Procedural Sedation in the Emergency Department

Deon Stoltz

Objectives

What does it mean What needs to be considered.

What do we normally use it for.

Review commonly used agents Briefly discuss alternatives to PSA

Overview

DISCLAIMER….

This is a very simplified overview of a complex topic.

It is not a substitute for in-depth research, background knowledge and training.

What is Procedural Sedation?

To reduce patient anxiety and awareness To facilitate a painful medical procedure Patient maintains their airway & breathing a.k.a “conscious sedation” “deep sedation”

Procedural Sedation

Positives Avoids the discomfort associated with local or regional anaesthetic techniques.

Doesn’t affect anatomy Relatively simple technique Negatives Consumes resources General anaesthesia in the ED is frowned upon…

The goals of PS

To 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.

How low should you go?

Depth of Procedural Sedation

Normal LOC Minimal Sedation (Anxiolysis) Moderate Sedation/Analgesia Deep Sedation/Analgesia General Anaesthesia

Uses

Reduction of dislocations:  shoulder, elbow, hip, patella, ankle Reduction of fractures:  wrist, ankle  washout compound fracture Paediatric injuries:  wound inspection, closure, suturing Abscess I&D

Considerations for PS in the ED

Patient Agent Environmen tal

Case – Mr. F. B.

Case

A 40 yo man presents with a painful, swollen right wrist after a fall. You do an x ray…

Allergies:

So what about our patient?

Eggs Medications: Enalapril Salbutamol • Last Meal: – 30 minutes ago • Events: – Patient came immediately to the hospital after falling.

Flovent Past Medical History: Asthma Obstructive sleep apnea Hypertension DM II

To sedate or not to sedate…

86 yo female with a dislocated hip

Allergies: NKDA Meds: Metoprolol Nitroglycerin patch Enalapril Lasix ASA Atrovent Last meal: NPO for 4 hours – • – – • – – – – PMHx: MI x 2 (multi-vessel CAD) Angina with minimal activity PVD HTN CVA CRF Events: Pt felt a pop while trying to get up from a chair.

To sedate or not to sedate…

22 yo intoxicated male with an ankle fracture

Allergies: NKDA Meds: unknown PMHx: unknown Last meal: Smells like EtOH Unknown Events: No one really knows

To sedate or not to sedate…

28 yo female with a fractured wrist

What risks are associated with sedation during pregnancy?

Patient Assessment

The AMPLE history Allergies Medications Past medical history Last meal Events before & after the incident Physical Exam Airway assessment Respiratory exam Cardiovascular exam

I.

II.

III.

ASA Physical Status Classification

Healthy Patient Mild systemic disease – no functional limitation Severe systemic disease – definite functional limitation IV.

Severe systemic disease that is a constant threat to life V.

Moribund patient that is not expected to survive with the operation

“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 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 III Procedural sedation and analgesia in the emergency department Canadian Consensus Guidelines

The Last Supper Fasting & PSA

ANZCA recommendations for healthy elective GA patients: 2 h NPO for liquids 6 h NPO for solids The 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.

Starved for how long…?

Controversial.

Probably not as rigid as anaesthetic guidelines for GA...

Depends on degree and duration of sedation Starship CED paediatric guideline:  Clear fluids: at least 2 hours  Non-clear fluids and solids: at least 4 hours

PATIENT SELECTION

Can you hold the fort if something goes wrong?

BREATHING & CIRCULATION:  Lung disease?

 Stable cardiac status?

 BP stable?

Medications Allergies (e.g. watch out for soy, eggs: Propofol)

Airway Assessment

Can you bag?

Can you intubate?

Predictors of Difficult BVM Ventilation

Beard Obesity Old (age > 55 yrs) Toothless Snores Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology. 2000; 92:1229-36.

The LEMON Method of Airway Assessment

• L ook for external characteristics known to causes problems with BVM or intubation.

• E valuate the 3-3-1 Rule: Mouth opening > 3 fingers Hyoid – chin distance > 3 fingers Anterior low jaw subluxation > 1 finger • M allampati Score • O bstruction – any pathology within or surrounding the upper airway • N eck Mobility - full flexion & extension

Considerations for PS in the ED

Patient Environmen tal Agent

The Perfect Drug

Provides adequate sedation and analgesia for: Patient comfort Easy completion of the procedure Maintains airway reflexes Does not affect hemodynamics Does not affect respiratory function

Commonly Used Agents

Propofol Fentanyl Ketamine Midazolam

Commonly Used Agents

Propofol

Category Sedative-Hypnotic What is it?

2,6-diisopropofol, an alkylphenol oil in an emulsion How does it work?

Potentiates GABA activity How much do you need?

Starting dose of 0.5 - 1 mg/kg

Commonly Used Agents

Propofol

What else does it do?

CNS: Mild analgesic properties; euphoria CVS: Myocardial depressant; vasodilation Resp: Respiratory depressant GI: Antiemetic MSK: Myoclonus What does the body do with it?

Rapid redistribution Hepatic and extrahepatic metabolism

Commonly Used Agents

Propofol

Pros Shown to be safe for ED PSA use Rapid onset and recovery Cons Must be combined with an analgesic agent May cause apnea & loss of airway reflexes Myocardial depressant and vasodilator

Commonly Used Agents

Fentanyl

Category Analgesic agent What is it?

Synthetic opioid How 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/kg

Commonly Used Agents

Fentanyl

What else does it do?

CNS: Euphoria (or dysphoria) Resp: Respiratory depressant; chest wall rigidity CVS: May decrease HR GI: Decreased motility What does the body do with it?

Hepatic metabolism (inactive metabolite) Renal excretion

Commonly Used Agents

Fentanyl

Pros Good hemodynamic stability Rapid onset and recovery Cons Must be combined with an amnestic agent May cause bradycardia May cause chest wall rigidity May cause apnea & loss of airway reflexes

Commonly Used Agents

Midazolam

Category Amnestic What is it?

Benzodiazepine How does it work?

Bind to benzodiazepine receptors which up regulate GABA activity How much do you need?

0.02 – 0.1 mg/kg IV

Commonly Used Agents

Midazolam

What else does it do?

CNS: Anxiolysis CVS: Slight decrease in PVR & decreased contractility.

Resp: Respiratory depression What does the body do with it?

Hepatic metabolism (active metabolite) Renal excretion

Commonly Used Agents

Ketamine

Category Dissociative Amnestic What 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 receptors

Commonly Used Agents

Ketamine

What else does it do?

CNS: Emergence reactions CVS: Increased contractility, HR and PVR through sympathetic stimulation. Direct myocardial depressant.

Resp: Laryngospasm, bronchodilation, increased secretions What does the body do with it?

Hepatic metabolism Renal excretion

But 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.

Commonly Used Agents

Ketamine

How much do you need?

1 – 2 mg/kg IV How much midazolam?

0.7 mg/kg given at the time of ketamine injection.

Mix & Match

Commonly used combinations: Propofol + Fentanyl Fentanyl + Midazolam Propofol + Midazolam + Fentanyl Ketamine + Midazolam

How low should you go?

Depth of Procedural Sedation

Normal LOC Minimal Sedation (Anxiolysis) Moderate Sedation/Analgesia Deep Sedation/Analgesia General Anaesthesia

Considerations for PS in the ED

Patient Environmen tal Agent

PREPARATION

Prepare for the worst….

What can go wrong?

 Unexpected drug reaction or anaphylaxis  Vomit and aspirate  Obstructed airway (e.g. laryngospasm, tongue)  Apnoea, respiratory arrest  Profound hypotension

PREPARATION

Not quite the worst … What can go wrong?

 Disinhibition / agitation  Terrors, nightmares  Unexpected drug reactions: dystonias  Inadequate sedation  Unsuccessful procedure… still needs GA

PREPARATION

ACEM POLICY DOCUMENT USE OF INTRAVENOUS SEDATION FOR PROCEDURES IN THE EMERGENCY DEPARTMENT © ACEM. 5 December 2001

PREPARATION

ENVIRONMENT The procedure must be performed in a suitable clinical area with facilities for:  Monitoring,  Oxygen  Suction  immediate access to emergency resuscitation equipment, drugs and other skilled staff.

PREPARATION

ENVIRONMENT Readily available equipment must include:  resuscitation trolley  defibrillator

PREPARATION

ENVIRONMENT Readily available equipment must include:  resuscitation trolley  Defibrillator  Bag-Valve-Mask device for ventilation

PREPARATION

MONITORING Cardiac rhythm, non-invasive blood pressure and pulse oximetry must be monitored throughout the procedure and recovery period

PREPARATION

PERSONNEL The involvement of at least two clinical staff is required:  PERSON PERFORMING PROCEDURE must 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.

PREPARATION

PERSONNEL The involvement of at least two clinical staff is required:  PERSON PERFORMING PROCEDURE must 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.

PREPARATION

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.

PREPARATION

PATIENT PREPARATION  Explanation  Consent  Secure IV access is mandatory.

PREPARATION

Other requirements  Separate space to perform the procedure  A recovery space: ideally quiet, available for 1-2 hours, easily observed.

READY TO GO…

Explain Pre-oxygenate IV Access and IV fluid running Splints or plaster or equipment all ready to go Hand over your phone or pager…

To sedate or not to sedate…

Phone a friend…

Consider sending the at-risk patient to the OR.

So what ARE you going to do?

Questions?

Key Points

Be prepared Know your drugs and your drug interactions Consider all your options

Guidelines

Other References

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; pp 177-196.

Innes 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.

Textbooks Miller RD. Miller’s Anesthesia, 6 th Ed. 2005 Marx JA. Rosen’s Emergency Medicine, 5 th Ed. 2002.

Roberts JR. Clinical Procedures in Emergency Medicine, 4 th Ed. 2004 Tintinalli JE. Emergency Medicine: A Comprehensive Study Guide, 6 th Ed. 2004

Other 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. 2006:23. 89-93.

Green SM and Krauss B. Propofol in emergency medicine: pushing the sedation frontier. Annals of Emergency Medicine. 2003:42. 792-797.

Bahn EL and Holt KR. Procedural sedation and analgesia: a review and new concepts. Emergency Medicine Clinics of North America. 2005:23. 503-517.

Green SM. Fasting is a consideration – not a necessity – for emergency department procedural sedation and analgesia. Annals of Emergency Medicine. 2003:42. 647-650.

Green SM and Sherwin TS. Incidence and severity of recovery agitation after ketamine sedation in young adults. American Journal of Emergency Medicine. 2005:23. 142-144.

Green SM and Li J. Ketamine in adults: what emergency physicians need to know about patient selection and emergency reactions. Academic Emergency Medicine. 2000:7(3). 278-280

Procedural Sedation & Analgesia in the Emergency Department