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Procedural Sedation

Procedural Sedation. Christian La Rivière, MD, FRCPC. “Conscious Sedation is very safe and therefore, occasionally, very dangerous.”. Dr. J. Mansfield. “…..the responsibility for administering conscious sedation ultimately lies with the individual practitioner.

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Procedural Sedation

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  1. Procedural Sedation • Christian La Rivière, MD, FRCPC

  2. “Conscious Sedation is very safe and therefore, occasionally, very dangerous.” Dr. J. Mansfield

  3. “…..the responsibility for administering conscious sedation ultimately lies with the individual practitioner. • He or She must ensure that drugs are being administered safely and appropriately. The practitioner must be aware of his or her own limitations, and when it is appropriate to request assistance. • These vary from individual to individual.” • Dr. Steve Kowalski • Physician Accreditation for Conscious Sedation

  4. Overview • Know your facility, equipment, and personnel. • Know your patient. • Know your drugs, doses, adverse effects. • Be aware of specific risks or problems associated with your procedure. • Know how to avoid trouble, but what to do if something happens.

  5. Why use procedural sedation? • “Premise: Painful procedures are inevitable in emergency medicine, but pain is not.” • “Any physician who practices emergency medicine without using some form of sedation technique is either not practicing emergency medicine or not practicing it humanely.” Dr. Grant Innes

  6. Why use procedural sedation? • “To provide analgesia and amnesia during painful diagnostic and therapeutic procedures in the ED. To minimize negative psychological responses associated with medical interventions” • “In children or uncooperative adults it may expedite the conduct of procedures that are not particularly uncomfortable but require the patient not to move.” Dr. Grant Innes • Dr. Jeffery Gross

  7. The Sedation Spectrum Simple anxiety reduction Light sedation Neurolepsis Dissociative state Deep sedation General anesthesia

  8. Potential Indications • reducing fractures and dislocations • scrubbing road rash • deep, complex, or multiple lacerations not amenable to local anesthetic esp. tongue and vermilion border • burn debridement • chest tubes • foreign body removal

  9. Potential Indications • radiographic imaging • neuro-imaging in a combative patient • endoscopy,bronchoscopy,colonoscopy • lumbar puncture

  10. Potential Indications • cardioversion • foley catheterization • hernia reduction • abscess incision and drainage • terrified, uncontrollable child • dilatation and curettage

  11. Contraindications • Lack of personnel experienced at airway management or advanced life support • Unfamiliarity with medications being administered for sedation • Lack of appropriate monitoring equipment • The unstable patient • Allergy or sensitivity to relevant medication • Potentially difficult airway (relative)

  12. Preparation and Planning • Patient assessment and selection • Airway assessment • Equipment selection • IV access • Appropriate support staff • Medication selection • Consent

  13. Airway Examination

  14. Difficult Airway? • Sometimes it is obvious • Know when to ask for help

  15. Airway • History • previous problems with anesthesia or sedation • stridor, snoring, or sleep apnea • advanced rheumatoid arthritis

  16. Airway • Physical exam • habitus - obesity • neck - movement, size, abnormalities • mouth - opening, tongue, teeth • jaw - movement, size

  17. Difficult Mask Ventilation • M - Mask Seal • O - Obesity / Obstruction • A - Age (advanced age) • N - No Teeth • S - Sleep apnea / Stiff Lungs

  18. Potential Difficult Airway • L - Look Externally • E - Examine 3-3-2 • M - Mallampati • O - Obesity/Obstruction • N - Neck Mobility

  19. Predicting the difficult airway: Class II Class I Mallampati scoring system Class III Class IV

  20. Experienced Personnel • familiar with pharmacology • cardiopulmonary resuscitation • airway management • Pediatrics: PALS • RN or RT

  21. Monitoring & Equipment • Adequate and accessible space • Nurse, MD • Equipment: • Pulse oximeter • BP machine • continuous EKG monitor

  22. Equipment • IV access • oxygen - suction • bag-valve mask that fits patient • airway basket at the bed side • defibrillator & emergency ACLS drugs • reversal drugs at the bedside

  23. Monitoring & Equipment

  24. Documentation

  25. Discharge Criteria • normal vital signs • baseline mental status • coherent speech • sit unattended • understand verbal post sedation instructions

  26. Overview of Drugs

  27. Drugs of Interest • Opioids (fentanyl) • Benzodiazepines (midazolam) • Dissociative agents (ketamine) • Propofol • Other agents (Etomidate)

  28. Which Drug Should I Choose? • choosing the drug or drug combination should depend on: • the patient • the procedure being performed • your comfort level with the drug

  29. The Ideal Drug • short half life • predictable effects • easily titratable • reversible • no side effects • low cost

  30. The Ideal Route • rapid, predictable, titratable; life line for fluids, reversal agents IV

  31. Opioids • fentanyl is the best opioid for procedural sedation • Morphine is no longer widely used in this setting

  32. Fentanyl • potent, rapid-acting opioid • physiologic effects mediated by binding to opiate receptors in the brain and spinal cord

  33. Fentanyl Pharmacokinetics • onset of action begins in about 90 seconds • clinical duration 20-30 minutes • serum half life 90 minutes • approximately 100x more potent than iv morphine (10 mg Morphine = 100 mcg Fentanyl)

  34. Fentanyl Dosing • iv: 1-3 mcg/kg, titrated to effect • in average sized adults, titrate in 25-75 mcg aliquots every 2-3 minutes

  35. Fentanyl- Adverse Effects • respiratory depression: • maximal respiratory depression occurs in about 5 minutes • dependent on dose, and co-administration of other agents (e.g.: midazolam)

  36. Adverse Effects (cont’d) • pruritis, but seldom causes any allergic reaction • nausea and vomiting (less than the other opioids) • muscular and glottic rigidity: • this will only happen if you make a dosing error (e.g.: giving 50 mcg/kg, instead of 50 mcg x 1!)

  37. Benzodiazepines • midazolam • other agents are not as well suited for procedural sedation

  38. Midazolam • acts on GABA receptors, resulting in anxiolytic, hypnotic, and amnestic effects • midazolam is rapid acting and easily titratable compared to the other benzodiazepines • water soluble and lipophilic

  39. Midazolam Pharmacokinetics • onset of action 1-3 minutes • clinical duration approximately 30 minutes • serum half life 1.5-3 hrs

  40. Midazolam Dosing • iv: recommended total is 0.02-0.1 mg/kg • for average adult, titrate using 1-2 mg aliquots every 2-3 minutes

  41. Midazolam Adverse Effects • respiratory depression • severity of respiratory compromise increased with alcohol, barbituates, opioids • clinically significant side effects with midazolam used alone are RARE • if used in combination with fentanyl, hypotension may ensue

  42. Ketamine • derivative of the street drug phencyclidine (PCP) • the only dissociative agent used in procedural sedation

  43. Ketamine • causes a dissociation between the thalamoneocortical and limbic systems • prevents the higher order centres from perceiving visual, auditory, or painful stimuli • “lights on, nobody’s home”

  44. Ketamine (cont’d) • does not cause respiratory depression (unless given in a rapid bolus and large enough dose) • muscle tone and airway protection maintained • water soluble and lipophilic

  45. Other Physiological Effects • inhibits re-uptake of catecholamines (may cause some tachycardia and hypertension) • relaxes bronchial smooth muscle • stimulates salivary and tracheobronchial secretions • may increase ICP and IOP

  46. Ketamine Pharmacokinetics • onset 1 minute (iv), 5 minutes (im) • duration 15 minutes (iv), 30 minutes (im) • complete recovery within 1-2 hrs

  47. Ketamine Dosing • if given alone or with midazolam, start with 0.5-1.0 mg/kg, iv; repeat doses of 0.05-0.1 mg/kg, iv as needed • if giving it im, the dose is 4-5 mg/kg • if giving it in children, consider a premedication with atropine, 0.01-0.02 mg/kg, iv for the bronchial secretions

  48. Adverse Effects • laryngospasm: • reported almost exclusively in infants < 3 months old • risk factors are infants and in patients with active upper respiratory tract infections • overall, still quite rare in the peds world • 0.4% incidence of laryngospasm in a study looking at 1022 cases • in pooled data involving 11,589 kids > 3 y.o., laryngospasm occurred 0.017%

  49. Adverse Effects (cont’d) • muscle rigidity, random movements, nystagmus • this usually is of no clinical consequence

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