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