcg/kg loading dose, with propofol or midazolam for sedation, reserving low-dose fentanyl for breakthrough needs 1, 2
This approach prioritizes morbidity and mortality reduction by minimizing opioid-related respiratory depression, postoperative nausea/vomiting, and ileus while maintaining adequate analgesia and sedation 1, 2

Acetaminophen 1000mg IV or 15-20 mg/kg in pediatrics is recommended as a non-opioid analgesic 1, 2, 4
Ketorolac 15-30mg IV is recommended as an NSAID, with dose reduction in elderly and renal impairment 1, 2
Gabapentinoids, such as pregabalin 75-150mg PO or gabapentin 300-600mg PO, may be used as a single dose for anxiolysis, but with caution due to increased sedation and dizziness 1, 2

Midazolam 1-2mg IV is recommended for moderate sedation, with dose reduction in elderly and ASA III-IV patients 5
Ketamine 0.5 mg/kg IV is recommended as a co-analgesic and MAC reduction agent, providing analgesia and reducing opioid requirements by 30-50% 3, 6
Dexmedetomidine 0.5-1 mcg/kg loading dose is recommended for sympatholysis and sedation, with caution due to potential bradycardia and hypotension 3, 6

The procedural sedation algorithm recommends pre-medication with acetaminophen and ketorolac, followed by induction with midazolam and ketamine, and maintenance with propofol or midazolam infusion 1, 2, 3, 5

Acetaminophen 1000mg IV/PO every 6 hours and NSAID (ketorolac 15-30mg IV every 6 hours or oral alternative) are recommended for post-procedural analgesia 1, 2
Opioids should be avoided for routine post-procedural analgesia, and used only for severe breakthrough pain 1, 4

Continuous monitoring of pulse oximetry, capnography, blood pressure, heart rate, and respiratory rate is recommended 3, 5
Immediate availability of naloxone and flumazenil for reversal is recommended 3, 5
Oxygen supplementation and airway equipment should be readily accessible 5

In elderly patients (>65 years), all sedative doses should be reduced by 50%, and benzodiazepines should be avoided when possible 1, 5
In patients with renal insufficiency (GFR <30), morphine and meperidine should be avoided, and fentanyl should be used as the preferred opioid if needed 7, 3