1. Procedural & Emergency Sedation for EMET Townsville
Based on a talk by Jane Dutson FACEM
Townsville Hospital Emergency Department

2. Emergency Procedural Sedation
What is it?
Why are we doing it?
Should we be doing it?
What do we need?
What next?
Not just the standard procedural sedation should be the aim of this talk but also emergency sedation to help the management of the acutely agitated – there will be some objection to doing any sedations at all – so mention acute limb threat and also ketamine assisted intubation

3. Procedural Sedation ?‘Conscious Sedation’.
A state of drug induced tolerance of uncomfortable or painful diagnostic or interventional medical, dental or surgical procedures.
Previously the remit of anaesthetists
‘& Analgesia’

4. Aims Minimise Pain & Discomfort Enable procedure Minimise Recall
Minimise Risk
Lack of response to painful stimulation is not a requirement.

5. If we are going to do this…..
We need to understand the characteristics of medication being administered
We must be able to monitor patients and maintain the desired level of sedation
&
We must be able to manage complications
Cardiovascular instability
Respiratory depression / airway compromise

6. Is Procedural Sedation Really Necessary?
What are we trying to achieve?
When practical ask the patient what they want.
Consider alternative techniques
Regional anaesthesia?
Adequate pain relief?
Is an RSI indicated?
Regional & cultural differences / expectations
Avoid ‘Out of Hours’ unless procedure is time critical

7. Factors to Consider History Examination ASA Score Mallampati Score
Obstructive Sleep Apnoea
Elderly / Co-morbidities
Airway / Previous Anaesthetic Problems
Fasting
Examination
ASA Score
Mallampati Score
3 or 4 Risks Airway Compromise
Urgency of Intervention
Obstructive Sleep Apneoa

8. ASA Score American Society of Anaesthesiologists
ASA I Normal Healthy Patient
ASA II Mild Systemic Disease
ASA III Severe Systemic Disease
ASA IV Severe Disease / Constant Life Threat
ASA V Moribund / Not Expected to Survive
ASA I & II & possibly III
ASA IV & V likely to need GA

9. Mallampati Score

10. Should they be Fasted? Debated
Beyond 2 hours of fasting there is no increase in risk or change in gastric pH.
Present ACEM / ASA Guidelines
2 hours post clear liquids
6 hours post ingestion of solids
Most aspiration events occur during airway manipulation.

11. Fasting versus Intervention
Recent ingestion of food / fluids should be weighed against the urgency of the procedure
The goal is to maintain airway reflexes
Examples….. Limb threatening injury for reduction v Incision and drainage procedure.
Inhalational agents are more emetogenic.

12. Levels of Procedural Sedation
ANXIOLYSIS
MODERATE SEDATION
DEEP SEDATION
GENERAL ANAESTHESIA
Responsiveness
NORMAL
Purposeful to Light Stimulation
Purposeful to Repeated Stimulation
NO Response to Painful Stimulation
Airway
PATENT
+/- Intervention
Needs Intervention
Ventilation
Adequate
+/- Assistance
Needs Assistance
CVS Function
Usually Adequate
Impairment Risk
This is important !!! The usual just give the patient (including children) a dissociative dose of Ketamine is – yes right – a GA!!!!

13. Dissociative Anaesthesia
‘A trance like cataleptic state characterised by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiovascular stability’
And as mentioned a type of GA – not actually a procedural sedation

14. Minimal Sedation /Anxiolysis
Still normally responsive to verbal stimulation
Entonox = Nitrous Oxide + Oxygen
Useful for making short, uncomfortable procedures tolerable.
Mix may be titrated up to
70%N2O:30%O2
Laughing Gas

16. Moderate Sedation (‘Conscious Sedation’)
BENZODIAZEPINES
Purposeful movements to light stimulation
(midazolam)
&
Making interventions tolerable
OPIATES
Always allow peak drug effect before titrating additional doses
(fentanyl / morphine)

17. Moderate Sedation Opiates & Benzodiazepine
FENTANYL
MORPHINE
Rapid Onset
Longer Onset
Short Duration
Longer Acting
No Histamine Release
Useful if long procedure
Histamine Release
No Amnesic Effect
Emetogenic
0.5-1mcg/kg
May cause Hypotension
Halve in elderly
0.1mg/kg

18. Moderate Sedation Opiates & Benzodiazepines
MIDAZOLAM
Amnesic and Anxiolytic
0.03 – 0.1mg/kg
SLOW onset of 2-5 minutes
More rapid than diazepam
30-60 minute duration
Increase risk of respiratory depression when combined with opiate
Watch for compounding effects of opioids and benzos but also other substances and drugs !! Mention the reversibility of both opiods and benzos!! Should always be available !!!!

19. Deep Sedation Benzodiazepine & Opiate Propofol
Purposeful movements to repeated stimulation
Benzodiazepine & Opiate
Propofol
At risk of becoming….. General Anaesthesia

20. Milk Of Amnesia

21. Propofol Deep Sedation Pre-oxygenation required
End Tidal CO2 Monitoring
No analgesic effect
1-1.5mcg/kg fentanyl pre-sedation
Propofol Dose mg/kg
mg/kg increments thereon
usually 200mg/20ml vial
Apnoea up to 60seconds (less if stimulus applied)
This is not reversible !!!!! As always the apnoea – drop in responsiveness always follows reduction of pain (ie post successfully reduction)

22. Dissociative Anaesthesia

23. ‘How they go down is how they come up’
Ketamine
Patient maintains own airway and respiratory drive
Pain free relaxation
Suitable for prolonged procedures
20 second apneoic episode common
Emergence Phenomena
‘How they go down is how they come up’

24. Ketamine Sympathomimetic
Raised BP
Raised HR
Relatively !!! contraindicated in hypertensive, elderly or patients with a history of psychosis
Emergency phenomena may be effectively treated with benzodiazepines
Avoidable if quiet, calm environment
Encourage pleasant thoughts at induction
Especially the relative contraindication of psychosis is probably rubbish – good experience has been gained from psych aeromedical transfers

25. Triple Check Doses

26. Procedural Drugs
And remember for rural locations – advantages of being able to reverse some of these drugs over others

27. Who Do We Need? Staff Clinician to administer the ‘sedation’
Another clinician to perform the procedure (unless only using anxiolysis)
Separate operator for monitoring, recording drug doses, times and observations
This will be hard in a one doctor town – nice how “big city” talks sometimes are incompatible with life 

28. What Do We Need? Equipment
Intubation Kit
Oxygen / Nasal Prongs
Intravenous Access
Plus ETCO2 sensor
Reversal Agents
Suction
Optimal Patient Positioning
Bag Valve Mask (BVM)
Airway Adjuncts

29. What Do We Need? Monitoring
Clinical & Objective
End Tidal CO2 (ETCO2) monitoring
Better predictor of respiratory depression than SpO2
Pulse Oximetry
ECG monitoring
Blood Pressure monitoring
Consider Sp02 monitoring on RA or ETCO2 on 15LFiO2.
Raised CO2 – acidosis – bradyarrythmias…..

30. What Do We Need? Documentation
Names of medical staff and their allocated roles
Pre-sedation Assessment
Drugs used, doses and times administered
Document vitals pre / mid / post sedation
Used for audit of practice in the ED
very helpful if patient reattends

31. What Do We Need? Supervised Recovery Phase
Duration determined by practitioner responsible for procedural sedation
If discharged home then provide post sedation advice
Patient should be back to baseline level of consciousness
Patient should have normal vital signs
Pain and discomfort issues must be addressed

32. What Next? Ketamine + Profopol = ‘Ketofol’
Deep Sedation with Propofol
Amnesia, Decrease BP, Decrease HR
Analgesia with Ketamine
Pain Control, Increase BP, Increase HR
Mix 100mg Propofol with 100mg Ketamine and dose as per Propofol (0.5mg/kg).
Not the holy grail it was promised to be – some issues of onset vs offset – pharmacologically the good idea may just suffer a couple of hicups

34. Summary
Procedural Sedation has an important role in expediting and preventing suffering during painful but necessary procedures
Assess the suitability of each patient and work within your level of experience
Use drugs which are familiar to you but tailored to the needs of the patient
Always aim to have separate clinicians performing sedation and intervention
Check your drugs and be patient!

35. Levels of Procedural Sedation
ANXIOLYSIS
MODERATE SEDATION
DEEP SEDATION
GENERAL ANAESTHESIA
Responsiveness
NORMAL
Purposeful to Light Stimulation
Purposeful to Repeated Stimulation
NO Response to Painful Stimulation
Airway
PATENT
+/- Intervention
Needs Intervention
Ventilation
Adequate
+/- Assistance
Needs Assistance
CVS Function
Usually Adequate
Impairment Risk

36. Discussion of local experience
Would you ever use procedural sedation?
Why if not…
Would you consider the same principle to prepare the resuscitation of agitated patients…
Ketamine assisted or Delayed sequence induction?
What are the cases you have struggled with?

37. Any Questions about Procedural Sedation in the ED?
No cats were harmed in the making of this presentation.