Errors in Procedural Sedation & Analgesia · oral airway, ventilation. stop the drugs position the...
Transcript of Errors in Procedural Sedation & Analgesia · oral airway, ventilation. stop the drugs position the...
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Errors in Procedural Sedation
& Analgesia
reuben j. strayer emupdates.com
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error: emergency physicians do conscious sedation
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general anesthesia
deep sedation
moderate sedation
minimal sedation
“cannot be easily aroused but respond purposefully
to painful stimulation”
“not arousable, even by painful stimulation”
“respond purposefully to verbal commands or light tactile stimulation”
“patients respond normally to verbal commands”
CMS 2011
conscious sedation
efficient and humane reduction of fractured wrist
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CMS 2011
“No interventions are required to maintain a patent airway, and
spontaneous ventilation is adequate”
“Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be
inadequate.”
“Patients often require assistance in maintaining a patent airway, and positive pressure ventilation may be required.”
general anesthesia
deep sedation
moderate sedation
minimal sedation
“Ventilatory and cardiovascular functions are unaffected.”
PSAprepared
solve
apnea
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error: PSA is lower risk than endotracheal intubation
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lower risk for the patient does not mean lower risk for you
be at least as vigilant in PSA preparation as you are for intubation
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your PSA checklist
verify appropriateness of ED PSA
full intubation setup for every PSA
Prepared to Solve Apnea
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error: I’m using ketamine so airway and breathing are not
an issuecentral apnea
airway malpositioning laryngospasm hypersalivation
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error: delaying emergency PSA for fasting
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error: aggressive, early bag mask ventilation
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the ABCs of PSA adverse events
AirwayBreathingCirculation
Detonate Everything else
obstruction loss of airway reflexes
hypoventilation
hypotension hypertension
bradycardia tachycardia
hypertonicity / myoclonus hypersalivation agitation rash
[anaphylaxis]
(vomiting)
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intubation PSAairway problems and oxygenation deficit
common
airway problems and oxygenation deficit
rareBMV more likely
to be difficultBMV less likely to be difficult
patient usually paralyzed
patient never paralyzed
vomiting less likely vomiting more likelyventilation likely to improve soonventilation unlikely
to improve soon
bag slowly and gently
bag early and often bag as part of
a stepwise approach
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position the patient
jaw thrust
intervening during PSAdetect hypoventilation
stop the drugs
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body ramus
angle
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BODYR A M U S
push from behind
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grasping the body of the mandible by the sides, attempting to pull the jaw forward - poor technique
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1. open the mouth
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2. Push the mandible anterior to the maxilla using four fingers behind the ramus and thumbs pushing against the maxilla
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3. Shift your hands so that your thumbs and index fingers are free to hold a mask to the face
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stop the drugs
position the patient
jaw thrust
suction if needed
laryngospasm notch pressure
intervening during PSAdetect hypoventilation
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Larson 1998
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stop the drugs
position the patient
jaw thrust
suction if needed
laryngospasm notch pressure
nasal airways
consider reversal agentsbag mask ventilation
intubate
intervening during PSAdetect hypoventilation
oral airway, ventilation
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stop the drugs
position the patient
jaw thrust
suction if needed
laryngospasm notch pressure
nasal airways
consider reversal agentsbag mask ventilation
intubate
intervening during PSAdetect hypoventilation
oral airway, ventilation
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stop the drugs
position the patient
jaw thrust
suction if needed
laryngospasm notch pressure
nasal airways
consider reversal agents
bag mask ventilation
oral airway, ventilation
intubate
intervening during PSAdetect hypoventilation
1 minute or
10 minutes
early
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error: if the patient's saturation is OK, everything is OK
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PSA
hypotension hypertension bradycardia tachycardia vomiting
hypoventilation
hypertonicity / myoclonus hypersalivation agitation rash
airway obstruction
loss of airway reflexes
hypoxiahypercapnia
acidemia
aspiration
AB
C DE
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PSA
hypotension hypertension bradycardia tachycardia vomiting
hypoventilation
hypertonicity / myoclonus hypersalivation agitation rash
airway obstruction
loss of airway reflexes
hypoxiahypercapnia
acidemia
aspiration
ventilation demonstrates airway patency
ventilation predicts
oxygenation
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hypoventilationis
king
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assessing ventilation
intubation is not PSA
NIV is fantastic unless the patient vomits
chest rise requires patience and is inaccuratebreath sounds requires a precordial stethoscope
pulse oximetry is a great monitor of ventilationif and only if
Baskett 1996 Poulton 2011 Witting 2005
Davidson 1993 Weingart 2012
the patient is not receiving any supplemental oxygen
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if I can provide oxygen and keep the saturation up, and hypercapnia isn’t important, why do I have to worry about ventilation?
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you need to know about hypoventilation.
you may choose to do nothing but observe, but you need to know about hypoventilation.
and the most effective way to detect hypoventilation is capnography.
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Goyal 2005
synypnea
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bradypneic hypoventilation
bradypnea rate slows but volumes are relatively preserved
slowly rising ETCO2
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hypopneic hypoventilation
hypopnea tidal volumes are low
rate can be normal or slow ETCO2 falls because more of each breath is dead space
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apnea
central apnea airway obstruction
laryngospasm
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should I use capnography?
detect hypoventilation early while providing supplemental oxygen
hard to improve on damn safe
ACEP: “Continuous capnography is not mandatory, but is increasingly
being recommended for deep sedation.”
O’Connor 2011 Deitch 2010 Green 2010
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we don’t have capnography. should I use supplemental oxygen?
early detection of hypoventilation
oxygenation reserve
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we don’t have capnography. should I use supplemental oxygen?
PSA
early detection of hypoventilation
oxygenation reserve
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we don’t have capnography. should I use supplemental oxygen?
monitoring patients at risk for respiratory
depression
early detection of hypoventilation
oxygenation reserve
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PSA oxygenation: nasal cannula under face mask
(+capnography)
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error: fentanyl/midazolam is safer than propofol or ketamine
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adverse events
fentanyl 9.5% midazolam 6.4% propofol 0.8% ketamine 0.7%
Sacchetti 2007
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peak effect
midazolam fentanyl
2-3 minutes 4-5 minutes
agony vs. apnea
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propofol and ketamine are enormously safe for different reasons
the gap between privileges and patient care
Green 1996
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error: you cannot use ketamine for PSA in adults
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psychiatric distress on emergence
15%
easily managed with midazolam or propofol
pre-induction comfort
pre-induction coaching
emerge somewhere other than an emergency room
if your patient freaks out a bit when they’re waking up, it’s O
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hypertension tachycardiatransient and almost always irrelevant
propofol
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ketofolcombination of ketamine and propofol in the same syringe
effects of one counteract the effects of the other
safe and effective for PSA
very different pharmacokinetics
as safe and effective as ketamine or propofol monotherapy but not more so
Andolfatto 2012 Green 2011
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error: an opiate needs to be added to ketamine or propofol
during PSA
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Prommer 2012 Bell 2006
Annetta 2005
pre-induction comfort
be careful with propofol for longer proceduresgradual drip titration safe and effective but requires patienceyou can run into trouble with repeated boluses
ketamine + opioid = makes no sense
propofol + opioid = propofol-sparingmakes no sense for brief proceduresuse single slug of propofol
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error: the dosing strategy you learned for fentanyl/midazolam
will work for propofol
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single slug: 1-2 mg/kg over 20 seconds
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error: not respecting the sensitivity of the elderly to fentanyl, midazolam, and
propofol
start low, go slow
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error: ignoring the IM route for ketamine in kids
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an IM shot is much less painful than starting an IV
if you want, start an IV after induction
pre-induction comfort with intranasal fentanyl
pre treat with ondansetron
Green 1990 Langston 2008
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a word about etomidate for PSA
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ketaminepropofolbrief procedures muscle relaxation
longer procedures kids
cardioversion
pediatric complicated
lac repairjoint reduction
fracture management
lumbar puncture
chest tube
pediatric FB removal
abscess drainage
dexmedetomidineremifentanil Mason 2011
Sacchetti 2011
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pre-induction comfort
preparation: use a checklist
propofol ketamine
early detection of hypoventilation
stepwise approach to management of hypoventilation
longer procedureskids
brief proceduresmuscle relaxation
patient selectionfull intubation setup
errors in PSA: avoiding them
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slideset references
PSA checklist comments questions criticisms
compliments get rich quick schemes