Presentation on theme: "Procedural Sedation in the Emergency Department"— Presentation transcript:
1Procedural Sedation in the Emergency Department Deon Stoltz
2Objectives What does it mean What needs to be considered. What do we normally use it for.Review commonly used agentsBriefly discuss alternatives to PSA
3OverviewDISCLAIMER….This is a very simplified overview of a complex topic.It is not a substitute for in-depth research, background knowledge and training.
4What is Procedural Sedation? To reduce patient anxiety and awarenessTo facilitate a painful medical procedurePatient maintains their airway & breathing- a.k.a “conscious sedation” “deep sedation”
5Procedural Sedation Positives Negatives Avoids the discomfort associated with local or regional anaesthetic techniques.Doesn’t affect anatomyRelatively simple techniqueNegativesConsumes resourcesGeneral anaesthesia in the EDis frowned upon…
6The goals of PSTo consider patient safety & welfare the first priority.To provide adequate analgesia, anxiolysis, sedation and amnesia during the performance of painful diagnostic or therapeutic procedures in the ED.To minimize the adverse psychological responses associated with painful or frightening medical interventions.To control motor behaviour that inhibits the provision of necessary medical care.To return the patient to a state in which safe discharge is possible.
7How low should you go? Depth of Procedural Sedation Minimal Sedation (Anxiolysis)Moderate Sedation/AnalgesiaDeep Sedation/AnalgesiaGeneral AnaesthesiaNormal LOCASA/Joint Commission of Accreditation of Healthcare Organizations – Definitions of Levels of SedationMinimal sedation: normal response to verbal commands. Ventillatory & CV function unaffected.Moderate sedation: pt responds to verbal commons +/- light tactile stimulus. No interventions required to maintain airway. Spont resp. CV function maintained.Deep sedation: pt cannot be aroused, but responds purposefully to repeated or painful stimulation. May require assistance maintaining a patent airway. Spont vent may be inadequate.General anaesthesia: Pt is unarousable. Patient typically requires assistance maintaining an airway +/- PPV.
8Uses Reduction of dislocations: shoulder, elbow, hip, patella, ankle Reduction of fractures:wrist, anklewashout compound fracturePaediatric injuries:wound inspection, closure, suturingAbscess I&D
9Considerations for PS in the ED PatientAgentEnvironmental
11CaseA 40 yo man presents with a painful, swollen right wrist after a fall. You do an x-ray…
12So what about our patient? Allergies:EggsMedications:EnalaprilSalbutamolFloventPast Medical History:AsthmaObstructive sleep apneaHypertensionDM IILast Meal:30 minutes agoEvents:Patient came immediately to the hospital after falling.
13To sedate or not to sedate… 86 yo female with a dislocated hip Allergies: NKDAMeds:MetoprololNitroglycerin patchEnalaprilLasixASAAtroventLast meal:NPO for 4 hoursPMHx:MI x 2 (multi-vessel CAD)Angina with minimal activityPVDHTNCVACRFEvents:Pt felt a pop while trying to get up from a chair.CAD…Limited ability to tolerate hypotension
14To sedate or not to sedate… 22 yo intoxicated male with an ankle fracture Allergies: NKDAMeds: unknownPMHx: unknownLast meal:Smells like EtOHUnknownEvents:No one really knowsAspiration & airway reflexes:Will he protect his airway?No idea of NPO statusIncreased risk of aspirationConsentDouble doctor is possibleConsider timing of reduction
15To sedate or not to sedate… 28 yo female with a fractured wrist What risks are associated with sedation during pregnancy?Difficult intubationDifficult BVMIncreased risk of aspiration
16Patient Assessment The AMPLE history Physical Exam Allergies MedicationsPast medical historyLast mealEvents before & after the incidentPhysical ExamAirway assessmentRespiratory examCardiovascular exam
17ASA Physical Status Classification Healthy PatientMild systemic disease – no functional limitationSevere systemic disease – definite functional limitationSevere systemic disease that is a constant threat to lifeMoribund patient that is not expected to survive with the operationLow inter-observer reliability.
18“It’s only a little chest pain” ASA Scores & PSA The ASA classification is not validated outside of the OR.Malviya et al showed an increased risk of adverse sedation-related events in paediatric patients with an ASA > 2.The ASA was developed to help identify patients at risk of developing complications as a result of undergoing general anesthesia.ASA: No formal support by emergency medicine associations; Supported by the American society of anestheologists
19“The patient’s ASA status should be determined “The patient’s ASA status should be determined. For non-emergent procedures, ED sedation and analgesia should be limited to ASA class 1 or 2 patients.”Class B, Level IIIProcedural sedation and analgesia in the emergency departmentCanadian Consensus GuidelinesThe guidelines go on to say that for ASA III-IV patients, anesthesia should be consulted and OR management should be considered.ASA status was not addressed in the American guidelines.
20The Last Supper Fasting & PSA ANZCA recommendations for healthy elective GA patients:2 h NPO for liquids6 h NPO for solidsThe risk of aspiration during PSA is extremely low.There is no evidence that fasting improves outcome during procedural sedation and analgesia.One large paediatric study of ED procedural sedation showed no increase in the number of adverse events in patients that were not fasting.In addition, the ASA indicates that there is no role for the use of antacids and gastric motility agents to prevent aspiration during elective GA in healthy patients. The ACEP guidelines apply this recommendation to ED PSA patients, while the Cdn guidelines recommend their use in patients who do not meet NPO criteria.Green proposes a number of reasons why the the ASA guidelines should not be generalized to ED PSAAspiration is most likely to occur during airway manipulation – this should not be happening during PSA.PSA is typically performed in younger patients. The risk of aspiration is higher in older patients.Most agents used during PSA are not pro-emetic, unlike the gases which are commonly used in the OR.Ideally, PSA should be in the range of moderate sedation with intact airway reflexesThe use of dissociative amnestics (ketamine) theoretically reduces the risk of aspiration because airway reflexes are “intact”
21Starved for how long…?Controversial.Probably not as rigid as anaesthetic guidelines for GA...Depends on degree and duration of sedationStarship CED paediatric guideline:Clear fluids: at least 2 hoursNon-clear fluids and solids: at least 4 hours
22PATIENT SELECTION Can you hold the fort if something goes wrong? BREATHING & CIRCULATION:Lung disease?Stable cardiac status?BP stable?MedicationsAllergies (e.g. watch out for soy, eggs: Propofol)
24Predictors of Difficult BVM Ventilation BeardObesityOld (age > 55 yrs)ToothlessSnoresLangeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology ; 92:
25The LEMON Method of Airway Assessment Look for external characteristics known to causes problems with BVM or intubation.Evaluate the Rule:Mouth opening > 3 fingersHyoid – chin distance > 3 fingersAnterior low jaw subluxation > 1 fingerMallampati ScoreObstruction – any pathology within or surrounding the upper airwayNeck Mobility - full flexion & extension
26Considerations for PS in the ED PatientAgentEnvironmental
27The Perfect Drug Provides adequate sedation and analgesia for: Patient comfortEasy completion of the procedureMaintains airway reflexesDoes not affect hemodynamicsDoes not affect respiratory function
28Commonly Used AgentsPropofolFentanylKetamineMidazolam
29Commonly Used Agents Propofol CategorySedative-HypnoticWhat is it?2,6-diisopropofol, an alkylphenol oil in an emulsionHow does it work?Potentiates GABA activityHow much do you need?Starting dose of mg/kgActual half-life of propofol is 4-7 hrsClearance is independent of renal or liver function and is not affected by renal or hepatic disease.Onset is one arm-brain circulation with peak affect at s.Anti-emetic properties
30Commonly Used Agents Propofol What else does it do?CNS: Mild analgesic properties; euphoriaCVS: Myocardial depressant; vasodilationResp: Respiratory depressantGI: AntiemeticMSK: MyoclonusWhat does the body do with it?Rapid redistributionHepatic and extrahepatic metabolism
31Commonly Used Agents Propofol ProsShown to be safe for ED PSA useRapid onset and recoveryConsMust be combined with an analgesic agentMay cause apnea & loss of airway reflexesMyocardial depressant and vasodilatorSymington and Thakore conducted a review of the safety of using propofol for procedural sedation in the ED and concluded that while the rate of “minor” adverse events (including transient hypoxia) was similar to other agents, the drug was overall very safe and offered advantages over other agents.
32Commonly Used Agents Fentanyl CategoryAnalgesic agentWhat is it?Synthetic opioidHow does it work?Decreases conduction along nociceptive pathways and increases activity in pain control pathways in the brain.How much do you need?Starting dose of 1-2 mcg/kgDoses > 5 mcg/kg bolused rapidly are required to cause chest wall rigidity. Rigidity is managed with paralysis or reversal agents.May cause coughing in 50% of patients.Peak effect in 2-3 min
33Commonly Used Agents Fentanyl What else does it do?CNS: Euphoria (or dysphoria)Resp: Respiratory depressant; chest wall rigidityCVS: May decrease HRGI: Decreased motilityWhat does the body do with it?Hepatic metabolism (inactive metabolite)Renal excretion
34Commonly Used Agents Fentanyl ProsGood hemodynamic stabilityRapid onset and recoveryConsMust be combined with an amnestic agentMay cause bradycardiaMay cause chest wall rigidityMay cause apnea & loss of airway reflexesCardiology study using high dose fentanyl for cardiac surgery – patients were hemodynamically stable and pain free.
35Commonly Used Agents Midazolam CategoryAmnesticWhat is it?BenzodiazepineHow does it work?Bind to benzodiazepine receptors which up- regulate GABA activityHow much do you need?0.02 – 0.1 mg/kg IVUse with caution in patients with renal failure b/c of potential buildup of metabolite.
36Commonly Used Agents Midazolam What else does it do?CNS: AnxiolysisCVS: Slight decrease in PVR & decreased contractility.Resp: Respiratory depressionWhat does the body do with it?Hepatic metabolism (active metabolite)Renal excretion
37Commonly Used Agents Ketamine CategoryDissociative AmnesticWhat is it?Derivative of phencyclidine with some opioid properties.How does it work?Stimulates the limbic system while inhibiting the thalamus & cortex (dissociation)Binds to NMDA and opioid receptorsMetabolite (norketamine) has 20-30% less activity than ketamineOnset within 30 s of administration (IV)Distribution half life is minutes (two compartment metabolism)
38Commonly Used Agents Ketamine What else does it do?CNS: Emergence reactionsCVS: Increased contractility, HR and PVR through sympathetic stimulation. Direct myocardial depressant.Resp: Laryngospasm, bronchodilation, increased secretionsWhat does the body do with it?Hepatic metabolismRenal excretion
39But won’t it give him nightmares? Ketamine & Emergence Reactions Frequency is reported to be anywhere from <1% to 50% in adults.Treatment with benzodiazepines is the most effective way to prevent emergence reactions.Emergence reaction: Anxiety, nightmares, hallucinations & delirium while waking upKetamine is extensively used in developing countries with great success.Evidence for benzos is debateable – several peds trials show no benefit. Anecdotally, some people will wait for signs of emergence before giving midazolam while others give it with ketamine. Two trials from the 70’s show a reduction in the incidence of emergence reactions when adult patients were pretreated with midazolam
40Commonly Used Agents Ketamine How much do you need?1 – 2 mg/kg IVHow much midazolam?0.7 mg/kg given at the time of ketamine injection.Several authors pointed out that this dose of midazolam may be higher than required to prevent emergency reactions.
41Mix & Match Commonly used combinations: Propofol + Fentanyl Fentanyl + MidazolamPropofol + Midazolam + FentanylKetamine + MidazolamCombinations of propofol + fentanyl, fentanyl + midazolam etc lead to synergistic effects on the cardiovascular system. This results in greater than expected amounts of hypotension, which is tolerated in the young health individual, but may be problematic in someone with less reserve.Midazolam may decrease the rate of ketamine metabolism, resulting in greater duration of sedation.
42How low should you go? Depth of Procedural Sedation Minimal Sedation (Anxiolysis)Moderate Sedation/AnalgesiaDeep Sedation/AnalgesiaGeneral AnaesthesiaNormal LOCASA/Joint Commission of Accreditation of Healthcare Organizations – Definitions of Levels of SedationMinimal sedation: normal response to verbal commands. Ventillatory & CV function unaffected.Moderate sedation: pt responds to verbal commons +/- light tactile stimulus. No interventions required to maintain airway. Spont resp. CV function maintained.Deep sedation: pt cannot be aroused, but responds purposefully to repeated or painful stimulation. May require assistance maintaining a patent airway. Spont vent may be inadequate.General anaesthesia: Pt is unarousable. Patient typically requires assistance maintaining an airway +/- PPV.
43Considerations for PS in the ED PatientAgentEnvironmental
44PREPARATION Prepare for the worst…. What can go wrong? Unexpected drug reaction or anaphylaxisVomit and aspirateObstructed airway (e.g. laryngospasm, tongue)Apnoea, respiratory arrestProfound hypotension
45PREPARATION Not quite the worst … What can go wrong? Disinhibition / agitationTerrors, nightmaresUnexpected drug reactions: dystoniasInadequate sedationUnsuccessful procedure… still needs GA
47PREPARATION ENVIRONMENT The procedure must be performed in a suitable clinical area with facilities for:Monitoring,OxygenSuctionimmediate access to emergency resuscitation equipment, drugs and other skilled staff.
48PREPARATION ENVIRONMENT Readily available equipment must include: resuscitation trolleydefibrillator
49PREPARATION ENVIRONMENT Readily available equipment must include: resuscitation trolleyDefibrillatorBag-Valve-Mask device for ventilation
50PREPARATION MONITORING Cardiac rhythm, non-invasive blood pressure and pulse oximetry must be monitored throughout the procedure and recovery period
51PREPARATION PERSONNEL The involvement of at least two clinical staff is required:PERSON PERFORMING PROCEDUREmust 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.
52PREPARATION PERSONNEL The involvement of at least two clinical staff is required:PERSON PERFORMING PROCEDUREmust 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.
53PREPARATION 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.
54PREPARATION PATIENT PREPARATION Explanation Consent Secure IV access is mandatory.
55PREPARATION Other requirements Separate space to perform the procedure A recovery space: ideally quiet, available for 1-2 hours, easily observed.
56READY TO GO… Explain Pre-oxygenate IV Access and IV fluid running Splints or plaster or equipment all ready to goHand over your phone or pager…
61Key Points Be prepared Know your drugs and your drug interactions Consider all your options
62Other References Guidelines Godwin SA, Caro DA, Wolf SJ, Jagoda AS, Charles R, Marett, BE and Moore J. Clinical policy: procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine. 45:2. February 2005; ppInnes G, Murphy M, Nijessen-Jordan C, Ducharme J and Drummond A. Procedural sedation and analgesia in the emergency department. Canadian consensus guidelines. The Journal of Emergency Medicine. 17:1. January 1999; pp 145 – 156.TextbooksMiller RD. Miller’s Anesthesia, 6th EdMarx JA. Rosen’s Emergency Medicine, 5th EdRoberts JR. Clinical Procedures in Emergency Medicine, 4th EdTintinalli JE. Emergency Medicine: A Comprehensive Study Guide, 6th Ed
63Other References Journal Articles Syminton L and Thakore S. A review of the use of propofol for procedural sedation in the emergency department. Emergency Medicine Journal :Green SM and Krauss B. Propofol in emergency medicine: pushing the sedation frontier. Annals of Emergency Medicine :Bahn EL and Holt KR. Procedural sedation and analgesia: a review and new concepts. Emergency Medicine Clinics of North America :Green SM. Fasting is a consideration – not a necessity – for emergency department procedural sedation and analgesia. Annals of Emergency Medicine :Green SM and Sherwin TS. Incidence and severity of recovery agitation after ketamine sedation in young adults. American Journal of Emergency Medicine :Green SM and Li J. Ketamine in adults: what emergency physicians need to know about patient selection and emergency reactions. Academic Emergency Medicine :7(3)
64Procedural Sedation & Analgesia in the Emergency Department