Procedural Sedation

Procedural Sedation

1. Procedural Sedation Kate Donaghy 26th March 2015

2. -American College of Emergency Physicians “Procedural sedation and analgesia refers to the technique of administering sedatives or dissociative agents with or without analgesics to induce an altered state of consciousness that allows the patient to tolerate painful or unpleasant procedures while preserving cardiorespiratory function.”

3. When Use it? Fracture reduction Joint Relocation Wound management Abscess I+D DC cardioversion

4. Why Use it? Avoid theatre Cost saving: £614 ( $1164) for P.S. vs OT Pain saving, anxiety-relieving

5. Alternatives Local anaesthetic direct infiltration Nerve blocks Bier’s Block GA

6. Policy Guidelines from collaboration of Australian and New Zealand College of Anaesthetists (ANZCA), ACEM, etc

7. Levels of Sedation (ASA) Minimal Sedation Moderate Sedation (‘Conscious sedation’) Deep Sedation General Anaesthesia Dissociative Sedation

8. The Ideal agent Predictable induction and maintenance of sedation prompt recovery minimal recal l no complications Often an opioid analgesic with a sedative and amnesic agent

9. Options Nitrous Oxide Propofol Ketamine Midazolam Etomidate Opioids in combination Combination eg Ketamine-Propofol

10. Propofol Benefits: rapid onset and recovery Onset: 30-60sec; Peak 60-120sec, Duration 3-10min Contraindication: allergy to egg and soy Caution:haemodynamically unstable, elderly SEs: hypotension, bradycardia, resp depression, pain on infusion No analgesic properties: give with an opioid Dose: 0.5-2mg/kg

11. Midazolam Anxiolytic, sedative, amnesic. No analgesia Reversible onset 1-5min, peak 10-15min, duration 1-2.5hrs SEs: hypotension, resp depression, paradoxical reaction Dose: 0.025-0.05mg/kg titrated to 0.4mg/kg max caution: avoid alcohol and mental-alert activities for 24hrs

12. Nitrous Oxide Inhalational: amnesia, sedation, analgesia Fast induction Contraindication: pneumothorax, bowel obstruction Caution: diffusion hypoxia: O2 for 20min after SEs: vomiting Dose: mask inhalation: 30-70% , safety valve, if pt overly sedated, m outh piece falls

13. Ketamine Dissociative Anaesthetic IV: Onset 1-2min, peak 2-3min, duration 5-15min Benefits: Increase HR and BP, maintain airway reflexes, bronchodilator SEs: laryngospasm, emergence reactions, oral secretions, reduce seizure threshold , vomiting, resp depression, ???raised ICP Good for children more than adults Contraindications: schizophrenia , raised IOP, (URTIs) Warn parents re stare; pleasant dreams!, room quiet Dose: 0.5-1.5mg/kg IV, 2-4mg/kg IM

14. Etomidate Acts on GABA receptor onset 20-60sec, peak 1min, duration 3-8min limited effects on cardiovascular function good for altered myocardial contractility and raised ICP SEs: n+v, pain at injection site, myoclonus, adrenocortical suppression? Dose: 0.1-0.15mg/kg

15. Opioids Morphine 0.05-0.1mg/kg every 5-15min onset 1-2.5min, peak 10-20min, duration 1-4hrs SEs: n+v, dizziness, injection site pain, agitation, flushing, paraesthesia Fentanyl 1-2mcg/kg onset immediate, peak 1-3min, duration 30-60min SEs: resp depression, rigidity (rapid IV), brady and hypotension, dizzy, n+v, diaphoresis

16. Ketofol Ketamine - emergence reactions in adults, emesis Propofol - hypotension and respiratory depression combination to give sedation that is closer to ideal, avoid opioid use with propofol RCTs suggest ketofol no better than propofol

17. Australia EMA - Procedural Sedation Practices - 2011 Propofol used in 2 /3 cases (adults 94%) 65% ketamine use was in children Half of pts did not have pre-procedural analgesia: oligoanalgesia is an issue Morphine:Fentanyl 4:1

18. Methods Assessment Preparation Procedure Aftercare

19. Assessment Patient: HPC, PMHx, DHx, Allergies, prev anaesthetics, loose teeth, exercise tolerance, LMP Fasting status Airway grade: Mallampati score CVS/Resp exam Review results Department Status Consent

20. Cautions elderly, children <2yr heart, lung, Cerebrovascular, renal, liver disease morbid obesity, OSA, difficult AW cardiovascular compromise, severe anaemia potential for aspiration e.g. Pregnant anaesthetic adverse events previously ASA grades P4-5

21. Preparation At least 3 appropriately trained staff (1 for drugs and AW, 1 proceduralist, assistant) (AW, ALS competent) Procedure Room appropriate, lighting oxygen (FM, NC) BMV apparatus, airways, intubation equip, suction crash cart, defibrillator medications, emergency drugs monitoring (cardiac, pulse oximeter, capnography, BP) Emergency Plan

22. Procedure IVC, positioning Pre-oxygenation Baseline observations Medications Monitoring, depth of sedation

23. Aftercare Documentation: drugs, IVF, monitoring, rescue interventions, complications Recovery: Doc present until spont respiration, stable vitals, protective reflexes, sedation level 2 Further recovery: fully awake, obs, pain, dressing, mobilising, E+D, voided discharge to responsible adult advice: E+D, analgesia, driving/machinery/decisions

24. Complications Sedation related events common: 1 in 5 Vomiting , aspiration, hypo/hypertension, brady/tachycardia, hypoventilation, desaturation, obstructed airway Adverse outcomes rare Higher risk (resp): age, level of sedation, premed, sedation drug (person in charge)

25. Managing Complications Resp Depression: stimulation, airway manoeuvres, BMV, Airways Hypotension: IVF, elevate legs, metaraminol Laryngospasm: 100% O2 with mask, tight seal, closed expiratory valve -> positive pressure manually ventilate Break laryngospasm - Larson’s point Deepening sedation - propofol suxamethonium IV or IM Intubate

26. Controversies Fasting status? 2+6 or no evidence of decreased aspiration? Capnography? prevent hypoxia but no difference in outcome How many doctors? 1 or 2? Supplemental Opioids? Respiratory depression vs catecholamine surge Nasal NIV?? - AJEM 2015

27. Conclusion Essential skill for ED trainees Know of policies and departmental credentialing Choose your patient Anticipate complications

28. References Australian and New Zealand College of Anaesthetists (ANZCA) (2014) Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. [Online]. Available at: http://www.anzca.edu.au/resources/professional-documents/pdfs/ps09-2014-guidelines-on-sedation-and-or-analgesia-for-diagnostic-and-interventional-medical-dental-or-surgical-procedures.pdf (Accessed: 24/3/15). Bell A, Taylor DM et al. (2011) 'Procedural sedation practices in Australian Emergency Departments', Emergency Medicine Australasia, 23, pp. 458-465. Godwin SA, Burton JH et al. (2014) 'Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department', Annals of Emergency Medicine, 63, pp. 247-258. Boyle A, Dixon V et al. (2010) 'Sedation of children in the emergency department for short painful procedures compared with theatre, how much does it save? Economic evaluation', Emergency Medicine Journal, 28, pp. 383-386. Andolfatto G, Abu-Laban RB et al (2012) 'Ketamine-Propofol Combination (Ketofol) Versus Propofol Alone for Emergency Department Procedural Sedation and Analgesia: A Randomized Double-Blind Trial', Annals of Emergency Medicine, 59(6), pp. 504-512. Miner JR, Moore JC et al (2013) 'Randomized Clinical Trial of the Effect of Supplemental Opioids in Procedural Sedation with Propofol on Serum Catecholamines', Academic Emergency Medicine, 20(4), pp. 330-337. Strayer RJ, Caputo ND (2015) 'Noninvasive ventilation during procedural sedation in the ED: a case series', American Journal of Emergency Medicine, 33, pp. 116-120. Taylor DM, Bell A et al. (2011) 'Risk factors for sedation-related events during procedural sedation in the emergency department', Emergency Medicine Australasia , 23(), pp. 466-473.