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Risk Reduction in Sedation and Analgesia Rowland P. Wu, MD Adapted from Glynne D. Stanley, MD Rowland P. Wu, MD Adapted from Glynne D. Stanley, MD.

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Presentation on theme: "Risk Reduction in Sedation and Analgesia Rowland P. Wu, MD Adapted from Glynne D. Stanley, MD Rowland P. Wu, MD Adapted from Glynne D. Stanley, MD."— Presentation transcript:

1 Risk Reduction in Sedation and Analgesia Rowland P. Wu, MD Adapted from Glynne D. Stanley, MD Rowland P. Wu, MD Adapted from Glynne D. Stanley, MD

2 Overview Complications occur because of: Inappropriate patient selection Unanticipated responses from patient or equipment Over-medication Wrong patient/wrong site/wrong procedure Complications occur because of: Inappropriate patient selection Unanticipated responses from patient or equipment Over-medication Wrong patient/wrong site/wrong procedure

3 Strategies to reduce risk, ‘patient selection’ Improve patient selection ASA Classification airway assessment and history identify other factors e.g. pregnancy, obesity Improve patient selection ASA Classification airway assessment and history identify other factors e.g. pregnancy, obesity

4 Patient Selection Important ‘baseline’ assessments are: actual or estimated weight vital signs including baseline oxygen saturation cardiopulmonary status general neurological status previous adverse responses to medication (not just allergy detection)_ ASA classification (Baseline airway evaluation) Important ‘baseline’ assessments are: actual or estimated weight vital signs including baseline oxygen saturation cardiopulmonary status general neurological status previous adverse responses to medication (not just allergy detection)_ ASA classification (Baseline airway evaluation)

5 ASA Classification ASA 1 Normal, healthy patient ASA 2Stable mild systemic disease ASA 3Severe systemic disease with functional impairment ASA 4Severe disease, constant threat to life, not necessarily to be improved by surgery ASA 5Moribund patient, not expected to survive without surgery ASA 6Brain-dead donor Emergency (E) ASA 1 Normal, healthy patient ASA 2Stable mild systemic disease ASA 3Severe systemic disease with functional impairment ASA 4Severe disease, constant threat to life, not necessarily to be improved by surgery ASA 5Moribund patient, not expected to survive without surgery ASA 6Brain-dead donor Emergency (E)

6 Patient Selection All patients should be carefully evaluated by the MD. Some ASA Class III, and most ASA Classes IV and V will not be suitable for sedation administered by non-anesthesiologists.

7 Mallampati classification

8 Airway Assessment Mallampati classification Neck extension Thyromental distance (?short neck) Interincisor distance (?poor mouth opening) Concurrent obesity (History of airway problems) Letters and bracelets

9 Patient Selection Anesthesia consultation should also be considered under the following circumstances: patient has limited neck motion or cervical instability patient has abnormal craniofacial anatomy patient is morbidly obese patient has a history of sleep apnea pregnant patients patient has not been NPO Anesthesia consultation should also be considered under the following circumstances: patient has limited neck motion or cervical instability patient has abnormal craniofacial anatomy patient is morbidly obese patient has a history of sleep apnea pregnant patients patient has not been NPO

10 Strategies to reduce risk, ‘unanticipated events’ Have available and be familiar with essential pieces of equipment basic interpretation of ECG understand pulse oximetry and know the limitations of use capnography reliable oxygen source, equipment for positive pressure ventilation know how to quickly and reliably get help Have available and be familiar with essential pieces of equipment basic interpretation of ECG understand pulse oximetry and know the limitations of use capnography reliable oxygen source, equipment for positive pressure ventilation know how to quickly and reliably get help

11 Ideal Patient Positioning

12 Obstructed Airway

13 Oral Airway

14 Nasal Airway

15 Mask Ventilation

16 EtCO2 Apparatus

17 EtCO2 Tracing

18 Unanticipated events Cardiac instability/dysrhythmia Respiratory depression and/or airway obstruction Neurological ‘disconnection’ Equipment malfunction Cardiac instability/dysrhythmia Respiratory depression and/or airway obstruction Neurological ‘disconnection’ Equipment malfunction

19 Unanticipated cardiovascular events Cardiovascular instability Hypotension Tachycardia PVC’s atrial arrhythmias ventricular arrhythmias cardiac arrest! Cardiovascular instability Hypotension Tachycardia PVC’s atrial arrhythmias ventricular arrhythmias cardiac arrest! Possible causes hypovolemia allergic reaction overmedication hypoxemia ischemia hypercarbia bleeding

20 Unanticipated respiratory events Respiratory complications depression airway obstruction bronchospasm Respiratory complications depression airway obstruction bronchospasm Possible causes overmedication relative absolute patient position ‘foreign material’ allergic reaction

21 Unanticipated neurological events Neurological ‘Disconnection’ drowsiness unresponsiveness uncooperative combative disinhibition Neurological ‘Disconnection’ drowsiness unresponsiveness uncooperative combative disinhibition Possible causes overmedication Hypoxemia hypercarbia cerebral ischemia hypoxemia cerebral hypoperfusion undermedication?

22 Unexpected events: The catastrophe! Call for help/Code Blue Discontinue sedative therapy, infusions /transfusions etc Begin BCLS/ACLS if appropriate prepare emergency equipment, drugs try to anticipate resuscitation needs Call for help/Code Blue Discontinue sedative therapy, infusions /transfusions etc Begin BCLS/ACLS if appropriate prepare emergency equipment, drugs try to anticipate resuscitation needs

23 Equipment problems: E.C.G. Problems No trace/loss of trace Poor quality Intermittent trace Interference Problems No trace/loss of trace Poor quality Intermittent trace Interference Possible causes ASYSTOLE!! loose leads incorrect placement dry electrodes! greasy skin respiratory variation electrical interference

24 Equipment problems: Non-invasive BP Problems no reading repetitive cycling very low/high BP ??Arterial line Problems no reading repetitive cycling very low/high BP ??Arterial line Possible causes: HYPOTENSION! HYPERTENSION! cuff leak wrong size cuff arrhythmia e.g. AF tubing kinked patient/MD movement

25 Equipment problems: Pulse oximetry Problems: no reading low reading intermittent trace frequent alarm Problems: no reading low reading intermittent trace frequent alarm Possible causes no pulse! hypoxemia! decreased perfusion dye injection electrical interference inappropriate sat/pulse settings incident light/nail polish

26 Equipment problems: Pulse oximetry REMEMBER! Oximetry does not measure respiration there may be a lag phase, depending on probe site as with all the equipment: if it isn’t working at the beginning it will not suddenly get better, it is likely to let you down when you need it most. REMEMBER! Oximetry does not measure respiration there may be a lag phase, depending on probe site as with all the equipment: if it isn’t working at the beginning it will not suddenly get better, it is likely to let you down when you need it most.

27 Strategies to reduce risk, ‘over-sedation’ Have an understanding of the pharmacology involved in conscious sedation Titrate drugs carefully to patient weight but especially to effect. Have appropriate reversal agents readily available and know how to use them Know where other emergency drugs can be found Have an understanding of the pharmacology involved in conscious sedation Titrate drugs carefully to patient weight but especially to effect. Have appropriate reversal agents readily available and know how to use them Know where other emergency drugs can be found

28 Commonly Used Medications Midazolam intravenous/oral/intramuscular/intranasal Initial dose 0.5-2mg iv over 2 min Onset 1minute, peak 3-5 mins Wait full 2 mins between doses with mg increments Duration 1-2 hours Midazolam intravenous/oral/intramuscular/intranasal Initial dose 0.5-2mg iv over 2 min Onset 1minute, peak 3-5 mins Wait full 2 mins between doses with mg increments Duration 1-2 hours

29 Commonly Used Medications Valium Initial dose 2-5 mg iv Onset 1-5 mins Wait full 5 mins between doses with 1 mg increments Duration 3-4 hours Valium Initial dose 2-5 mg iv Onset 1-5 mins Wait full 5 mins between doses with 1 mg increments Duration 3-4 hours

30 Commonly Used Medications Fentanyl Onset 1-3 min; peak-effect at 3-5 minutes Initial dose mcg iv titrated in 25mcg doses low dose drug is short acting Duration of effect mins Fentanyl Onset 1-3 min; peak-effect at 3-5 minutes Initial dose mcg iv titrated in 25mcg doses low dose drug is short acting Duration of effect mins

31 Commonly Used Medications Morphine Onset 1-6 min Initial dose 2-5 mg iv titrated in 2 mg doses but wait 3-5 mins between doses Duration of effect 3-5 hours Morphine Onset 1-6 min Initial dose 2-5 mg iv titrated in 2 mg doses but wait 3-5 mins between doses Duration of effect 3-5 hours

32 Commonly Used Medications Meperidine Initial dose mg iv Onset 2-8 mins, peak 20 mins Mild vagolytic and antispasmodic Normeperidine is pro-convulsant Dose titration mg; Duration 2- 3hrs Interaction with MAOIs Meperidine Initial dose mg iv Onset 2-8 mins, peak 20 mins Mild vagolytic and antispasmodic Normeperidine is pro-convulsant Dose titration mg; Duration 2- 3hrs Interaction with MAOIs

33 Overmedication Why does overmedication occur? Excessive dose Overly sensitive patient, concurrent medications or disease states Inadequate time for effect before more drug administered Abnormal response such as hyperactivity leading to more medication Why does overmedication occur? Excessive dose Overly sensitive patient, concurrent medications or disease states Inadequate time for effect before more drug administered Abnormal response such as hyperactivity leading to more medication

34 Overmedication What problems does overmedication cause? Airway obstruction Hypoxemia and hypercarbia Loss of protective reflexes Loss of contact with the caregiver Hemodynamic instability Interferes with the procedure What problems does overmedication cause? Airway obstruction Hypoxemia and hypercarbia Loss of protective reflexes Loss of contact with the caregiver Hemodynamic instability Interferes with the procedure

35 Overmedication How may overmedication be managed? stop medicating! open airway and stimulate to breathe ensure adequate oxygen supply call for help early, especially if hemodynamic instability consider reversal of medication have suction immediately available How may overmedication be managed? stop medicating! open airway and stimulate to breathe ensure adequate oxygen supply call for help early, especially if hemodynamic instability consider reversal of medication have suction immediately available

36 Overmedication How may medication be reversed? Opiates and benzodiazepines are the only drugs with specific antagonists: REMEMBER: once reversal agents are used this MUST lead to a longer period of post-procedure monitoring. How may medication be reversed? Opiates and benzodiazepines are the only drugs with specific antagonists: REMEMBER: once reversal agents are used this MUST lead to a longer period of post-procedure monitoring.

37 Reversal Agents NALOXONE, 40mcg - 400mcg slow I.V. Onset 1-3 minutes, duration 45 minutes will reverse analgesia may cause pulmonary edema beware withdrawal effects if long term narcotic use may need repeating or infusion NALOXONE, 40mcg - 400mcg slow I.V. Onset 1-3 minutes, duration 45 minutes will reverse analgesia may cause pulmonary edema beware withdrawal effects if long term narcotic use may need repeating or infusion

38 Reversal Agents FLUMAZENIL, 0.1mg mg I.V. for partial reversal 0.4mg - 1.0mg I.V. for complete reversal Onset 1-2 minutes, duration 45 minutes may precipitate withdrawal seizure not to be used routinely half life of benzodiazepine may be long so flumazenil may need to be repeated FLUMAZENIL, 0.1mg mg I.V. for partial reversal 0.4mg - 1.0mg I.V. for complete reversal Onset 1-2 minutes, duration 45 minutes may precipitate withdrawal seizure not to be used routinely half life of benzodiazepine may be long so flumazenil may need to be repeated

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42 Summary Choose your patients carefully. Check and understand your equipment Use medication judiciously, you can’t take it out but you can always give more! Have reversal agents available but remember basic airway techniques. Be vigilant and prepare for the unexpected. Choose your patients carefully. Check and understand your equipment Use medication judiciously, you can’t take it out but you can always give more! Have reversal agents available but remember basic airway techniques. Be vigilant and prepare for the unexpected.


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