Download Procedural Sedation Course

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
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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
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•
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:
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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
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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
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fracture reduction, electrical cardioversion
choice of agents depend on the anticipated
length of procedure and depth of sedation
required
joint reductions:
•
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deep plane of sedation required
best to choose short acting agents
Complications
• respiratory depression
• hypotension
• vomiting
• emergence reactions
The End!
Questions?