Download Procedural Sedation & Regional Anaesthesia

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
Positives
Avoids the discomfort associated with local or regional
anaesthetic techniques.
Doesn’t affect anatomy
Relatively simple technique
Negatives
Consumes resources
General anaesthesia in the ED
is frowned upon…
The goals of PS
To 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
Normal LOC
Minimal Sedation (Anxiolysis)
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anaesthesia
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
Patient
Agent
Environmen
tal
Case – Mr. F. B.
Case
A 40 yo man presents with a painful, swollen right wrist after a fall.
You do an x-ray…
So what about our
Allergies:
patient?
Eggs
Medications:
• Last Meal:
– 30 minutes ago
Enalapril
• Events:
Salbutamol
– Patient came immediately to the
hospital after falling.
Flovent
Past Medical History:
Asthma
Obstructive sleep apnea
Hypertension
To sedate or not to sedate…
86 yo female with a dislocated hip
Allergies: NKDA
Meds:
Metoprolol
Nitroglycerin patch
Enalapril
Lasix
ASA
Atrovent
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 Assessment
The AMPLE history
Allergies
Medications
Past medical history
Last meal
Events before & after the incident
Physical Exam
Airway 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
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
Patient
Agent
Environmen
tal
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
Propofol
Category
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
Propofol
What 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
Propofol
Pros
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
Fentanyl
Category
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
Fentanyl
What 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
Fentanyl
Pros
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
Midazolam
Category
Amnestic
What is it?
Benzodiazepine
How does it work?
Bind to benzodiazepine receptors which upregulate GABA activity
How much do you need?
0.02 – 0.1 mg/kg IV
Commonly Used Agents
Midazolam
What 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
Ketamine
Category
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
Ketamine
What 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
But won’t it give him nightmares?
Ketamine & Emergence Reactions
Frequency is reported to
be anywhere from <1% to
50% in adults.
Treatment with
benzodiazepines is the
most effective way to
prevent 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
Normal LOC
Minimal Sedation (Anxiolysis)
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anaesthesia
Considerations for PS in
the ED
Patient
Agent
Environmen
tal
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
Guidelines
Other References
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 References
Journal 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.
Procedural Sedation & Analgesia in the
Emergency Department