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Procedural Sedation

Procedural Sedation. Jan 27, 2011 Jason Mitchell Dr. Gil Curry Dr. Marc Francis. Acknowledgments. Dr. James Huffman Dr. Dave Choi. OUTLINE. INTRODUCTION PRE-SEDATION PREPARATION AGENTS MONITORING OTHER CONTROVERSIES FUTURE DIRECTIONS. INTRODUCTION. Procedural Sedation

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Procedural Sedation

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  1. Procedural Sedation Jan 27, 2011 Jason Mitchell Dr. Gil Curry Dr. Marc Francis

  2. Acknowledgments Dr. James Huffman Dr. Dave Choi

  3. OUTLINE • INTRODUCTION • PRE-SEDATION PREPARATION • AGENTS • MONITORING • OTHER CONTROVERSIES • FUTURE DIRECTIONS

  4. INTRODUCTION • Procedural Sedation • Technique to induce a state of lowered awareness and pain sensation • Preserves independent cardiac and respiratory functions • Employs sedative, dissociative, and analgesic agents • CORE COMPETENCY for ED Practice

  5. INTRODUTION • CAEP, ACEP, and ASA Guidelines assert sedation provider must: • understand agent characteristics and relevant antagonists • be able to maintain desired sedation level • be able to manage potential complications • agent specific • airway management • hemodynamic instability 1 Innes G, Murphy M, Nijssen-Jordan C, et al. Procedural Sedation and Analgesia in the Emergency Department. Canadian Consensus Guidelines. J Emerg Med 1999:17(1);145-156. 2. Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005 ;45(2):179-196 3. Gross JB, Farmington CT, Bailey PL, et al. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96(4)1004

  6. INTRODUCTION • SEDATION CONTINUUM 4. American Society of Anesthesiologists. Continuum of depth of sedation definition of general anesthesia and levels of sedation/analgesia. October 27, 2004. Available at http://www.asahq.org/publicationsAndServices/sgstoc.htm 5. Green SM, Mason KP. Reformulation of the Sedation Continuum. JAMA 303(9);876-877.

  7. INTRODUCTION • SEDATION CONTINUUM

  8. INTRODUCTION • SEDATION CONTINUUM

  9. INTRODUCTION • SEDATION CONTINUUM

  10. INTRODUCTION • SEDATION CONTINUUM

  11. INTRODUCTION • SEDATION CONTINUUM DISSOCIATIVE SEDATION

  12. INTRODUCTION • The deeper the sedation, the greater the risk of: • Loss of airway protection • Apnea • Cardiovascular compromise • Hemodynamic collapse

  13. PRE-SEDATION PREPARATION • CASE • 26 yo M Tennis Injury • R Shoulder Dislocation • No # • NV stable • History??

  14. PRE-SEDATION ASSESSMENT • PATIENT ASSESSMENT • Focused history: • PMHX • Assess degree of cardiopulmonary reserve

  15. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT • Focused history: • PMHX • Assess degree of cardiopulmonary reserve ? ✗ ✗ ✓ ✓

  16. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT • Focused history: • PMHX • Assess degree of cardiopulmonary reserve • Medications • Allergies • Anesthetic history • Pre-procedural fasting

  17. PRE-SEDATION PREPARATION • CASE • Focused history: • PMHX • Medications • Allergies • Anesthetic history • Pre-procedural fasting

  18. PRE-SEDATION PREPARATION

  19. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT – FASTING • Controversial • Loss of airway reflexes and vomiting exceptionally rare • No evidence-based ED guidelines for optimal fasting • Limited data for improved ED outcomes with prolonged fasting duration

  20. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT – FASTING • Most data derived from GA literature • Aspiration 1:3,420 elective Sx; 1:895 emergent Sx • Mortality 1:125,109 • Not our patients!

  21. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT – FASTING • ASA recommends the following:

  22. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT – FASTING • Pediatric prospective observational study • n = 905, 56% noncompliant with ASA guidelines • Emesis in 15 (1.5%) of patients, 1 during procedure • No evidence of pulmonary aspiration • No significant difference in fasting duration and emesis or airway complications • No reports of pediatric aspiration pneumonitis in the literature 6. Agrawal D, Manzi SF, Gupta R, et al. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003:42(5);636-646.

  23. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT – FASTING • A review of 25 papers addressing adult emesis with ED PSA: • 4657 cases non-compliant with ASA fasting • 17 cases of emesis (0.3%) • 1 case intubation, 1 case ICH • 0 cases evidence of aspiration • One reported case of adult aspiration after PSA 7. Thorpe RJ, Binger J. Pre-procedural fasting in emergency sedation. Emerg Med J 2010:27;254-261. 8. Cheung KW, Watson ML, Field S, et al. Aspiration pneumonitis requiring intubation after procedural sedation and analgesia: a case report. Ann Emerg Med 2007:49(4)462-464.

  24. PRE-SEDATION PREPARATION • Guidelines: • ACEP and CAEP • Insufficient evidence • Recent food intake is not an absolute contraindication • But must be considered in timing of procedure

  25. PRE-SEDATION PREPARATION • ED Specific Practice Advisory 2007 • Risk Assessment • Baseline risk • Timing/nature of intake • Urgency of procedure • Emergent: Cardioversion • Urgent: Abscess I&D • Semi-urgent: Shoulder reduction • Non-urgent: Ingrown toenail • Required depth of sedation 9. Green SM, Roback MG, Miner JR, et al. Fasting and emergency department procedural sedation and analgesia: a concensus-based clinical practice advisory. Ann Emerg Med 2007;49(4):454-461

  26. PRE-SEDATION PREPARATION

  27. PRE-SEDATION PREPEARAT

  28. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT – FASTING • Bottom line: • Risk of aspiration event is rare • Very limited data • Recent food intake is not an absolute contraindication • Weigh the risks of possible aspiration vs. urgency of procedure

  29. PRE-SEDATION PREPARATION • BACK TO THE CASE • 26 yo M R Shoulder Dislocation • PMHx Healthy • No Meds, No Allergies • Fasted • Physical Exam??

  30. PRE-SEDATION PREPARATION • PATIENT ASSESSMENT • Focused physical: • Vitals • Mental status • Airway • Cardiopulmonary exam

  31. PRE-SEDATION ASSESSMENT • CASE CONTINUED • 26 yo M R Shoulder Dislocation • PMHx: Healthy • No Meds, No Allergies • Fasted • AVSS • P/E: Normal

  32. PRE-SEDATION PREPARATION • EQUIPMENT

  33. PRE-SEDATION ASSESSMENT • CASE CONTINUED • 26 yo M R Shoulder Dislocation • PMHx: Healthy • Egg allergy • Fasted • AVSS • P/E: Normal

  34. PRE-SEDATION ASSESSMENT • CASE CONTINUED • 26 yo M R Shoulder Dislocation • PMHx: Psychosis • Egg allergy • Fasted • AVSS • P/E: Normal

  35. AGENTS • Sedatives • Propofol • Midazolam • Etomidate • Analgesics • Opioids • Nitrous oxide • Dissociative agents • Ketamine

  36. AGENTS - SEDATIVES • PROPOFOL • PSA Starting Dose: 0.5-1.0 mg/kg, titrate 0.25-0.5 q45-60 sec • Onset: <1 min • Duration: 5-10 min

  37. AGENTS - SEDATIVES • KETAMINE • PSA Starting Dose: IV 1-2 mg/kg, repeat 0.25-0.5 mg/kg prn IM 2-5 mg/kg, repeat 1 mg/kg prn PO 6-10 mg/kg • Onset: IV: 1 min IM: 5 min • Duration: 15-30 min Complete Recovery: 1-2 hours

  38. AGENTS - SEDATIVES • MIDAZOLAM • PSA Starting Dose: IV 0.05-0.2 mg/kg IM 0.1-0.2 mg/kg IN 0.2-0.6 mg/kg PO 0.5-0.75 mg/kg • Onset: 1-30 min • Duration: 30-12o min

  39. AGENTS - SEDATIVES • BENZODIAZEPINE REVERSAL • FLUMAZENIL • Dose: Adults: 0.1-0.2 mg IV q 1-2 minutes to max 2 mg Peds: 0.02 mg/kg titrated to a max of 0.2 mg • Onset: 1-2 min • Duration: 5-10 min peak • Half-life: 45-90 min • CAUTION: May precipitate status epilepticus in those with benzo dependence or seizure history

  40. AGENTS - SEDATIVES • ETOMIDATE • PSA Starting Dose: IV 0.1-0.2 mg/kg • Onset: <1 min • Duration 5-10 min

  41. AGENTS - ANALGESICS • FENTANYL • PSA Starting Dose: IV 1.0-3.o mcg/kg TM 10-20 mcg/kg • Onset: IV 1-2min TM 10-30 min • Duration: IV 30-40 min TM 60-120 min

  42. AGENTS - ANALGESICS • OPIATE REVERSAL • NALOXONE • Dose: 0.1-0.2 mg q 1-2 min • Onset: < 1 min • Duration 15-30 minutes • CAUTION: Complete reversal in pts who are dependent on opioids may precipitate acute opioid withdrawal

  43. AGENTS - ANALGESICS • NITROUS OXIDE • PSA Starting Dose: 30%-70% inhaled N2O • Onset: 1-2 min • Offset: 3-5 min

  44. AGENTS • CASE CONTINUED • 26 yo M R Shoulder Dislocation • Sedated with propofol • Currently undergoing reduction • What should you be monitoring?

  45. MONITORING • GUIDELINES • Recommend monitoring: • Sedation level • Heart rate • Blood pressure • Pulse oximetry with supplemental oxygen • Controversial

  46. MONITORING • SUPPLEMENTAL OXYGEN • Helpful or harmful? • Controversial • Supplemental O2 impairs ability to detect respiratory depression 10. Green SM, Krauss B. Supplemental oxygen during propofol sedation: yes or no? Ann Emerg Med. 2008 Jul;52(1):9-10.

  47. MONITORING • SUPPLEMENTAL OXYGEN • Does it prevent respiratory depression? • n=80, sedation: propofol 11. Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with propofol: a randomized, controlled trial. Ann Emerg Med. 2008;52(1)1-8.

  48. MONITORING • CAPNOGRAPHY • Controversial • Adjunct to evaluate pre-hypoxic respiratory depression • Superior to clinical exam and oximetry

  49. MONITORING • CAPNOGRAPHY

  50. MONITORING • CAPNOGRAPHY - EVIDENCE • Pediatrics • Comparison of oximetry, capnography, clinical observation in patients receiving midaz/fent • Capnography provided an earlier indication of respiratory depression than pulse ox and clinical exam alone • RCT: blinded staff reported hypoventilation in 3% of cases, did not identify apnea • Capnography disclosed 56% hypoventilation, 24% apnea • Also identified all cases of hypoxia before it occured 12. Hart LS, Berns SD, Houck CS, et al. The value of end-tidal CO2 monitoring when comparing three emthods of conscious sedation for children undergoing painful procedures in the emegency department. Pediatr Emerg Care 1997:13(3);189-193. 13 Lightdale JR, Goldmann DA, Feldman HA, et al. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006:117(6);e1170-1178.

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