1. Procedural Sedation M Anto ED prov fellow Mona Vale Hospital
29 Sep 2016

2. What is proc sed
ACEP:
Technique of administering sedatives or dissociative agents
With or without analgesics
Induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function
Procedural sedation and analgesia is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently
ANZCA/ACEM:
State of drug induced tolerance of uncomfortable/painful medical/dental/surgical procedure

3. Indications Reduction of dislocation or fracture Laceration repair
DCCV
Abcess incision and drainage LP

4. Benefits
Provides analgesia
Avoid OT
Cost
Reduces LOS
Safe in ED

5. Alternative treatments
LA – topical, local infiltrate
Nerve blocks
Biers block
GA (in OT)
Nothing

6. Definitions Minimal sedation: Moderate sedation:
Normal response to verbal stimuli
Cognition + coordination may be affected
CVS/resp normal
Moderate sedation:
Depression of consciousness
Response to verbal stimuli
Airway patent, resp good, CVS usually normal

7. Definitions Deep sedation: Depression of consciousness
Not easily aroused
May have impaired ventilatory function
May need assistance to maintain patent airway
CVS usually maintained
GA:
Loss of consciousness
Ventilatory function requires assistance
Assistance for patent airway
CVS may be affected

8. Preprocedure evaluation
History
Examination
Investigations

9. Preprocedure eval: hx Details of the current problem
Co-existing and past medical and surgical history
History of previous sedation and anaesthesia
Current medications (including non-prescribed medications)
Allergies
Fasting status
Dentition - false, damaged or loose teeth
Other evidence of potential airway problems
Patient’s exercise tolerance or functional status

10. Preprocedure eval: exam
Airway
Respiratory
CVS
Other systems as indicated by the history, including that relevant to the current problem

11. Preprocedure eval: Ix
?Baseline ECG
BSL

12. High risk patients All children less than 2 years of age Elderly
Pregnancy
Severe comorbidities
CVS, CNS, resp, liver, renal disease
Morbid obesity
Severe OSA
Acute gastrointestinal bleeding +/- shock
Severe anaemia
Potential for aspiration of stomach contents (which may necessitate endotracheal intubation)
Patients in ASA Grades P4-5
Previous adverse events due to sedation, analgesia or anaesthesia
Known or suspected difficult ETT

13. Patient counselling Informed consent Indications Complications
Alternative treatments
Discharge advice

14. Preprocedure fasting Regurgitation, aspiration syndrome – 0.5% all PSA
ANZCA:
Prolonged fasting from fluids for more than 6 hours fails to achieve an optimally empty stomach
Clear fluids up to 2hrs
Limited solid food 6hrs
ACEP: Fasting not required – Level B
?Antacids

15. Personnel
Single trained person to monitor patient during mod and deep sedation
ED consultant or most senior doctor needs to be aware of the patient receiving sedation – does not necessarily need to be in room
Proceduralist (1-2)
Nursing staff to document and assist

16. Training
Supervised training
CRM
BSL/ALS
CPD
Audit

17. Preparation Room/location Lighting OT table/trolley/chair preferred
Suction O2
Emergency equipment
Monitoring
Meds
Equipment for procedure
Means of summoning assistance
Clinical response plan

18. Monitoring
The following data should be recorded at appropriate intervals before, during, and after the procedure, with alarms set:
Pulse oximetry
Response to verbal commands (when practical)
Pulmonary ventilation (observation, auscultation)
EtCO2
BP/HR q5min
ECG for patients with significant cardiovascular disease

19. Emergency equipment Airway trolley (+ difficult airway trolley) BVM
Defib
ECG
IV trolley

20. Supplemental O2
Considered and available for all patients for as much of the procedure as possible
Prior to sedation may not benefit all patients, and may not need be practical e.g. small children, IH
Pulse oximetry

21. IV access Required in most cases for medication and analgesia
Not requiring with low doses inhaled/oral meds

22. Medications Sedation Analgesia Propofol Ketamine Midazolam NO2
Fentanyl
Morphine
Ketamine

23. Propofol Onset 30sec, peak 120sec, duration 3-10min
CI: allergy to egg, soy
SE: hypotension, bradycardia, resp depression, pain on infusion
No analgesia
Dose: 0.5-2mg/kg

24. Ketamine Disassociative
Onset 2min, peak 3min, duration 15min IV or 30min IM
Benefits: maintains airway reflexes + spont resp, CVS stable, bronchodilator
SE: laryngospasm, emergence, secretions, reduces seizure threshhold, vomiting
Technique
Dose: IV 0.5-2mg/kg, IM 2-4mg/kg

25. Midazolam Anxiolysis, sedation, amnesia, no analgesia
Onset 1-5min, peak 10-15min, duration 60min
SE: hypotension, resp depression, paraxodical rxn
Dose: mg/kg max 0.4mg/kg
Avoid EtOH

26. NO2 Inhalation, sedative, amnesiac, analgesia Fast induction
Requires scavenging system
CI: bowel obstruction, Ptx
Monitor for diffusion hypoxia – O2 post procedure
SE: vomiting
Dose: 30-70%

27. Opiates
Morphine
Fentanyl

28. Reversal agents
Naloxone
Flumazenil

29. Recovery Sedation Dr present until: Monitor in ED until: Spont resps
Obs stable
Protecting airway
Monitor in ED until:
Fully awake
Tolerating oral intake
Analgesia adequate
Mobilising

30. Documentation Name of staff involved Hx, exam, Ix Doses/time of meds
Monitor readings inc during recovery

31. Discharge advice Written instructions Supervision at home E+D
Analgesia
Resumption of normal activities
Legally binding decisions
EtOH
Driving
Heavy machinery

32. Take home message Assess the patient adequately Prepare
Understand your meds
Situational awareness

33. References
ANZCA Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures
Emcrit
HETI clinical update 349 (27/2/04)
Medscape
Uptodate
PEMSoft
LITFL
SCGH ED CME