PROCEDURAL ANALGESIAS AND SEDATION:

COMPLICATIONS AND ADVERSE EVENTS

Winchana Srivilaithon, MD.Emergency Physician

Thammasat University

Procedural analgesia and sedation: complication and adverse event

• Overview of adverse events

• Factor predisposing to adverse event

• Evidences review of adverse events

• Adverse event terminology

Overview of adverse event

• Procedural sedation and analgesia is: – The use of anxiolytic, sedative, analgesic, or

dissociative drugs to induce an alter state of consciousness–Help to facilitate the performance of a

necessary diagnostic or therapeutic procedure–Preserving cardio-respiratory function

Overview of adverse event

Overview of adverse event

• Pre-sedation phase: Anxiolytic or Analgesia

• Sedation phase: Sedative agents

• Mainly focus on Airway-Breathing-Circulation

Factor predisposing to adverse event

• Patient clinical status

• Fasting time before procedure

• Depth of sedation

• Type and used of analgesic agents

• Type and used of sedative agents

Potential adverse effects • Lack of adequate sedation• Oversedation• Hypoxemia• Respiratory depression• Airway obstruction• Pulmonary aspiration• Hemodynamic instability• Arrhythmia• Nausea, emesis• Pain with injection

• Myoclonus• Muscle rigidity• Seizure • Unplanned admission

EVIDENCES REVIEW OF ADVERSE EVENTS

Evidences review of adverse events

• How safe for Emergency medicine physicians to do PSA?

• From 131,751 cases of pediatric sedation • Examine for major complications: aspiration,

death, cardiac arrest, unplanned hospital admission, level-of-care increase and emergency anesthesia consultation

• No difference among providers’ complication rate

From 1,180 patients

From 1,244 proceduresComplication rate = 17.8%No major complication observed

• Compared patients at least 65 yr. with aged 18 to 49 and 50 to 64 yr.

• Number of patients in each group: 50, 665 and 149, respectively

Propofol: potential adverse effects

• Respiratory depression

Propofol: potential adverse effects

• Hypotension –Risk in hypovolemic patient–Only 3.5% of patients experienced BP

decreases of > 20% before procedure• Pain with injection –Uncommon–Reported 2-20%

Ketamine: potential adverse effects

• Laryngospasm – Reported 0.3% – Risk factor: URI, active pulmonary disease, asthma

• Respiratory depression– Uncommon– Associated with rapid IV injection

• Emesis

Ketamine: potential adverse effects

• Recovery reaction– Emergence reaction (0-30%)– Hallucination– Nightmare – Delirium– Physical combativeness

Etomidate Versus Propofol

ADVERSE EVENT TERMINOLOGY

Adverse event terminology

• Airway–Partial upper airway obstruction–Complete upper airway obstruction– Laryngospasm

• Breathing –Oxygen desaturation–Central apnea–Clinical apparent pulmonary aspiration

Adverse event terminology

• Circulation–Bradycardia– Tachycardia–Hemodynamic instability

• Excitatory movements–Myoclonus–Muscle rigidity–Generalized motor seizure

Airway

• Partial upper airway obstruction– Incomplete obstruction to air exchange –Manifestation• Stridor• Snoring• Chest wall and suprasternal retraction (child)

–Rapid resolution by• Airway repositioning• Suctioning• Oral or nasal airway placement

Airway

• Complete upper airway obstruction– Ventilatory effort with no air exchange – Require one or more following interventions• Airway repositioning• Suctioning• Oral or nasal airway placement• Positive pressure with bag mask +/- assisted

ventilation• Tracheal intubation• Administration of neuromuscular blockade agents

Airway

• Laryngospasm–Partial or complete upper airway

obstruction with oxygen desaturation –Caused by involuntary and sustained

closure of vocal cord–Not relieved by routine airway repositioning

maneuvers, suctioning, or nasal or oral airway

Airway

• Laryngospasm–Clinical diagnosis–Associated with common sedation drug– Interventions• BMV ventilation• Administration of neuromuscular blockade

agents

Breathing• Oxygen desaturation– Combination of threshold and duration– Intervention to improve oxygen saturation• Vigorous tactile stimulation• Airway repositioning• Suctioning• Supplemental or increased oxygen delivery• Oral or nasal airway placement• Application of positive pressure or ventilation with

bag mask• Tracheal intubation

Breathing

• Central apnea–Cessation or pause of ventilatory effort–One or more interventions are performed • Vigorous tactile stimulation• Application of bag mask with assisted ventilation• Tracheal intubation• Administration of reversal agents (opioid or

benzodiazepine antagonists)

Breathing

• Clinical apparent pulmonary aspiration– Suspicion or confirmation† of oropharyngeal

or gastric contents in the trachea during the sedation

And – The appearance of respiratory signs and

symptoms that were not present before the sedation

Breathing

• Clinical apparent pulmonary aspiration–Physical signs• Cough• Crackles/rales• Decreased breath sounds• Tachypnea• Wheeze or Rhonchi• Respiratory distress

Breathing

• Clinical apparent pulmonary aspiration–Oxygen requirement: decrease in oxygen

saturation from baseline, requiring supplemental oxygen–Chest radiograph findings: focal infiltrate,

consolidation or atelectasis

Circulation

• Arrhythmia–Bradycardia– Tachycardia

• Hemodynamic instability–Hypotension–Hypertension

Agent BP Cardiac contractility

CBF ICP

Etomidate _ _

Propofol

Midazolam _ _

Ketamine

Fentanyle _ _

Excitatory movements

• Myoclonus– Involuntary, brief contraction of some

muscle fibers, of a whole muscle, or of different muscles of one group– Interferes with the procedure, requiring an

intervention or administration of medications –Hiccupping is a form of myoclonus

Excitatory movements

• Muscle rigidity– Involuntary muscle stiffening in extension

that can be associated with shaking – Interferes with the procedure–Requiring an intervention or administration

of medications

Excitatory movements

• Generalized Motor Seizure–Contractions can be sustained (tonic) or

repeated (tonic-clonic)–Confirming a true seizure may require the

use of electroencephalography– Interrupt the procedure and require

additional medications

References• Maala B, Robert M, Martin H, et al. Consensus-Based Recommendations for Standardizing

Terminology and Reporting Adverse Events for Emergency Department Procedural Sedation and Analgesia in Children. Ann Emerg Med. 2009;53:426-435.

• Robert E, Andrew S, John H, et al. Procedural Sedation and Analgesia in the Emergency Department: Recommendations for Physician Credentialing, Privileging, and Practice. Ann Emerg Med. 2011;58;365-370.

• Couloures KG, Beach M, Cravero JP, et al. Impact of provider specialty on pediatric procedural sedation complication rate. Pediatrics. 2011;127:e1154-e1160.

• Barbara M,Barucb K. Adverse Events of Procedural Sedation and Analgesia in a Pediatric Emergency Department. ANNALS OF EMERGENCY MEDICINE OCTOBER 1999, 34:4.

• Christopher S, Kevin M, Robert B, et al. ED procedural sedation of elderly patients: is it safe? American Journal of Emergency Medicine (2011) 29, 541–544.

• James R. Miner,John H. Burton. Clinical Practice Advisory: Emergency Department Procedural Sedation With Propofol. Annals of Emergency Medicine Volume August 2007.

• Steven M. Green, MD, Mark G. Roback, MD, Robert. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Ann Emerg Med. 2011;57:449-461.

• James R. Miner, Mark Danahy, Abby Moch. Randomized Clinical Trial of Etomidate Versus Propofol for Procedural Sedation in the Emergency Department. Ann Emerg Med. 2007;49:15-22.

THANK YOU FOR YOUR ATTENTION