Download IV DRUGS in the EMERGENCY ROOM

Procedural Sedation
in the ER
L M H ER R O U N D S
P R EPA R ED BY S H A N E BA R C LAY
Procedural Sedation
The biggest obstacles for emergency physicians
to effectively and safely treat patients with
analgesia and sedation are:
Hospital Bureaucracy and Anesthesiologists
Procedural Sedation
ACEP October 2013 – “Procedural Sedation and Analgesia in the
Emergency Department”
1. Does preprocedural fasting reduce risk of emesis or aspiration?
NO – preprocedural fasting has not shown to reduce the risk of
emesis or aspiration. (level B)
2. Does capnography reduce the incidence of adverse respiratory events?
- capnography may detect hypoventilation and apnea earlier
than oximetry and/or clinical assessment. (level B)
Procedural Sedation
ACEP October 2013 – “Procedural Sedation and Analgesia in the
Emergency Department”
3. What is the minimum number of personnel necessary to manage
sedation complications?
Besides the attending physician, one other nurse or qualified
individual should be present for sedation. (level C)
4. Can Propofol and Ketamine be safely administered in the ER for
sedation?
Ketamine can be safely administered to children. Propofol
can safely be administered to children and adults. (level A)
Procedural Sedation
Pre-oxygenate with non re-breather for 5 minutes.
Will delay/blunt the O2 saturation measurements.
Use EtCO2 – more sensitive for apnea/hypoxia
Procedural Sedation
First – consider the degree of sedation you want and
the implications.
Can be from simple IM/PO analgesia, which is
sedating, to full general anesthesia.
Procedural Sedation
Minimal sedation
Analgesia
Responsiveness
Airway
Spontaneous
ventilation
Moderate sedation
“conscious sedation”
Deep sedation
General Anesthesia
Procedural Sedation
Moderate sedation
“conscious sedation”
Deep sedation
Responsiveness
Purposeful response to Purposeful response
verbal or tactile
following repeated
stimulation
or painful stimuli
Airway
No intervention
required
Intervention may be
required
Spontaneous
ventilation
Adequate
May be inadequate
Procedural Sedation
• In recent years, the most common PSA medications have
been Midazolam and Fentanyl. These were used for ‘deep
sedation’ procedures ie fracture reduction etc.
• However, as per the previous slide, responsiveness is often
only to painful or repeated stimuli.
• Once the procedure is complete, you can still have 30 +/minutes of deep sedation on board.
• This is traditionally when interventions for airway and
ventilation could/did occur.
Drug
Ketamine
a1
b1
b1
b1
Inotr Chron Dromo
_
Fentanyl
Morphine
Propofol
Midazolam
+
b2
V/C
V/D
+
_
_
++
++
Midazolam and Fentanyl
ER literature is suggesting using this combination in
lower doses for ‘moderate sedation’ that traditionally
only local anesthesia or nothing was given.
i.e. I&D of abscess, LP, complex lacerations, road rash
debridement, burn dressings …
Propofol
Dr. James Miner
Chief of Emergency Medicine Hennepin County Medical Center,
Hennepin, Minnesota.
Dr. James Miner
• Miner, James R, Mark Danahy, Abby Moch, and Michelle Biros. 2006. Randomized clinical trial of etomidate versus propofol
for procedural sedation in the emergency department. Annals of emergency medicine, no. 1 (September 25).
http://www.ncbi.nlm.nih.gov/pubmed/16997421.
• Miner, James R, Richard O Gray, Jennifer Bahr, Roma Patel, and John W McGill. 2010. Randomized clinical trial of propofol
versus ketamine for procedural sedation in the emergency department. Academic emergency medicine : official journal of the
Society for Academic Emergency Medicine, no. 6. doi:10.1111/j.1553-2712.2010.00776.x.
http://www.ncbi.nlm.nih.gov/pubmed/20624140.
• Miner, James R, Richard O Gray, Dana Stephens, and Michelle H Biros. 2009. Randomized clinical trial of propofol with and
without alfentanil for deep procedural sedation in the emergency department. Academic emergency medicine : official
journal of the Society for Academic Emergency Medicine, no. 9. doi:10.1111/j.1553-2712.2009.00487.x.
http://www.ncbi.nlm.nih.gov/pubmed/19845550.
• Miner, James R, Marc L Martel, Madeline Meyer, Robert Reardon, and Michelle H Biros. 2005. Procedural sedation of
critically ill patients in the emergency department. Academic emergency medicine : official journal of the Society for Academic
Emergency Medicine, no. 2. http://www.ncbi.nlm.nih.gov/pubmed/15692132.
• Miner, James R, Johanna C Moore, Erin J Austad, David Plummer, Laura Hubbard, and Richard O Gray. 2014. Randomized,
double-blinded, clinical trial of propofol, 1:1 propofol/ketamine, and 4:1 propofol/ketamine for deep procedural sedation in
the emergency department. Annals of emergency medicine, no. 5 (October 16). doi:10.1016/j.annemergmed.2014.08.046.
http://www.ncbi.nlm.nih.gov/pubmed/25441247.
• Miner, James R, Johanna C Moore, David Plummer, Richard O Gray, Sagar Patel, and Jeffrey D Ho. 2013. Randomized clinical
trial of the effect of supplemental opioids in procedural sedation with propofol on serum catecholamines. Academic
emergency medicine : official journal of the Society for Academic Emergency Medicine, no. 4. doi:10.1111/acem.12110.
http://www.ncbi.nlm.nih.gov/pubmed/23701339.
Propofol – key points
1. Propofol for short procedures (2-3 minutes) in a stable patient is safer
than any other sedation medication.
2. Use Pre- procedural analgesia rather than peri-procedural.
3. Use 1 – 2 mg/kg Propofol.
4. Use less in the elderly, especially if they have opioids on board.
5. Use more in thin and obese patients.
6. Use less in volume depleted patients.
7. Need to wait 60 seconds (by the clock!) before giving a second dose
Propofol
8. Patient will have 30 – 60 seconds retrograde amnesia.
9. Amnesia is while Propofol is starting to work, NOT when it is
wearing off.
10. After the first dose of 1.5 mg/kg the patient may still be talking etc,
but as long you have the given the patient adequate pre-analgesia, they
will have amnesia for the event.
Ketamine
• Can be used to start and maintaining anesthesia, sedation,
analgesia, amnesia and treatment of bronchospasm.
• Acts on many receptors, one of which are the opioid
receptors. Can be used is sub dissociative doses for pain.
• Downside is the psychological reactions as it wears off –
agitation, confusion, psychosis.
• ‘Recovery agitation’ is associated with dosage, younger age
and co-morbid conditions, thus ranging from 15-35%.
Ketamine
• Historically recommended for intubation of asthmatics and
head injury patients as it causes bronchodilation and does
not increase ICP.
• Now is recommended for procedural sedation in children
and adults.
• Can be used for the above as well as RSI in hypotensive
trauma patients.
• In combination?
“Ketofol”
This is a ketamine/propofol combination that has been
advocated for use in both pediatric and adult sedation.
Mixing instructions:
take a 20 cc syringe and draw up 10 cc of Propofol 10 mg/ml.
Then draw up 2 ml of Ketamine 50mg/ml.
Then draw up 8 cc of normal saline.
You know have 20 ml of “ketofol” mixture of 10 mg/ml
concentration.
“Ketofol”
Dosage:
0.5 mg/kg
Wait 30-45 seconds, if not sedated give a second dose 0.5
mg/kg.
May continue boluses of 0.25 - 0.5 mg/kg q 1 -1.5 minute
intervals.
A Procedural Sedation Protocol?
1. Have a PSA check list
2. Pre-oxygenate with non rebreather for 5 minutes
3. Use SpO2 and EtCO2 monitor
4. Have at least one other person – nurse
5. Plan your procedure before you give the drugs
6. Use pre- procedure analgesia – fentanyl, morphine, hydromorph …
7. Bolus Propofol 1 -1.5 mg/kg.
8. Do the procedure
PSA Checklist
One example in your handouts.
Questions ?