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Transcript
Procedural Sedation Christian La Rivière, MD, FRCPC • “Conscious Sedation is very safe and therefore, occasionally, very dangerous.” Dr. J. Mansfield • “…..the responsibility for administering conscious sedation ultimately lies with the individual practitioner. • He or She must ensure that drugs are being administered safely and appropriately. The practitioner must be aware of his or her own limitations, and when it is appropriate to request assistance. • These vary from individual to individual.” •Dr. Steve Kowalski •Physician Accreditation for Conscious Sedation Overview • Know your facility, equipment, and personnel. • Know your patient. • Know your drugs, doses, adverse effects. • Be aware of specific risks or problems associated with your procedure. • Know how to avoid trouble, but what to do if something happens. Why use procedural sedation? • “Premise: Painful procedures are inevitable in emergency medicine, but pain is not.” • “Any physician who practices emergency medicine without using some form of sedation technique is either not practicing emergency medicine or not practicing it humanely.” Dr. Grant Innes Why use procedural sedation? • “To provide analgesia and amnesia during painful diagnostic and therapeutic procedures in the ED. To minimize negative psychological responses associated with medical interventions” Dr. Grant Innes • “In children or uncooperative adults it may expedite the conduct of procedures that are not particularly uncomfortable but require the patient not to move.” •Dr. Jeffery Gross The Sedation Spectrum Simple anxiety reduction Light sedation Neurolepsis Dissociative state Deep sedation General anesthesia Potential Indications • reducing fractures and dislocations • scrubbing road rash • deep, complex, or multiple lacerations not amenable to local anesthetic esp. tongue and vermilion border • burn debridement • chest tubes • foreign body removal Potential Indications • radiographic imaging • neuro-imaging in a combative patient • endoscopy,bronchoscopy,colonoscopy • lumbar puncture Potential Indications • cardioversion • foley catheterization • hernia reduction • abscess incision and drainage • terrified, uncontrollable child • dilatation and curettage Contraindications • Lack of personnel experienced at airway management or advanced life support • Unfamiliarity with medications being administered for sedation • Lack of appropriate monitoring equipment • The unstable patient • Allergy or sensitivity to relevant medication • Potentially difficult airway (relative) Preparation and Planning • • • • • • • Patient assessment and selection Airway assessment Equipment selection IV access Appropriate support staff Medication selection Consent Airway Examination Difficult Airway? Sometimes it is obvious Know when to ask for help Airway • History • previous problems with anesthesia or sedation • stridor, snoring, or sleep apnea • advanced rheumatoid arthritis Airway • Physical exam • habitus - obesity • neck - movement, size, abnormalities • mouth - opening, tongue, teeth • jaw - movement, size Difficult Mask Ventilation • M - Mask Seal • O - Obesity / Obstruction • A - Age (advanced age) • N - No Teeth • S - Sleep apnea / Stiff Lungs Potential Difficult Airway • L - Look Externally • E - Examine 3-3-2 • M - Mallampati • O - Obesity/Obstruction • N - Neck Mobility Predicting the difficult airway: Class I Class II Class III Class IV Mallampati scoring system Experienced Personnel • familiar with pharmacology • cardiopulmonary resuscitation • airway management • Pediatrics: PALS • RN or RT Monitoring & Equipment • Adequate and accessible space • Nurse, MD • Equipment: • Pulse oximeter • BP machine • continuous EKG monitor Equipment • IV access • oxygen - suction • bag-valve mask that fits patient • airway basket at the bed side • defibrillator & emergency ACLS drugs • reversal drugs at the bedside Monitoring & Equipment Documentation Discharge Criteria • normal vital signs • baseline mental status • coherent speech • sit unattended • understand verbal post sedation instructions Overview of Drugs Drugs of Interest • Opioids (fentanyl) • Benzodiazepines (midazolam) • Dissociative agents (ketamine) • Propofol • Other agents (Etomidate) Which Drug Should I Choose? • choosing the drug or drug combination should depend on: • the patient • the procedure being performed • your comfort level with the drug The Ideal Drug • short half life • predictable effects • easily titratable • reversible • no side effects • low cost The Ideal Route IV • rapid, predictable, titratable; life line for fluids, reversal agents Opioids • • fentanyl is the best opioid for procedural sedation Morphine is no longer widely used in this setting Fentanyl • potent, rapid-acting opioid • physiologic effects mediated by binding to opiate receptors in the brain and spinal cord Fentanyl Pharmacokinetics • onset of action begins in about 90 seconds • clinical duration 20-30 minutes • serum half life 90 minutes • approximately 100x more potent than iv morphine (10 mg Morphine = 100 mcg Fentanyl) Fentanyl Dosing • iv: 1-3 mcg/kg, titrated to effect • in average sized adults, titrate in 25-75 mcg aliquots every 2-3 minutes Fentanyl- Adverse Effects • respiratory depression: • maximal respiratory depression occurs in about 5 minutes • dependent on dose, and coadministration of other agents (e.g.: midazolam) Adverse Effects (cont’d) • pruritis, but seldom causes any allergic reaction • nausea and vomiting (less than the other opioids) • muscular and glottic rigidity: • this will only happen if you make a dosing error (e.g.: giving 50 mcg/kg, instead of 50 mcg x 1!) Benzodiazepines • • midazolam other agents are not as well suited for procedural sedation Midazolam • acts on GABA receptors, resulting in anxiolytic, hypnotic, and amnestic effects • midazolam is rapid acting and easily titratable compared to the other benzodiazepines • water soluble and lipophilic Midazolam Pharmacokinetics • onset of action 1-3 minutes • clinical duration approximately 30 minutes • serum half life 1.5-3 hrs Midazolam Dosing • iv: recommended total is 0.02-0.1 mg/kg • for average adult, titrate using 1-2 mg aliquots every 2-3 minutes Midazolam Adverse Effects • respiratory depression • severity of respiratory compromise increased with alcohol, barbituates, opioids • clinically significant side effects with midazolam used alone are RARE • if used in combination with fentanyl, hypotension may ensue Ketamine • • derivative of the street drug phencyclidine (PCP) the only dissociative agent used in procedural sedation Ketamine • causes a dissociation between the thalamoneocortical and limbic systems • prevents the higher order centres from perceiving visual, auditory, or painful stimuli • “lights on, nobody’s home” Ketamine (cont’d) • does not cause respiratory depression (unless given in a rapid bolus and large enough dose) • muscle tone and airway protection maintained • water soluble and lipophilic Other Physiological Effects • inhibits re-uptake of catecholamines (may cause some tachycardia and hypertension) • relaxes bronchial smooth muscle • stimulates salivary and tracheobronchial secretions • may increase ICP and IOP Ketamine Pharmacokinetics • onset 1 minute (iv), 5 minutes (im) • duration 15 minutes (iv), 30 minutes (im) • complete recovery within 1-2 hrs Ketamine Dosing • if given alone or with midazolam, start with 0.5-1.0 mg/kg, iv; repeat doses of 0.05-0.1 mg/kg, iv as needed • if giving it im, the dose is 4-5 mg/kg • if giving it in children, consider a premedication with atropine, 0.01-0.02 mg/kg, iv for the bronchial secretions Adverse Effects • laryngospasm: • reported almost exclusively in infants < 3 months old • risk factors are infants and in patients with active upper respiratory tract infections • overall, still quite rare in the peds world • 0.4% incidence of laryngospasm in a study looking at 1022 cases • in pooled data involving 11,589 kids > 3 y.o., laryngospasm occurred 0.017% Adverse Effects (cont’d) • muscle rigidity, random movements, nystagmus • this usually is of no clinical consequence Adverse Effects (cont’d) • Emergence phenomenom: • hallucinations and nightmares • may occur in up to 30% adult PSA’s, and about 10-17% peds cases • risk in adults if > 16 y.o., female, psychiatric history, illicit drug use, large doses • some evidence to support pre-medication with benzos in adults, but not in children Propofol • • ultra-short acting sedative hypnotic derived from the alkylphenols highly lipid soluble Propofol • ultra-short acting sedative hypnotic • dose-depedent sedation, ranging from minimal sedation to a general anesthesia • also possesses anti-emetic properties and can lower ICP during intubation • does NOT provide analgesia Propofol Pharmacokinetics • onset of action 15-30 seconds • duration less than 10 minutes • rapidly metabolized, does not accumulate in the blood or tissues Propofol Dosing • most of the clinical trials use the following: • 1 mg/kg, iv bolus, followed by 0.5 mg/kg, iv, q3-5 minutes • be more cautious in elderly patients, hypovolemic patients, or other patients with significant co-morbidities Propofol Adverse Effects • Hypotension: actually quite rare in kids and healthy adults; treatment is rarely required • increased risk in elderly, hypovolemic patients, or if given rapidly Adverse Effects (cont’d) • respiratory depression: • dose-related apnea and respiratory depression • risk increases if too much is given, or if it is given too rapidly • also increased risk in those with respiratory co-morbidities Is Propofol Safe? YES • respiratory depression is rare overall • if it does occur, the most common intervention is a jaw thrust and supplemental oxygen • the need for endotracheal intubation has not yet been reported during procedural sedation Rescue Agents • Narcan and Flumazenil • always important to have these close by with a knowledge about their indication and dose So, which drugs should I use? • a number of factors determine the choice of agents: • • • • your comfort level with the drugs the type of procedure being performed the length of the procedure patient age, comorbidities, past history of sedations, drug allergies Getting Comfortable • if you are using an agent for the first time, start with low doses and titrate to effect • don’t be too cautious as the drug will wear off and sedation will not be achieved • spend some time with others with more experience Type of Procedure • • • noninvasive (sedation for imaging) low pain, high anxiety high pain, high anxiety Non-invasive Procedures • e.g.: taking young child to CT, agitated elderly patient • consider using a single agent with sedative, amnestic, and anxiolytic properties • benzodiazepines (Versed, Ativan, etc.) Low Pain, High Anxiety • laceration repair, lumbar puncture • requires minimal sedation; analgesia usually provided with local anesthetic • options: • midazolam alone • ketamine High Pain, High Anxiety • • • fracture reduction, electrical cardioversion choice of agents depend on the anticipated length of procedure and depth of sedation required joint reductions: • • deep plane of sedation required best to choose short acting agents Complications • respiratory depression • hypotension • vomiting • emergence reactions The End! Questions?