Procedural Sedation in the Emergency Department Deon Stoltz.
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Transcript of Procedural Sedation in the Emergency Department Deon Stoltz.
Procedural Sedation in the Emergency Department
Deon Stoltz
Objectives
What does it mean
What needs to be considered.
What do we normally use it for.
Review commonly used agents
Briefly discuss alternatives to PSA
Overview
DISCLAIMER….
This is a very simplified overview of a complex topic.
It is not a substitute for in-depth research, background knowledge and training.
What is Procedural Sedation?
To reduce patient anxiety and awareness
To facilitate a painful medical procedure
Patient maintains their airway & breathing
- a.k.a “conscious sedation” “deep sedation”
Procedural Sedation
PositivesAvoids the discomfort associated with local or regional anaesthetic techniques.
Doesn’t affect anatomy
Relatively simple technique
NegativesConsumes resources
General anaesthesia in the ED
is frowned upon…
The goals of PSTo consider patient safety & welfare the first priority.
To provide adequate analgesia, anxiolysis, sedation and amnesia during the performance of painful diagnostic or therapeutic procedures in the ED.
To minimize the adverse psychological responses associated with painful or frightening medical interventions.
To control motor behaviour that inhibits the provision of necessary medical care.
To return the patient to a state in which safe discharge is possible.
How low should you go?
Depth of Procedural Sedation
Minimal Sedation (Anxiolysis)
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anaesthesia
Normal LOC
Uses
Reduction of dislocations:
shoulder, elbow, hip, patella, ankle
Reduction of fractures:
wrist, ankle
washout compound fracture
Paediatric injuries:
wound inspection, closure, suturing
Abscess I&D
Considerations for PS in the ED
EnvironmeEnvironme
ntalntal
PatientPatient
Agent Agent
Case – Mr. F. B.
CaseA 40 yo man presents with a painful, swollen right wrist after a fall. You do an x-ray…
So what about our patient?
Allergies:
Eggs
Medications:
Enalapril
Salbutamol
Flovent
Past Medical History:
Asthma
Obstructive sleep apnea
Hypertension
DM II
• Last Meal:– 30 minutes ago
• Events:– Patient came immediately to
the hospital after falling.
To sedate or not to sedate…
86 yo female with a dislocated hip
Allergies: NKDA
Meds: MetoprololNitroglycerin patchEnalaprilLasixASAAtrovent
Last meal:NPO for 4 hours
• PMHx:– MI x 2 (multi-vessel CAD)– Angina with minimal activity– PVD– HTN– CVA– CRF• Events:– Pt felt a pop while trying to get
up from a chair.
To sedate or not to sedate…
22 yo intoxicated male with an ankle fracture
Allergies: NKDA
Meds: unknown
PMHx: unknown
Last meal:
Smells like EtOH
Unknown
Events:
No one really knows
To sedate or not to sedate…28 yo female with a fractured wrist
What risks are associated with sedation during pregnancy?
Patient AssessmentThe AMPLE history
Allergies
Medications
Past medical history
Last meal
Events before & after the incident
Physical ExamAirway assessment
Respiratory exam
Cardiovascular exam
ASA Physical Status Classification
I. Healthy Patient
II. Mild systemic disease – no functional limitation
III. Severe systemic disease – definite functional limitation
IV. Severe systemic disease that is a constant threat to life
V. Moribund patient that is not expected to survive with the operation
“It’s only a little chest pain”
ASA Scores & PSA
The ASA classification is not validated outside of the OR.
Malviya et al showed an increased risk of adverse sedation-related events in paediatric patients with an ASA > 2.
“The patient’s ASA status should be determined. For non-emergent procedures, ED sedation and analgesia should be limited to ASA class 1 or 2 patients.”
Class B, Level III
Procedural sedation and analgesia in the emergency department
Canadian Consensus Guidelines
The Last Supper
Fasting & PSA
ANZCA recommendations for healthy elective GA patients:
2 h NPO for liquids
6 h NPO for solids
The risk of aspiration during PSA is extremely low.
There is no evidence that fasting improves outcome during procedural sedation and analgesia.
One large paediatric study of ED procedural sedation showed no increase in the number of adverse events in patients that were not fasting.
Starved for how long…?
Controversial.
Probably not as rigid as anaesthetic guidelines for GA...
Depends on degree and duration of sedation
Starship CED paediatric guideline:
Clear fluids: at least 2 hours
Non-clear fluids and solids: at least 4 hours
PATIENT SELECTION
Can you hold the fort if something goes wrong?
BREATHING & CIRCULATION:
Lung disease?
Stable cardiac status?
BP stable?
Medications
Allergies (e.g. watch out for soy, eggs: Propofol)
Airway Assessment
Can you bag?
Can you intubate?
Predictors of Difficult BVM Ventilation
Beard
Obesity
Old (age > 55 yrs)
Toothless
Snores
Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000; 92:1229-36.
The LEMON Method of Airway Assessment
• Look for external characteristics known to causes problems with BVM or intubation.
• Evaluate the 3-3-1 Rule:
Mouth opening > 3 fingers
Hyoid – chin distance > 3 fingers
Anterior low jaw subluxation > 1 finger
• Mallampati Score
• Obstruction – any pathology within or surrounding the upper airway
• Neck Mobility - full flexion & extension
Considerations for PS in the ED
EnvironmeEnvironme
ntalntal
PatientPatient
Agent Agent
The Perfect Drug
Provides adequate sedation and analgesia for:
Patient comfort
Easy completion of the procedure
Maintains airway reflexes
Does not affect hemodynamics
Does not affect respiratory function
Commonly Used Agents
Propofol
Fentanyl
Ketamine
Midazolam
Commonly Used Agents
PropofolCategory
Sedative-Hypnotic
What is it?
2,6-diisopropofol, an alkylphenol oil in an emulsion
How does it work?
Potentiates GABA activity
How much do you need?
Starting dose of 0.5 - 1 mg/kg
Commonly Used Agents
PropofolWhat else does it do?
CNS: Mild analgesic properties; euphoria
CVS: Myocardial depressant; vasodilation
Resp: Respiratory depressant
GI: Antiemetic
MSK: Myoclonus
What does the body do with it?
Rapid redistribution
Hepatic and extrahepatic metabolism
Commonly Used Agents
PropofolPros
Shown to be safe for ED PSA use
Rapid onset and recovery
Cons
Must be combined with an analgesic agent
May cause apnea & loss of airway reflexes
Myocardial depressant and vasodilator
Commonly Used Agents
FentanylCategory
Analgesic agent
What is it?
Synthetic opioid
How does it work?
Decreases conduction along nociceptive pathways and increases activity in pain control pathways in the brain.
How much do you need?
Starting dose of 1-2 mcg/kg
Commonly Used Agents
FentanylWhat else does it do?
CNS: Euphoria (or dysphoria)
Resp: Respiratory depressant; chest wall rigidity
CVS: May decrease HR
GI: Decreased motility
What does the body do with it?
Hepatic metabolism (inactive metabolite)
Renal excretion
Commonly Used Agents
FentanylPros
Good hemodynamic stability
Rapid onset and recovery
Cons
Must be combined with an amnestic agent
May cause bradycardia
May cause chest wall rigidity
May cause apnea & loss of airway reflexes
Commonly Used Agents
MidazolamCategory
Amnestic
What is it?
Benzodiazepine
How does it work?
Bind to benzodiazepine receptors which up-regulate GABA activity
How much do you need?
0.02 – 0.1 mg/kg IV
Commonly Used Agents
MidazolamWhat else does it do?
CNS: Anxiolysis
CVS: Slight decrease in PVR & decreased contractility.
Resp: Respiratory depression
What does the body do with it?
Hepatic metabolism (active metabolite)
Renal excretion
Commonly Used Agents
KetamineCategory
Dissociative Amnestic
What is it?
Derivative of phencyclidine with some opioid properties.
How does it work?
Stimulates the limbic system while inhibiting the thalamus & cortex (dissociation)
Binds to NMDA and opioid receptors
Commonly Used Agents
KetamineWhat else does it do?
CNS: Emergence reactions
CVS: Increased contractility, HR and PVR through sympathetic stimulation. Direct myocardial depressant.
Resp: Laryngospasm, bronchodilation, increased secretions
What does the body do with it?
Hepatic metabolism
Renal excretion
Frequency is reported to be anywhere from <1% to 50% in adults.
Treatment with benzodiazepines is the most effective way to prevent emergence reactions.
But won’t it give him nightmares?
Ketamine & Emergence Reactions
Commonly Used Agents
Ketamine
How much do you need?
1 – 2 mg/kg IV
How much midazolam?
0.7 mg/kg given at the time of ketamine injection.
Mix & Match
Commonly used combinations:
Propofol + Fentanyl
Fentanyl + Midazolam
Propofol + Midazolam + Fentanyl
Ketamine + Midazolam
How low should you go?
Depth of Procedural Sedation
Minimal Sedation (Anxiolysis)
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anaesthesia
Normal LOC
Considerations for PS in the ED
EnvironmeEnvironme
ntalntal
PatientPatient
Agent Agent
PREPARATION
Prepare for the worst….
What can go wrong?
Unexpected drug reaction or anaphylaxis
Vomit and aspirate
Obstructed airway (e.g. laryngospasm, tongue)
Apnoea, respiratory arrest
Profound hypotension
PREPARATION
Not quite the worst …
What can go wrong?
Disinhibition / agitation
Terrors, nightmares
Unexpected drug reactions: dystonias
Inadequate sedation
Unsuccessful procedure… still needs GA
PREPARATION
ACEM POLICY DOCUMENT -
USE OF INTRAVENOUS SEDATION FOR PROCEDURES IN THE EMERGENCY
DEPARTMENT
© ACEM. 5 December 2001
PREPARATION
ENVIRONMENT
The procedure must be performed in a suitable clinical area with facilities for:
Monitoring,
Oxygen
Suction
immediate access to emergency resuscitation equipment, drugs and other skilled staff.
PREPARATION
ENVIRONMENT
Readily available equipment must include:
resuscitation trolley
defibrillator
PREPARATION
ENVIRONMENT
Readily available equipment must include:
resuscitation trolley
Defibrillator
Bag-Valve-Mask device for ventilation
PREPARATION
MONITORING
Cardiac rhythm, non-invasive blood pressure and pulse oximetry must be monitored throughout the procedure and recovery period
PREPARATION
PERSONNEL
The involvement of at least two clinical staff is required:
PERSON PERFORMING PROCEDURE
must understand the procedure and its potential complications.
PERSON GIVING DRUGS AND MONITORING PATIENT - must have training and experience of resuscitation, emergency drugs and …. (details of) the drugs used.
This person is not involved in the performance of the procedure but is dedicated to care and monitoring of the patient.
PREPARATION
PERSONNEL
The involvement of at least two clinical staff is required:
PERSON PERFORMING PROCEDURE
must understand the procedure and its potential complications.
PERSON GIVING DRUGS AND MONITORING PATIENT - must have training and experience of resuscitation, emergency drugs and …. (details of) the drugs used.
This person is not involved in the performance of the procedure but is dedicated to care and monitoring of the patient.
PREPARATION
PERSONNEL
The involvement of at least two clinical staff is required:
SUPERVISING PERSON –
a specialist or advanced trainee in emergency medicine who has specific experience in airway control and resuscitation must be either directly involved in the procedure (taking one of the above roles) or must be aware of the procedure and provide overall supervision and back-up assistance.
PREPARATION
PATIENT PREPARATION
Explanation
Consent
Secure IV access is mandatory.
PREPARATION
Other requirements
Separate space to perform the procedure
A recovery space: ideally quiet, available for 1-2 hours, easily observed.
READY TO GO…
Explain
Pre-oxygenate
IV Access and IV fluid running
Splints or plaster or equipment all ready to go
Hand over your phone or pager…
To sedate or not to sedate…
Phone a friend…
Consider sending the at-risk patient to the OR.
So what ARE you going to do?
Questions?
Key Points
Be prepared
Know your drugs and your drug interactions
Consider all your options
Other ReferencesGuidelines
Godwin SA, Caro DA, Wolf SJ, Jagoda AS, Charles R, Marett, BE and Moore J. Clinical policy: procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine. 45:2. February 2005; pp 177-196.
Innes G, Murphy M, Nijessen-Jordan C, Ducharme J and Drummond A. Procedural sedation and analgesia in the emergency department. Canadian consensus guidelines. The Journal of Emergency Medicine. 17:1. January 1999; pp 145 – 156.
Textbooks
• Miller RD. Miller’s Anesthesia, 6th Ed. 2005
• Marx JA. Rosen’s Emergency Medicine, 5th Ed. 2002.
• Roberts JR. Clinical Procedures in Emergency Medicine, 4th Ed. 2004
• Tintinalli JE. Emergency Medicine: A Comprehensive Study Guide, 6th Ed. 2004
Other ReferencesJournal Articles
Syminton L and Thakore S. A review of the use of propofol for procedural sedation in the emergency department. Emergency Medicine Journal. 2006:23. 89-93.
Green SM and Krauss B. Propofol in emergency medicine: pushing the sedation frontier. Annals of Emergency Medicine. 2003:42. 792-797.
Bahn EL and Holt KR. Procedural sedation and analgesia: a review and new concepts. Emergency Medicine Clinics of North America. 2005:23. 503-517.
Green SM. Fasting is a consideration – not a necessity – for emergency department procedural sedation and analgesia. Annals of Emergency Medicine. 2003:42. 647-650.
Green SM and Sherwin TS. Incidence and severity of recovery agitation after ketamine sedation in young adults. American Journal of Emergency Medicine. 2005:23. 142-144.
Green SM and Li J. Ketamine in adults: what emergency physicians need to know about patient selection and emergency reactions. Academic Emergency Medicine. 2000:7(3). 278-280
Procedural Sedation & Analgesia in the Emergency Department