Procedural Sedation

- alternatives to Brutane

Dr Garry ClearwaterMBChB FACEM

Overview

What is procedural sedation? Alternatives: Analgesia Preparation Drugs Discharge More alternatives…

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 medical procedure

Patient maintains their airway & breathing

- a.k.a “conscious sedation” “deep sedation”

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

Advantages

Compared to Brutane: Less stress and anxiety… for nearly everyone Better chance of success (relaxation, time)

Compared to GA: PS is quicker – for the patient PS is generally safer

Still some uses for Brutane…?

Simple, very quick, curative procedures:

Reduction of “pulled elbow”:

- Pronate/supinate flexed elbow

- with pressure over the radial head

Reduction of simple patella dislocation:

- Extend the knee

- with sideways pressure on the patella towards the midline.

Supplementary analgesia may be warranted before and during.

ANALGESIA

Procedural sedation is:

Pain relief +

Relaxation

• Pain relief by itself often reduces anxiety

ANALGESIA

Reassurance and explanation Simple analgesia: paracetamol

ANALGESIA

Reassurance and explanation Simple analgesia: paracetamol Entonox

ANALGESIA

Entonox: Nitrous OxideWeak analgesic Onset 1 min (12-15 breaths) Peak 5 minNeed co-operative patient

Avoid in: retained gas: SABO, pneumothorax etc Cardiac disease, shock Pregnancy 1st trimesterS/Es: Dysphoria, nausea

ANALGESIA

Reassurance and explanation Simple analgesia: paracetamol Entonox Methoxyflurane

ANALGESIA

Penthrox: MethoxyfluraneModerate analgesicFluorinated Hydrocarbon- Metabolised to Fluoride Onset 1-2 minutes Peak 5 minAvoid in: Renal impairment, diabetesS/Es: - Nephrotoxic; nausea, dizziness.- bradycardia, low BP

ANALGESIA

Reassurance and explanation Simple analgesia: paracetamol Entonox Methoxyflurane Intranasal Fentanyl

ANALGESIA

Fentanyl IntranasalNarcotic analgesicChildren >2 yo, up to max 70 kgVia atomiser on end of syringe Rapid onset: 2 minutes Duration 30 minsAvoid in: Nasal congestionS/Es: - nausea, dizziness.- low BP

ANALGESIA

Fentanyl Intranasal (Starship CED guideline):100 mcg / 2 ml with 1 ml tuberculin syringe- 1.5 mcg/kg (0.03 ml/kg)Repeat if necessary:- 0.5 mcg/kg

Patient sits at 45 degreesSyringe held horizontal:- one quick sprayObserve for 20 min after dose

ANALGESIA

Reassurance and explanation Simple analgesia: paracetamol Entonox Methoxyflurane Intranasal Fentanyl Intravenous Morphine

ANALGESIA

Morphine IV- Titrate- Reversible

0.1 mg / kg- 2 mg increments in adults

S/Es: - nausea, dysphoria.- low BP- Transient anaphylactoid rash (often mislabelled as

allergy)

ANALGESIA

Morphine IV

Tricks of the trade: EMLA or Ametop skin anaesthesia for at least 30 mins

- or insulin syringe local injection

Have the morphine ready to inject as soon as IV established

Alternatives to Procedural Sedation…not

In general, stay away from: SC and IM injections: variable and prolonged effects

Fallen out of favour … Intranasal Midazolam: not an analgesic, works by

ingestion

In the future … Fentanyl lollipop? Fentanyl nebulised?

ANALGESIA

Horses for Courses:

Renal colic: NSAIDs

Biliary colic: NSAIDs Antacids

ANALGESIA

Caution….

Paradex / Capadex / Dextropropoxyphene

Pethidine (Fentanyl is an alternative to morphine)

Tramadol: Potential serotonergic interactions with… SSRIs Dextropropoxyphene Pethidine

A Little Bit of Sedation…

Oral sedation: anxiolysis for children

Use the IV preparation, mix with Paracetamol or Sprite

Variable onset and effect

Low-level prolonged sedation.

Starship Hospital CED “Sedation – Paediatric” guideline:

www.starship.org.nz/index.php/pi_pageid/1065.

ANXIOLYSIS

Midazolam POOnset: 10-30 min Duration: 30-90 minAnalgesia: No

Dose: 0.5 mg/kg, max 15 mg

Variable effectMay cause Paradoxical Agitation

ANXIOLYSIS

Ketamine PO (3 mo – 12 yrs)

Onset: 15-30 min

Duration: 15-60 min

Analgesia: Some

Dose: 5-7 mg/kg

mix with 15-25 ml cold Sprite

Maintains airway

Multiple contra-indications

ANXIOLYSIS

Ketamine PO (3 mo – 12 yrs)

Contra-indications: URTI Head injury Psychiatric or personality disorder

Risks: Nausea, vomiting Transient respiratory events Requires low-stimulation recovery

PREPARATION

Prepare for the worst 2 clinical staff Choose your patient carefully Choose your poison carefully

PREPARATION

Prepare for the worst …

What can go worng? 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 worng? 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

2. 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

2. ENVIRONMENT

Readily available equipment must include: resuscitation trolley defibrillator

PREPARATION

2. ENVIRONMENT

Readily available equipment must include: resuscitation trolley Defibrillator Bag-Valve-Mask device for ventilation

PREPARATION

3. MONITORING

Cardiac rhythm, non-invasive blood pressure and pulse oximetry must be monitored throughout the procedure and recovery period

PREPARATION

1. 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

1. 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

1. 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

5. 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.

PATIENT SELECTION

Can you hold the fort if something goes wrong?

AIRWAY: Thyromental distance Open mouth > 3 FB Stable teeth View hypopharynx Mobile neck

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)

PATIENT SELECTION

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

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…

DRUGS

Choose your poison carefully…

Wide variation in individual responses

Clearwater’s Textbook Rule:

Doctors read textbooks…

but patients don’t.

Titrated is best.

DRUGS

FENTANYL: IV adjunct Onset: 2-5 min Duration: 30 minAnalgesia: Yes

Advantage: Reversible (Naloxone)Alternative to Morphine

But… BP dropChest wall rigidityNausea

DRUGS

MIDAZOLAMOnset: 1-2 min Duration: 10-30 minAnalgesia: No

Advantage: Reversible

But… BP dropSlower, not as deep as

Propofol

DRUGS

ETOMIDATEOnset: <1 min Duration: 5-8 minAnalgesia: No

Advantage: BP maintained

But… Twitching / myoclonusNauseaNot fully registered

(s.29)

DRUGS

PROPOFOLOnset: <1 min Duration: 5-10 minAnalgesia: No

Advantage: Not cumulative

But… BP dropAllergy soy or eggs

DRUGS

KETAMINEOnset: 1-3 min Duration: 5-20 minAnalgesia: Yes!

Advantage: Preserves ABC

But… Emergence phenomenaEyes open, random

movementsSalivation,

Laryngospasm

DRUGS

KETAMINE

Atypical reactions more common in: older children >10 yrs girls agitated children URTI / rhinitis

Need low-stimulus recovery room.

May need IV Midazolam

OFF WE GO….

Prepare for the worst 2 clinical staff Choose your patient carefully Choose your poison carefully Keep watching the patient … during Keep watching the patient … after Discharge with a well-advised capable observer

PATIENT DISCHARGE

Allow at least 1 hour after last dose given

Various criteria for discharge: Normal vital signs Alert / orientated / back to baseline Able to sit / mobilise unaided Able to drink Sensible capable observer Good advice

More alternatives to Procedural Sedation

Infant analgesia: 0 – 3 mo.

25-33% sucrose0.25 – 2 ml PO (give with dummy)

Mild analgesiaReleases endogenous opiods:- Reversible with Naloxone

Onset 2-5 minsDuration 5-8 mins

More alternatives to Procedural Sedation

Wound Care:

Topical anaesthesia:

“Topicaine”:

0.1 ml/kg

Apply to open wound

on a small gauze swab;

Cover with Opsite

… and wait

More alternatives to Procedural Sedation

Wound Care:

Topical anaesthesia:

“Topicaine”:

0.1 ml/kg

Apply to open wound

on a small gauze swab;

Cover with Opsite

… and wait

… 30 mins

More alternatives to Procedural Sedation

Dislocated shoulder

Intra-articular anaesthesia:

More alternatives to Procedural Sedation

Dislocated shoulder

Intra-articular anaesthesia:

Lignocaine 1% 20 ml

20G 3.5 cm needle.

Insert just lateral to acromion.

Aim to glenoid.

Aspirate sero-sanguinous fluid

Inject over 30 sec.

Takes 15-20 min to work

Acknowledgements & resources

ACEM (Info Centre > Policies Guidelines): www.acem.org.au

Starship Hospital CED (Health professionals > Clinical guidelines:

www.starship.org.nz

Kidz First / Middlemore Hospital ED clinical guidelines

RCH Melbourne guidelines www.rch.org.au/rchcpg